Fluorescence-Guided Surgery for Gliomas: Past, Present, and Future

Background/Objectives: Glioblastoma (GBM) is the most common primary malignant central nervous system tumor, accounting for 50.9% of malignant CNS diagnoses and carrying a median survival of 15 months despite maximal standard therapy. High recurrence rates are driven by residual infiltrative tumor cells at the resection margin. Fluorescence-guided surgery (FGS) has emerged as a key innovation to improve intraoperative tumor visualization and maximize the extent of resection (EOR). This review examines the historical development, current clinical applications, and future directions of FGS in GBM surgery. Methods: A comprehensive literature review was conducted, covering the evolution of fluorophores (fluorescein, indocyanine green [ICG], and 5-aminolevulinic acid [5-ALA]), visualization technologies (wide- and narrow-field modalities), therapeutic adjuncts (photodynamic and sonodynamic therapies), and clinical adoption patterns and outcomes. Results: Early intraoperative fluorescence using fluorescein dates to 1947. ICG angiography has broad surgical utility, while 5-ALA received FDA approval in 2017, with phase III trials demonstrating gross total resection rates of 65% versus 36% with white-light surgery. Adjunct technologies-3D exoscopes, FGS-compatible loupes, and quantitative spectroscopy probes-enhance detection of residual tumor. Preliminary studies of intraoperative photodynamic and sonodynamic therapies show feasibility and potential survival benefits. Global adoption of 5-ALA FGS exceeds 75% among surveyed neurosurgeons. Conclusions: FGS significantly improves EOR in GBM surgery, translating into better patient outcomes. Ongoing clinical trials and technological refinements-novel fluorophores, quantitative imaging, and therapeutic applications-promise to further optimize tumor visualization and treatment.