gms | German Medical Science

Introduction: Glioblastoma is one of the most malignant brain tumors with a mean survival time in adults of 12-16 months after diagnosis. New evidence points toward always achieving maximal surgical resection. Surgery provides some survival benefit (>78% resection), rapid reduction of tumor bulk mass effect with concomitant symptoms palliation and provides tissue for histopathological diagnosis. Ventricular irruption during surgery increase the possibility of acquiring hydrocephalus, estimated to occur in 15% of surgical cases with a 4% incidence. The 5-Aminolevulinic acid (5-ALA) fluorescence guided resection for high-grade glioma has become a useful took to achieve maximal safe tumor removal decreasing the probability of local recurrence. The aim of this paper is to establish the relationship between ventricular irruption and use of 5-ALA fluorescence guided surgery in high-grade tumors.

Methods: We prospectively reviewed 168 patients with newly diagnosed and previously untreated GBM diagnosed between 2005 and 2013 at a single center in University of Tübingen Hospital, Germany, who had ventricular irruption during tumor resection using 5-ALA. We included all adult patients had high-grade glioma cytoreductive surgery using 5-ALA for fluorescence guided resection. Ventricular irruption was register if stated in the surgical technique note or when evident in the postoperative scan.

Results: We collected a total of 168 candidates harboring high-grade glioma; we categorized them according to extent of resection into total (n=91), subtotal (n=53) and biopsy (n=24). A total of 48 patients were recruited, 5-ALA guided surgery was employed in 30 cases of total resection, 17 for subtotal resection and 1 biopsy (p=0.001). Neurological deficit was the most common postoperative complication, followed by anopsia. There was not increased risk of ventricular irruption during 5-ALA surgery (P = 0.52). Late-onset hydrocephalus was not higher in 5-ALA guided surgery (P = 0.20). To assess the risk of ventricular irruption we subdivided the population into high-risk and low-risk according to the tumor localization near the lateral ventricles.

Discussion: Surgical resection of high-grade glioma has evolved in the last decade in achieving maximal safe resection and most prospective data indicates a trend without level I evidence that points extent in survival. In our population, ventricular irruption while using 5-ALA was not an independent risk of late-onset hydrocephalus.

Ventricular breach can occur most frequent in tumors located near the lateral ventricles, the survival graph of our population showed partial resection decreases survival and that can be explained as consequence of tumor cytoreduction.

Data presented in this study suggest that 5-ALA guided surgery does not increases the risk of ventricular irruption and neither the development of late-onset communicating hydrocephalus.