Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA; Rutgers Robert Wood Johnson School of Medicine, Rutgers University, New Brunswick, New Jersey, USA.
Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA.
World Neurosurg. 2021 Jun;150:9-16. doi: 10.1016/j.wneu.2021.02.118. Epub 2021 Mar 5.
Surgical management of gliomas is predicated on "safe maximal resection" across all histopathologic grades because progression-free survival and overall survival are positively affected by the increasing extent of resection. Administration of the prodrug 5-aminolevulinic acid (5-ALA) induces tumor fluorescence with high specificity and sensitivity for malignant high-grade glioma (HGG). Fluorescence-guided surgery (FGS) using 5-ALA improves the extent of resection in the contrast-enhancing and nonenhancing tumor components in HGG. It has also shown preliminary usefulness in other central nervous system tumors, but with certain limitations.
We review and discuss the state of 5-ALA FGS for central nervous system tumors and identify the limitations in its use as a guide for future clinical optimization.
5-ALA FGS provides maximum clinical benefits in the treatment of newly diagnosed glioblastoma. 5-ALA fluorescence specificity is limited in low-grade glioma, recurrent HGG, and non-glial tumors. Several promising intraoperative adjuncts to 5-ALA FGS have been developed to expand its indications and improve the clinical efficacy and usefulness of 5-ALA FGS.
5-ALA FGS improves the clinical outcomes in HGG. However, further optimization of the diagnostic performance and clinical use of 5-ALA FGS is necessary for low-grade glioma and recurrent HGG tumors. Neurosurgical oncology will benefit from the novel use of advanced technologies and intraoperative visualization techniques outlined in this review, such as machine learning, hand-held fibe-optic probes, augmented reality, and three-dimensional exoscope assistance, to optimize the clinical usefulness and operative outcomes of 5-ALA FGS.
在所有组织病理学分级中，神经胶质瘤的手术治疗都基于“安全最大程度切除”，因为无进展生存期和总生存期受切除范围的增加而得到积极影响。前体药物 5-氨基酮戊酸（5-ALA）的给药诱导肿瘤荧光，对恶性高级别神经胶质瘤（HGG）具有高度特异性和敏感性。使用 5-ALA 的荧光引导手术（FGS）可提高 HGG 增强和非增强肿瘤成分的切除程度。它在其他中枢神经系统肿瘤中也显示出初步的有用性，但存在一定的局限性。
我们回顾和讨论了 5-ALA 用于中枢神经系统肿瘤的 FGS 的现状，并确定了其作为未来临床优化指导的使用限制。
5-ALA FGS 在治疗新诊断的胶质母细胞瘤方面提供了最大的临床益处。5-ALA 荧光的特异性在低级别神经胶质瘤、复发性 HGG 和非神经胶质瘤肿瘤中受到限制。已经开发了几种有前途的术中 5-ALA FGS 辅助手段，以扩大其适应证并提高 5-ALA FGS 的临床疗效和实用性。
5-ALA FGS 改善了 HGG 的临床结果。然而，需要进一步优化 5-ALA FGS 的诊断性能和临床应用，以治疗低级别神经胶质瘤和复发性 HGG 肿瘤。神经外科肿瘤学将受益于本综述中概述的先进技术和术中可视化技术的新应用，例如机器学习、手持式光纤探头、增强现实和三维外窥镜辅助，以优化 5-ALA FGS 的临床实用性和手术结果。
