Fluorescein-guided resection of newly diagnosed high-grade glioma: Impact on extent of resection and outcome

Karl-Michael Schebesch; Julius Höhne; Katharina Rosengarth; Ekaterina Noeva; Nils Ole Schmidt; Martin Proescholdt

doi:10.1016/j.bas.2022.101690

Fluorescein-guided resection of newly diagnosed high-grade glioma: Impact on extent of resection and outcome

Brain Spine. 2022 Nov 9:2:101690. doi: 10.1016/j.bas.2022.101690. eCollection 2022.

Authors

Karl-Michael Schebesch^{1

2}, Julius Höhne^{1

2}, Katharina Rosengarth^{1

2}, Ekaterina Noeva³, Nils Ole Schmidt^{1

2}, Martin Proescholdt^{1

2}

Affiliations

¹ Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany.
² Wilhelm-Sander Neuro-Oncology Unit, University Medical Center Regensburg, Regensburg, Germany.
³ Neuroradiology Branch, Department of Radiology, University Medical Center Regensburg, Regensburg, Germany.

Abstract

Introduction: Maximal resection of high-grade glioma (HGG) improves progression-free survival (PFS) and overall survival (OS). Fluorescein sodium (FL) in combination with the YELLOW 560 nm filter (Carl Zeiss Meditec, Germany) is a safe and feasible method of visualizing residual tumor tissue during brain tumor resection.

Research question: We hypothesized that use of FL positively influenced the volumetric extent of resection (EOR), PFS, and OS in patients undergoing resection of a newly diagnosed HGG.

Materials and method: Using a prospective HGG registry, we identified 347 patients (median age 62.4 years; 141 women) with preoperative high-quality magnetic resonance images for volumetric analysis. Resection was performed under white light in n = 151 (43.5%, white-light group) and under FL-guidance in n = 196 (56.5%, FL group). Sex, age, presurgical Karnofsky Performance Index (KPI), O6-Methylguanin-DNA-Methyltransferase-Gene (MGMT) status, and adjuvant treatment modalities were well balanced between the groups. Volumetric analysis was performed by quantifying pre- and postoperative tumor volume based on gadolinium-enhanced T1 sequences in a blinded fashion.

Results: In the FL group, postoperative tumor volume was significantly smaller (p = 0.003); accordingly, quantitative EOR was significantly larger (p = 0.003). Significantly more complete resections were achieved in the FL group than in the white-light group (p = 0.003). The FL group showed significantly longer PFS (p = 0.020) and OS (p = 0.015, log rank testing). Multivariate Cox regression modelling showed age, presurgical KPI, MGMT status, and FL-guided resection to be independent prognostic factors for survival.

Discussion and conclusion: Compared to white-light resection, FL-guided resection of newly diagnosed HGG significantly improved EOR and prolonged OS.

Keywords: Extent of resection; Fluorescein sodium; Fluorescence-guided surgery; High-grade glioma; Malignant brain tumors; Neuro-oncologic surgery; Neuro-oncology.