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Prognostic Value of Residual Fluorescent Tissue in Glioblastoma Patients After Gross Total Resection in 5-Aminolevulinic Acid-Guided Surgery

Aldave, Guillermo MD*; Tejada, Sonia MD, PhD*; Pay, Eva MD*; Marigil, Miguel MD*; Bejarano, Bartolomé MD, PhD*; Idoate, Miguel A. MD, PhD; Díez-Valle, Ricardo MD, PhD*

doi: 10.1227/NEU.0b013e31828c3974
Research-Human-Clinical Studies

BACKGROUND: There is evidence in the literature supporting that fluorescent tissue signal in fluorescence-guided surgery extends farther than tissue highlighted in gadolinium in T1 sequence magnetic resonance imaging (MRI), which is the standard to quantify the extent of resection.

OBJECTIVE: To study whether the presence of residual fluorescent tissue after surgery carries a different prognosis for glioblastoma (GBM) cases with complete resection confirmed by MRI.

METHODS: A retrospective review in our center found 118 consecutive patients with high-grade gliomas operated on with the use of fluorescence-guided surgery with 5-aminolevulinic acid. Within that series, the 52 patients with newly diagnosed GBM and complete resection of enhancing tumor (CRET) in early MRI were selected for analysis. We studied the influence of residual fluorescence in the surgical field on overall survival and neurological complication rate. Multivariate analysis included potential relevant factors: age, Karnofsky Performance Scale, O6-methylguanine methyltransferase methylation promoter status, tumor eloquent location, preoperative tumor volume, and adjuvant therapy.

RESULTS: The median overall survival was 27.0 months (confidence interval = 22.4-31.6) in patients with nonresidual fluorescence (n = 25) and 17.5 months (confidence interval = 12.5-22.5) for the group with residual fluorescence (n = 27) (P = .015). The influence of residual fluorescence was maintained in the multivariate analysis with all covariables, hazard ratio = 2.5 (P = .041). The neurological complication rate was 18.5% in patients with nonresidual fluorescence and 8% for the group with residual fluorescence (P = .267).

CONCLUSION: GBM patients with CRET in early MRI and no fluorescent residual tissue had longer overall survival than patients with CRET and residual fluorescent tissue.

ABBREVIATIONS: 5-ALA, 5-aminolevulinic acid

CRET, complete resection of enhancing tumor

DC, dendritic cell

EOR, extent of resection

FGS, fluorescence-guided surgery

GBM, glioblastoma

GTR, gross total resection

KPS, Karnofsky Performance Scale

MGMT, O6-methylguanine methyltransferase

OS, overall survival

T1Gd, gadolinium in T1 sequence

*Department of Neurosurgery, Clínica Universidad de Navarra, Pamplona, Spain;

Department of Pathology, Clínica Universidad de Navarra, Pamplona, Spain

Correspondence: Guillermo Aldave, MD, Clínica Universidad de Navarra, C/Pio XII 36 (31008 Pamplona, Navarra), Spain. E-mail:

Received October 31, 2012

Accepted January 29, 2013

Copyright © by the Congress of Neurological Surgeons