5ALA in pediatric brain tumors is not routinely beneficial

Over recent years, 5-aminoluvolinic acid (5ALA) has been increasingly used for resection guidance in adult high-grade gliomas. However, amongst pediatric patients, publication of intraoperative fluorescence has been limited, with inconsistent outcomes. We describe our experience and intraoperative finding amongst children with various brain tumors that were given 5ALA prior to tumor resection.

Since October 2014, data regarding intraoperative findings amongst children that received 5ALA prior to tumor resection were prospectively collected. Inclusion criteria included any intracranial tumor amongst children 3-18 years of age. Data included intraoperative findings (regarding fluorescence of the tumor), as well as postoperative follow-up and documentation of complications.

Fourteen children were included, covering a wide pathological spectrum: pilocytic astrocytoma (PA) (6), medulloblastoma (2), and one each of DNET, hemangiopericytoma, hemangioblastoma, ganglioneuroblastoma, oligodendroglioma grade II (OD), and ganglioglioma grade I. Fluorescence was clearly visible in one case (PA), and in a heterogeneous and slighter degree in two (PA, OD). One patient had a rash, fever, and leukocytosis 6 days after surgery and died 1 month later from extensive tumor progression (large cell medulloblastoma with leptomeningeal spread).

5ALA showed a low rate of fluorescence amongst this pediatric brain tumor cohort. These findings are consistent with the literature, where the role of 5ALA in guidance of pediatric brain tumor resection is limited mainly to glioblastoma multiforme. This stems not only from the low rate of significant fluorescence, but also from inherent structural properties of these lesions such as color, consistency, and invasion.