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Is it a glioblastoma? In dubio pro 5-ALA!

  • Clinical Article
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Summary

Background

Differential diagnosis of unclear contrast-enhancing cerebral lesions includes cerebral metastases as well as malignant glioma. In the majority of cases, a definite preoperative diagnosis by neuroradiological assessment alone cannot be made. Since the introduction of 5-ALA-induced fluorescence-guided resection in the treatment of glioblastoma (GBM), the preoperative putative diagnosis of metastasis vs. GBM triggers a specific preoperative preparation of the patients. We analyzed the patient population with known cancer outside the central nervous system who underwent surgery for an assumed cerebral metastasis and for whom the intraoperative diagnosis was corrected to a malignant glioma.

Methods

Retrospective analysis of patients with a known primary cancer who were operated on for an assumed cerebral metastasis, which turned out to be a GBM. The patients were treated at our center between January 2008 and June 2011.

Results

We identified ten patients who underwent surgery for an assumed cerebral metastasis and for whom the diagnosis was corrected intraoperatively to a malignant glioma by frozen section. The median age was 68 years (41–82 years). The female-to-male ratio was 2:8. In all patients, the final histopathological analysis of the intracerbral tumors revealed a glioblastoma, while the patients suffered from diverse primary carcinomas.

Conclusion

A malignant glioma should always be considered as a differential diagnosis of an unclear contrast-enhancing cerebral lesion even for patients with a known malignancy. Furthermore, we make the case for a more liberal indication for 5-ALA.

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Conflicts of interest

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Authors and Affiliations

  1. Department for Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany

    Marcel A. Kamp, Antonio Santacroce, Samis Zella, Hans-Jakob Steiger, Jan Frederick Cornelius & Michael Sabel

  2. Department for diagnostic and interventional Radiology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany

    Dorothea C. Reichelt

  3. Department for Neuropathology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany

    Jörg Felsberg

Authors
  1. Marcel A. Kamp
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  2. Antonio Santacroce
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  3. Samis Zella
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  4. Dorothea C. Reichelt
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  5. Jörg Felsberg
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  6. Hans-Jakob Steiger
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  7. Jan Frederick Cornelius
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  8. Michael Sabel
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Corresponding author

Correspondence to Marcel A. Kamp.

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Comments

The 5-ALA method in microsurgical neuro-oncology—brought from the laboratory to the Zeiss operation microscope by Prof. Walter Stummer and his colleagues—is an important piece of European neurosurgically applied research and technical development. This raises the question of personal lifetime accomplishments that may pester aging technology-minded neurosurgeons.

Acta Neurochirurgica has reported on the growing clinical experience with the 5-ALA method, e.g., in malignant gliomas (1,2), intracerebral metastases and their unnoticed pink remnants in the operative cavity wall (3), stereotactic biopsy samples that become pink under blue light, which saves OR time from waiting for the frozen section diagnosis (4), and intracranial meningiomas, which raises the question which other benign tumors could become pink (5). There is also the important and open question of which non-neoplastic lesions will become pink—such as tumor-like MS lesions that open the blood-brain barrier and involve inflammatory reactions and infiltrating leukocytes (6).

In the present communication, the authors report brain lesions that looked like metastases in ten patients with previous cancer diagnoses that were GBMs instead and that the 5-ALA method should be used more liberally. Indeed, we use 5-ALA for any lesion that looks malignant or inflammatory with contrast uptake and requires histological verification.

Juha E. Jääskeläinen

Kuopio, Finland

1. Stummer W, Stepp H, Möller G, Ehrhardt A, Leonhard M, Reulen HJ (1998) Technical principles for protoporphyrin-IX-fluorescence guided microsurgical resection of malignant glioma tissue. Acta Neurochir (Wien) 140:995–1000.

2. Stummer W, Reulen HJ, Novotny A, Stepp H, Tonn JC (2003) Fluorescence-guided resections of malignant gliomas--an overview. Acta Neurochir Suppl 88:9–12.

3. Kamp MA, Grosser P, Felsberg J, Slotty PJ, Steiger HJ, Reifenberger G, Sabel M (2012) 5-Aminolevulinic acid (5-ALA)-induced fluorescence in intracerebral metastases: a retrospective study. Acta Neurochir (Wien) 154:223–8; discussion 228.

4. von Campe G, Moschopulos M, Hefti M (2012) 5-Aminolevulinic acid-induced protoporphyrin IX fluorescence as immediate intraoperative indicator to improve the safety of malignant or high-grade brain tumor diagnosis in frameless stereotactic biopsies. Acta Neurochir (Wien) [Epub ahead of print]

5. Coluccia D, Fandino J, Fujioka M, Cordovi S, Muroi C, Landolt H (2010) Intraoperative 5-aminolevulinic-acid-induced fluorescence in meningiomas. Acta Neurochir (Wien) 152:1711–9.

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Kamp, M.A., Santacroce, A., Zella, S. et al. Is it a glioblastoma? In dubio pro 5-ALA!. Acta Neurochir 154, 1269–1273 (2012). https://doi.org/10.1007/s00701-012-1369-2

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  • DOI: https://doi.org/10.1007/s00701-012-1369-2

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