gms | German Medical Science

Objective: Gross-Total Resection (GTR) is one of the most important predictors of overall survival in patients affected by High-Grade Glioma (HGG). In the literature there are no studies on the association between intra-operative ultrasound (io-US) and 5-ALA. We show a case description about this new multimodal approach to achieve a maximal safe resection (MSR) in patient with a recurrence of a glioma in an eloquent area.

Method: We report the case of a 48-year-old man at the third operation for recurrence and malignant progression of an oligodendroglioma. We use both 5-ALA and io-US to achieve the MSR.

Results: Neuronavigation systems based on preoperative images are not fully reliable due to the "brain shift". A method to improve this bias, was the utilization of io-US. Intra-operative fluorescence (Io-F)-guided resection has been vastly investigated by several neurosurgical groups. A randomized, multicentric, phase III trial was conducted in Europe in newly diagnosed HGGs. The study clearly documented that GTR was obtained more frequently in patients with 5-ALA induced Io-F with improvement of OS. We describe a case of a patient with diagnosis of anaplastic oligodendroglioma. He underwent his first surgery in 2004 (Oligodendroglioma WHO II) followed by chemotherapy (CT). In 2011, the patient underwent a second surgical procedure for progression of the disease. Histological finding revealed an oligodendroglioma (WHO III). He was treated with Stupp's protocol. On March 2013, a follow-up MRI showed further progression of the disease. Cyber-Knife radiosurgery followed by fotemustine CT were then performed. After 6 months, the patient reported aphasia and right-sided motor impairment. A new MRI showed further progression of an enhancing nodule in the left motor area. He was then admitted in our department and underwent surgery. 5-ALA was administerd 2 hours before surgery. We also utilized io-US to reach a MSR. Using this multimodal approach, we report clear demarcation of neoplastic borders both on io-US and Io-F guided surgery. Post-operative neuroradiological controls confirmed GTR. After the procedure, the patient suffered a transient aphasia and impairment of motor performance of the right side with rapid recovery.

Conclusions: It is clear that GTR improves the prognosis of patients with HGGs. We believe that a multimodal approach using both 5-ALA and io-US could improve surgical resection, aiming at MSR as the gold standard.