Detection of Biologically Relevant Tumour Areas

Chapter 7 - Surgery, Indications and Limitations

Complete resection of a malignant glioma can be facilitated by use of 5-aminolevulinic acid (5-ALA) fluorescence-guided tumour resection, more often than by using white light only. 

Fluorescence-guided tumour resection has therefore become a major and widespread standard for tumour resection in malignant gliomas in Europe.

To preserve functional activity within the respective brain areas, other tools such as neuronavigation or intraoperative (sub)cortical stimulation techniques should be used.

Biological tumour activity may reach far beyond CE displayed by conventional T1-weighted MRI, and can be detected by use of amino acid PET.

PET with amino acid tracers better differentiates between tumour and normal brain, but also between tumour recurrence and treatment-associated changes.

The combination of FET-PET with neuronavigation helps to assess biologically active tumour, as well as the risks and benefits of tumour resection during surgery.

Application of 5-ALA fluorescence in glioma surgery presents some risks, since it is enriched not only in tumour cells but also in the ependymal lining of the ventricles.

The same risk applies to tumours within eloquent brain areas, since 5-ALA fluorescence or FET-PET does not distinguish functional from non-functional tissue.

Close to eloquent areas, use of other surgical instruments such as neuronavigation or intraoperative mapping and monitoring are recommended.

Revision Questions

  1. Why should 5-ALA fluorescence-guided tumour resection be a standard of care in malignant gliomas?
  2. Which other imaging methods may be useful to delineate the biological tumour volume?
  3. What are the surgical risks and benefits when using 5-ALA- or FET-PET-guided neuronavigation?

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Last update: 18 September 2017