Indications of 5-Aminolevulinic Acid and Intraoperative MRI in Glioma Surgery: First Cases in Latin America in a Single Reference Center

Ricardo Ramina; Erasmo Barros da Silva Júnior; Felipe Constanzo; Maurício Coelho Neto

doi:10.1055/s-0038-1667182

Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery, Table of Contents

CC BY-NC-ND 4.0 · Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery 2018; 37(02): 088-094
DOI: 10.1055/s-0038-1667182

Original Article | Artigo Original

Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil

Indications of 5-Aminolevulinic Acid and Intraoperative MRI in Glioma Surgery: First Cases in Latin America in a Single Reference Center

Indicações de ácido 5-aminolevulínico e ressonância magnética intraoperatória em cirurgia de gliomas: primeiros casos na América Latina em um único centro de referência

Ricardo Ramina

¹Department of Neurosurgery, Instituto de Neurologia de Curitiba, Curitiba, PR, Brazil

,

Erasmo Barros da Silva Júnior

¹Department of Neurosurgery, Instituto de Neurologia de Curitiba, Curitiba, PR, Brazil

,

Felipe Constanzo

¹Department of Neurosurgery, Instituto de Neurologia de Curitiba, Curitiba, PR, Brazil

,

Maurício Coelho Neto

¹Department of Neurosurgery, Instituto de Neurologia de Curitiba, Curitiba, PR, Brazil

› Author Affiliations

Abstract

Introduction The improvement on the extent of resection (EOR) of gliomas with the combination of 5-aminolevulinic acid (5-ALA) and intraoperative magnetic resonance imaging (iMRI) has been demonstrated in previous studies. We present our results with the combined use of 5-ALA and (iMRI) in the surgery of glial lesions.

Methods A total of 64 cases of patients with intracranial gliomas who underwent image-guided surgery using 5-ALA with and without (iMRI) were reviewed. All patients underwent an early postoperative MRI to evaluate the EOR. Other intra-operative techniques (awake surgery, electrophysiological stimulation and monitoring) were also performed according to the location of the tumor.

Results A total of 18 tumors did not show intraoperative 5-ALA fluorescence (according to the World Health Organization [WHO] classification of tumors, 2 WHO-grade I, 14 WHO-grade II, 1 WHO-grade III and 1 WHO-grade IV), and 46 tumors showed intraoperative 5-ALA fluorescence (3 WHO-grade II, 3 WHO-grade III, 40 WHO-grade IV). In 28 of the 46 5-ALA positive cases, a safe 5-ALA free resection was achieved. In the 5-ALA negative cases, the (iMRI) findings guided the EOR, and complete resection was achieved in 11 cases. Complete resection was opted out in gliomas infiltrating eloquent areas.

Conclusions The combined use of 5-ALA and IMRI showed improved results in glioma surgery, offering the safest maximal EOR. In the 5-ALA positive cases (mostly high-grade), fluorescence was a more useful tool. In the 5- ALA negative cases (mostly low-grade), the (iMRI) was decisive to guide the EOR of the tumor.

Resumo

Introdução Em estudos anteriores, foi demonstrado um aperfeiçoamento na extensão da resecção (EDR) de gliomas com a combinação de ácido 5-aminolevulínico (5-ALA) e a imagem de ressonância magnética intraoperatória (iRM). Nossos resultados são apresentados com o uso combinado de 5-ALA e (iRM) para a cirurgia de lesões gliais.

Métodos Foram revisados 64 casos de gliomas intracranianos submetidos a cirurgia guiada por imagem por meio do uso de 5-ALA, com ou sem RMI. Todos os pacientes foram submetidos a ressonância magnética (RM) pré-operatória para a avaliação da EDR do tumor. Outras técnicas intraoperatórias (cirurgia acordado, estimulação eletrofisiológica e monitoração) também foram realizadas segundo a localização do tumor.

Resultados Um total de 18 tumores não apresentaram fluorescência com o 5-ALA (segundo a classificação de tumores da Organização Mundial de Saúde [OMS], 2 com grau OMS I, 14 com grau II, 1 com grau III e 1 com grau IV) e 46 tumores foram fluorescentes (3 com grau II, 3 com grau III, 40 com grau IV). Dos 46 casos positivos para 5-ALA, em 28 foi obtida uma ressecção segura e livre. Nos casos negativos para 5-ALA, os achados da (iRM) orientaram a EDR, e alcançou-se ressecção total em 11 casos. A ressecção total foi descartada em gliomas com infiltração em áreas eloquentes.

Conclusões O uso combinado de 5-ALA e (iRM) mostrou melhores resultados na cirurgia de gliomas, oferecendo uma EDR de segurança máxima. Nos casos positivos para 5-ALA (a maioria de grau alto), a fluorescência mostrou-se um instrumento mais útil. Nos casos negativos para 5-ALA (a maioria de grau baixo), a RMI foi decisiva para orientar a EDR tumoral.

Keywords

5-aminolevulinic acid - brain cancer - extent of resection - glioma surgery - intraoperative MRI - glioblastoma

Palavras-chave

ácido 5-aminolevulínico - câncer de cérebro - extensão da ressecção - cirurgia de glioma - ressonância magnética intraoperatória - glioblastoma

Full Text

References

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