Stummer W et al. (2006) Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol 7: 392–401

A recent trial by Stummer et al. on behalf of the ALA-Glioma Study Group has shown that fluorescence-guided surgery with 5-aminolevulinic acid results in a twofold increase in the number of patients free from residual malignant glioma, detected by postoperative MRI, when compared with conventional white-light surgery.

Complete resection of glioma is challenging, as tumor margins are difficult to define. The prodrug 5-aminolevulinic acid improves visibility by producing intratumoral accumulation of fluorescent porphyrins, which can be visualized with a modified neurosurgical microscope. In this study, 322 patients with malignant glioma were randomized to undergo tumor resection with either white light or fluorescence-guided neurosurgery at one of 17 German treatment centers. MRI was performed on all patients 72 h postoperatively and at regular intervals during follow-up. After a median follow-up of 35.4 months, significantly more patients in the fluorescence-guided surgery group than in the white-light surgery group had complete tumor resection (P <0.0001); of those with residual disease, patients in the former group had significantly smaller tumor volumes (P <0.0001). Progression-free survival at 6 months was also significantly greater in patients whose tumors were resected under fluorescent light (P = 0.0003) than in those who underwent white-light surgery. There were no significant long-term differences in neurotoxicity or Karnofsky performance status between the two groups. The authors conclude that patients with malignant glioma derive substantial clinical benefit from fluorescence-guided tumor resection with 5-aminolevulinic acid.