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Updated: Jul 26, 2025
Image-Guided Resection of Glioblastoma and Intracranial Implantation of Therapeutic Stem Cell-seeded Scaffolds
Published on: July 16, 2018
Intraoperative MRI-Guided Resection Is Not Superior to 5-Aminolevulinic Acid Guidance in Newly Diagnosed
Constantin Roder1, Walter Stummer2, Jan Coburger3
1Department of Neurosurgery, University Hospital Tübingen, Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, Eberhard-Karls-University, Tübingen, Germany.
Purpose:
Prospective data suggested a superiority of intraoperative MRI (iMRI) over 5-aminolevulinic acid (5-ALA) for achieving complete resections of contrast enhancement in glioblastoma surgery. We investigated this hypothesis in a prospective clinical trial and correlated residual disease volumes with clinical outcome in newly diagnosed glioblastoma.
Methods:
This is a prospective controlled multicenter parallel-group trial with two center-specific treatment arms (5-ALA and iMRI) and blinded evaluation. The primary end point was complete resection of contrast enhancement on early postoperative MRI. We assessed resectability and extent of resection by an independent blinded centralized review of preoperative and postoperative MRI with 1-mm slices. Secondary end points included progression-free survival (PFS) and overall survival (OS), patient-reported quality of life, and clinical parameters.
Results:
We recruited 314 patients with newly diagnosed glioblastomas at 11 German centers. A total of 127 patients in the 5-ALA and 150 in the iMRI arm were analyzed in the as-treated analysis. Complete resections, defined as a residual tumor ≤0.175 cm³, were achieved in 90 patients (78%) in the 5-ALA and 115 (81%) in the iMRI arm (P = .79). Incision-suture times (P < .001) were significantly longer in the iMRI arm (316 v 215 [5-ALA] minutes). Median PFS and OS were comparable in both arms. The lack of any residual contrast enhancing tumor (0 cm³) was a significant favorable prognostic factor for PFS (P < .001) and OS (P = .048), especially in methylguanine-DNA-methyltransferase unmethylated tumors (P = .006).
Conclusion:
We could not confirm superiority of iMRI over 5-ALA for achieving complete resections. Neurosurgical interventions in newly diagnosed glioblastoma shall aim for safe complete resections with 0 cm³ contrast-enhancing residual disease, as any other residual tumor volume is a negative predictor for PFS and OS.
Insights
Intraoperative MRI (iMRI) and 5-aminolevulinic acid (5-ALA) showed similar complete resection rates for glioblastoma surgery. Achieving no residual contrast enhancement is crucial for better progression-free and overall survival in glioblastoma patients.
Area of Science:
- Neurosurgery
- Oncology
- Medical Imaging
Background:
- Glioblastoma surgery aims for complete resection of contrast-enhancing tumor.
- Intraoperative MRI (iMRI) and 5-aminolevulinic acid (5-ALA) are techniques used to guide glioblastoma resection.
- Previous data suggested iMRI superiority over 5-ALA for complete tumor removal.
Purpose of the Study:
- To prospectively investigate the superiority of iMRI over 5-ALA in achieving complete glioblastoma resection.
- To correlate residual tumor volume with clinical outcomes (progression-free survival and overall survival).
Main Methods:
- A prospective, controlled, multicenter, parallel-group clinical trial comparing 5-ALA and iMRI arms.
- Blinded evaluation of preoperative and postoperative MRI scans to assess the extent of resection.
- Primary endpoint: complete resection of contrast enhancement on early postoperative MRI.
- Secondary endpoints: progression-free survival (PFS), overall survival (OS), and quality of life.
Main Results:
- Complete resection rates were similar: 78% for 5-ALA and 81% for iMRI (P = .79).
- Incision-suture times were significantly longer in the iMRI arm (316 min vs. 215 min for 5-ALA).
- Median PFS and OS were comparable between the two arms.
- Absence of residual contrast-enhancing tumor (0 cm³) was a significant positive prognostic factor for PFS and OS.
Conclusions:
- iMRI did not demonstrate superiority over 5-ALA for complete glioblastoma resection.
- Complete resection with no residual contrast-enhancing tumor is critical for improved PFS and OS.
- Surgical goal in newly diagnosed glioblastoma should be safe, complete resection aiming for 0 cm³ residual disease.
