# Comparative Analysis of Clinical Outcomes in High-Grade Glioma Patients: 5-ALA Fluorescence-Guided Surgery vs. Conventional White-Light Resection

## TL;DR

This study compares two brain tumor surgery techniques and finds that 5-ALA improves tumor removal but does not boost survival on its own.

## Contribution

The study provides new evidence that 5-ALA increases resection rates but does not independently improve survival in high-grade glioma patients.

## Key findings

- 5-ALA use was associated with a higher rate of gross total resection compared to conventional surgery.
- Survival outcomes were not significantly different between the two surgical techniques.
- Radiotherapy, Karnofsky Performance Status, and extent of resection were key predictors of improved survival.

## Abstract

Brain tumors known as high-grade gliomas are difficult to treat because they grow quickly and are hard to remove completely. A special technique using a compound called 5-ALA helps surgeons better see the tumor during surgery by making cancer cells glow under blue light. This study looked at how patients who had surgery with this glowing technique compared to those who had regular surgery without it. We found that using 5-ALA helped surgeons remove more of the tumor but did not clearly improve survival when other treatments and factors were considered. Our findings suggest that while this technique can help achieve more complete tumor removal, its full benefit may depend on additional treatments like radiotherapy and the overall health of the patient. These results may help guide future research and improve how we use advanced surgical tools in real-world hospital settings.

Background High-grade gliomas (HGGs) are aggressive brain tumors with poor prognoses. Maximizing the extent of resection (EOR) is a critical surgical goal. Fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) has been proposed to enhance tumor visualization and resection. MethodsWe retrospectively analyzed 141 patients with histologically confirmed HGGs who underwent either 5-ALA-guided (n = 71) or conventional white-light (n = 70) resection between 2018 and 2023. Propensity score matching and multivariate Cox regression models were used to assess the impact of 5-ALA on surgical outcomes and survival. Results: Gross total resection (GTR) was significantly more common in the 5-ALA group than the conventional white-light group (28.17% vs. 12.86%, p = 0.0245). Kaplan–Meier analysis showed no statistically significant difference in overall survival between groups after matching (log-rank p = 0.6371). However, patients with GTR had significantly improved survival compared to those with subtotal resection (log-rank p = 0.0423). Multivariate Cox regression identified radiotherapy (HR = 0.291, 95% CI: 0.166–0.513, p < 0.001), higher Karnofsky Performance Status (HR = 0.962, 95% CI: 0.942–0.982, p = 0.0003), and GTR (HR = 0.476, 95% CI: 0.272–0.834, p = 0.0091) as independent predictors of improved survival. 5-ALA usage was not an independent predictor (HR = 0.885, 95% CI: 0.554–1.413, p = 0.612). Radiotherapy and chemotherapy were more frequently administered in the conventional white-light group (p = 0.0404 and p = 0.0085, respectively). Conclusions 5-ALA fluorescence-guided surgery significantly increases the rate of gross total resection in high-grade glioma patients but does not independently confer a survival advantage. Survival outcomes are primarily influenced by the extent of resection, adjuvant therapy, and functional status. Integration of 5-ALA within a comprehensive oncological framework may enhance its clinical utility.