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Various shades of red—a systematic analysis of qualitative estimation of ALA-derived fluorescence in neurosurgery

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Abstract

5-Aminolevulinic acid (5-ALA)–fluorescence-guided resection is well established in many neuro-oncologic centers. Different classifications of 5-ALA-induced fluorescence have been reported. The aim of the systematic analysis was to evaluate the frequency of graduations, definitions, and designations of 5-ALA-induced fluorescence qualities. A systematic database search of PubMed was performed to identify studies reporting (1) on 5-ALA fluorescence-guided either spinal or cranial surgery, (2) on qualitative estimation and/or categorization of 5-ALA-induced fluorescence, (3) in English, and (4) were published as peer-reviewed original studies. Totally, 93 studies were identified. Different classification systems of 5-ALA-induced fluorescence were found. Over 60 % of the included studies used a dichotomized categorization of 5-ALA-induced fluorescence and 27.5 % of studies distinguished two different intensities of 5-ALA fluorescent tissue in addition to non-fluorescing tissue. More than 50 % of studies explicitly defined criteria for categorization of 5-ALA-induced fluorescence. The major limitation of the present analysis might be that it mainly comprises data from retrospective, uncontrolled, non-randomized trials. However, a precise definition of each 5-ALA-induced fluorescence quality is essential. Although dichotomized classification is the most common and simple graduation system, it may not be suitable for every clinical or scientific task. A three-level 5-ALA-induced fluorescence classification with precise definition of each fluorescence quality and their correlation with histological features would be more useful and reproducible in these cases.

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Authors and Affiliations

  1. Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany

    Marcel A. Kamp, Zarela Krause Molle, Christopher Munoz-Bendix, Marion Rapp, Michael Sabel, Hans-Jakob Steiger & Jan F. Cornelius

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  1. Marcel A. Kamp
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  2. Zarela Krause Molle
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  3. Christopher Munoz-Bendix
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  4. Marion Rapp
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  5. Michael Sabel
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  6. Hans-Jakob Steiger
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  7. Jan F. Cornelius
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Correspondence to Marcel A. Kamp or Jan F. Cornelius.

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Conflict of interest statement

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

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The present study was not funded.

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Comments

Kazunori Arita, Kagoshima, Japan

Authors collected 378 studies from the PubMed database and finally analyzed 93 studies reporting qualitative estimation of 5-aminolevulinic acid–fluorescence (5-AIF). The quality of the studies was evaluated according to modified STROBE scale. Through their extensive review, they found the use of dichotomized categorization of 5-ALA-induced fluorescence in more than half of the reported studies. And they recommend a three-level 5-ALA-induced fluorescence classification for precise definition of each fluorescence quality and their correlation with histological features.

In these 93 studies, they analyzed, however, included wide variety in histopathology, malignancy, 5-ALA dose, elapsed time after oral intake, light source, wave length, and filter. We know that all these factors influence the 5-ALA fluorescence intensity and visibility.

Thus, future study should aim to establish a new classification system of fluorescence intensity considering these variances.

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Kamp, M.A., Krause Molle, Z., Munoz-Bendix, C. et al. Various shades of red—a systematic analysis of qualitative estimation of ALA-derived fluorescence in neurosurgery. Neurosurg Rev 41, 3–18 (2018). https://doi.org/10.1007/s10143-016-0745-4

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  • DOI: https://doi.org/10.1007/s10143-016-0745-4

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