Utility of 5-ALA for fluorescence-guided resection of brain metastases: a systematic review

• Published in: Journal of neuro-oncology Vol. 160; no. 3; pp. 669 - 675
• Main Authors: Shah, Harshal A., Leskinen, Sandra, Khilji, Hamza, Narayan, Vinayak, Ben-Shalom, Netanel, D’Amico, Randy S.
• Format: Journal Article
• Language: English
• Published: New York Springer US 01.12.2022; Springer Nature B.V
• Subjects: Aminolevulinic Acid; Brain cancer; Brain Neoplasms - diagnostic imaging; Brain Neoplasms - pathology; Brain Neoplasms - surgery; Brain tumors; Fluorescence; Glioma; Glioma - pathology; Humans; Medicine; Medicine & Public Health; Metastases; Metastasis; Neuroimaging; Neurology; Neuronavigation - methods; Oncology; Retrospective Studies; Review; Surgery, Computer-Assisted - methods; Survival; Systematic review; Tumors; Brain tumor; Fluorescence guided surgery; Brain metastases; Aminolevulinic acid; Protoporphyrin ix; Metastatic cancer
• ISSN: 0167-594X; 1573-7373; 1573-7373
• DOI: 10.1007/s11060-022-04188-0

Purpose 5-aminolevulinic acid (5-ALA) has demonstrated its utility as an intraoperative imaging adjunct during fluorescence guided resection of malignant gliomas. However, literature regarding 5-ALA-guided resection for brain metastases is limited. We conducted a systematic review to evaluate the efficacy of 5-ALA fluorescence for resection of metastatic brain tumors. Methods PubMed was queried for studies involving 5-ALA and brain metastases, and results were screened following PRISMA guidelines. Articles related to 5-ALA and brain metastasis were further assessed based on inclusion and exclusion criteria and results were analyzed for 5-ALA fluorescence rates stratified by tumor primary sites and histological subtypes. Results Of 421 identified search results, 10 studies were included and a total of 631 patients analyzed. Of these studies, 60% were retrospective in design. The reported rates of 5-ALA fluorescence in included brain metastases ranged from 27.6 to 86.9%, with variability across and within tumor types. No studies concluded improved operative outcomes or survival outcomes related to 5-ALA use. Conclusions Current studies regarding 5-ALA fluorescence in brain metastases are limited and do not confirm efficacy for improving extent of resection or post-operative survival. Fluorescence is variable across and within tumor types. Further studies are necessary to evaluate whether specific tumors may benefit from 5-ALA FGS or if changes in delivery protocols or fluorescence quantification may affect intraoperative utility.