Detailed analysis of 5-aminolevulinic acid induced fluorescence in different brain metastases at two specialized neurosurgical centers: experience in 157 cases

Franz Marhold, Petra A Mercea, Florian Scheichel, Anna S Berghoff, Patricia Heicappell, Barbara Kiesel, Mario Mischkulnig, Martin Borkovec, Stefan Wolfsberger, Adelheid Woehrer, Matthias Preusser, Engelbert Knosp, Karl Ungersboeck, Georg Widhalm

Research output: Journal article (peer-reviewed)Journal article

14 Citations (Scopus)

Abstract

OBJECTIVE: Incomplete neurosurgical resection of brain metastases (BM) due to insufficient intraoperative visualization of tumor tissue is a major clinical challenge and might result in local recurrence. Recently, visible 5-aminolevulinic acid (5-ALA) induced fluorescence was first reported in patients with BM. The aim of this study was thus to investigate, for the first time systematically, the value of 5-ALA fluorescence for intraoperative visualization of BM in a large patient cohort.

METHODS: Adult patients (≥ 18 years) with resection of suspected BM after preoperative 5-ALA administration were prospectively recruited at two specialized neurosurgical centers. During surgery, the fluorescence status (visible or no fluorescence); fluorescence quality (strong, vague, or none); and fluorescence homogeneity (homogeneous or heterogeneous) of each BM was investigated. Additionally, these specific fluorescence characteristics of BM were correlated with the primary tumor type and the histopathological subtype. Tumor diagnosis was established according to the current WHO 2016 criteria.

RESULTS: Altogether, 157 BM were surgically treated in 154 patients. Visible fluorescence was observed in 104 BM (66%), whereas fluorescence was absent in the remaining 53 cases (34%). In detail, 53 tumors (34%) showed strong fluorescence, 51 tumors (32%) showed vague fluorescence, and 53 tumors (34%) had no fluorescence. The majority of BM (84% of cases) demonstrated a heterogeneous fluorescence pattern. According to primary tumor, visible fluorescence was less frequent in BM of melanomas compared to all other tumors (p = 0.037). According to histopathological subtype, visible fluorescence was more common in BM of ductal breast cancer than all other subtypes (p = 0.008). It is of note that visible fluorescence was observed in the surrounding brain tissue after the resection of BM in 74 (67%) of 111 investigated cases as well.

CONCLUSIONS: In this largest series to date, visible 5-ALA fluorescence was detected in two-thirds of BM. However, the characteristic heterogeneous fluorescence pattern and frequent lack of strong fluorescence limits the use of 5-ALA in BM and thus this technique needs further improvements.

Original languageEnglish
Pages (from-to)1032-1043
Number of pages12
JournalJournal of Neurosurgery
Volume133
Issue number4
Early online date27 Sep 2019
DOIs
Publication statusPublished - Oct 2020

Keywords

  • 5-aminolevulinic acid
  • Brain metastases
  • Fluorescence
  • Histopathological subtype
  • Oncology
  • Primary tumor

ASJC Scopus subject areas

  • Surgery
  • Neurology (clinical)

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