Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery

Neurochirurgie. 2019 Aug;65(4):164-177. doi: 10.1016/j.neuchi.2019.04.005. Epub 2019 May 21.


Background: When feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection.

Methods: A Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines.

Results: 5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications.

Conclusion: Although 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.

Keywords: 5-ALA; Efficacy; Extent of resection; Fluorescence-guided surgery; High-grade glioma; Safety.

Publication types

  • Review

MeSH terms

  • Aminolevulinic Acid*
  • Brain Neoplasms / surgery*
  • Fluorescence
  • France
  • Glioma / surgery*
  • Humans
  • Neurosurgical Procedures / methods*
  • Societies, Medical
  • Surgery, Computer-Assisted / methods*


  • Aminolevulinic Acid