title: The role of 5-aminolevulinic acid in enhancing surgery for high-grade glioma, its current boundaries, and future perspectives: A systematic review.
abstract: 5-Aminolevulinic acid (5-ALA) has been approved as an intraoperative adjunct in glioma surgery in Europe, but not North America. A systematic review was conducted to assess the evidence regarding 5-ALA as a surgical adjunct. The MEDLINE, EMBASE, and CENTRAL databases were searched, using terms relevant to "5-ALA" and "high-grade gliomas." Included studies were based on adults aged ≥18 years who underwent surgical resection/biopsy. No language or date limitations were used. Forty-three studies (1830 patients) were identified. Thirty-six were coordinated by European countries, 2 were in the United States, and none were in Canada. One was randomized, 28 were prospective, and 14 were retrospective. Twenty-six studies assessed the utility of 5-ALA as a diagnostic tool, 24 assessed its influence on the extent of resection (EOR), 9 assessed survival, and 22 reported adverse events. 5-ALA had high sensitivity and positive predictive value, whereas its specificity increased with additional adjuncts. The EOR increased with 5-ALA, but only progression-free survival was significantly influenced. Reporting of adverse events was not systematic. The use of 5-ALA improved tumor visualization and thus enabled a greater EOR and perhaps increased survival. However, additional adjuncts may be necessary for maximizing the specificity of resection and patient safety. Additional parameters, such as patient quality of life and health economic analyses, would be informative. Thus, additional systematic collection of prospective evidence may be necessary for the global incorporation of this potentially valuable surgical adjunct into routine practice. Cancer 2016;122:2469-78. © 2016 American Cancer Society.
authors.affiliation: Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.|Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.|Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Alireza
authors.initials: A
authors.lastname: Mansouri
authors.affiliation: MacFeeters Adult Brain Tumor Research Program, Toronto, Ontario, Canada.
authors.forename: Sheila
authors.initials: S
authors.lastname: Mansouri
authors.affiliation: Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Laureen D
authors.initials: LD
authors.lastname: Hachem
authors.affiliation: Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.|Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: George
authors.initials: G
authors.lastname: Klironomos
authors.affiliation: Department of Neurological Surgery, Center for Translational Therapeutics, Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Vogelbaum
authors.affiliation: Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.|Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Mark
authors.initials: M
authors.lastname: Bernstein
authors.affiliation: Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.|Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.|MacFeeters Adult Brain Tumor Research Program, Toronto, Ontario, Canada.
authors.forename: Gelareh
authors.initials: G
authors.lastname: Zadeh
mesh_terms: D000622:Aminolevulinic Acid; D001932:Brain Neoplasms / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery*; D005910:Glioma / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007430:Intraoperative Care; D008279:Magnetic Resonance Imaging; D060787:Neoplasm Grading; D009364:Neoplasm Recurrence, Local; D011182:Postoperative Care; D015203:Reproducibility of Results; D025321:Surgery, Computer-Assisted; D016896:Treatment Outcome
chemical_list: D000622:Aminolevulinic Acid
keywords: 5-aminolevulinic acid (5-ALA); adverse events; high-grade glioma; surgery; survival; systematic review