Comparison of fluorescein sodium, 5-ALA, and intraoperative MRI for resection of high-grade gliomas: A systematic review and network meta-analysis. (April 2022)

• Record Type: Journal Article
• Authors: Naik, Anant; Smith, Emily J.; Barreau, Ariana; Nyaeme, Mark; Cramer, Samuel W.; Najafali, Daniel; Krist, David T.; Arnold, Paul M.; Hassaneen, Wael
• Is Part Of: Journal of clinical neuroscience. Volume 98(2022)
• Page Start: 240
• Page End: 247
• Publication Date: 2022-04
• Subjects: 5-Aminolevulinic acid -- Fluorescein-sodium -- Glioma -- Gross total resection -- Intraoperative MRI -- Intraoperative navigation; Brain -- Surgery -- Periodicals; Neurosciences -- Periodicals; Nervous system -- Surgery -- Periodicals; Brain -- surgery -- Periodicals; Neurosurgical Procedures -- Periodicals; Neurosciences -- Periodicals; Electronic journals; 616.8
• DOI: 10.1016/j.jocn.2022.02.028
• Languages: English
• ISSNs: 0967-5868

Abstract

Highlights: Fluorescein-sodium is comparable to 5-ALA and intraoperative MRI in terms of achieving gross-total resection of high-grade gliomas. The use of intraoperative Fluorescein Sodium (vs. control) was associated with improved OS, and comparable rates of PFS as 5-ALA. Fluorescein-sodium is an acceptable intraoperative agent that can be used effectively to guide surgical resection of high-grade gliomas. Abstract: High grade gliomas (HGGs) are aggressive brain tumors associated with poor prognosis despite advances in surgical treatment and therapy. Navigated tumor resection has yielded improved outcomes for patients. We compare 5-ALA, fluorescein sodium (FS), and intraoperative MRI (IMRI) with no image guidance to determine the best intraoperative navigation method to maximize rates of gross total resection (GTR) and outcomes. A frequentist network meta -analysis was performed following standard PRISMA guidelines (PROSPERO registration CRD42021268659). Surface-under-the-cumulative ranking (SUCRA) analysis was executed to hierarchically rank modalities by the outcomes of interest. Heterogeneity was measured by the I 2 statistic. Publication bias was assessed by funnel plots and the use of Egger's test. Statistical significance was determined by p < 0.05. Twenty-three studies were included for analysis with a total of 2, 643 patients. Network meta -analysis comparing 5-ALA, IMRI, and FS was performed. The primary outcome assessed was the rate of GTR. Analysis revealed the superiority of all intraoperative navigation to control (no navigation). SUCRA analysis revealed the superiority of IMRI + 5-ALA, IMRI alone, followed by FS, and 5-ALA. Overall survival (OS) and progression free survival (PFS) were also examined. FS (vs. control) was associated with improved OS, while IMRI was associated with improved PFS (vs. control, FS, and 5-ALA). Intraoperative navigation using IMRI, FS, and 5-ALA lead to greater rates of GTR in HGGs. FS and 5-ALA also yielded improvement in OS and PFS. Further studies are needed to evaluate differences in survival benefit, operative duration, and cost.