Correlation of Fluorescence Intensity with the Relative Proportion of Malignant Cells in the Tissue in 5-ALA-guided Resection of Glioblastoma

Authors: T. Krčík 1,2;  P. Buzrla 2,3;  K. Křivánková 4;  R. Lipina 1,2;  M. Smrčka 5
Authors‘ workplace: Neurochirurgická klinika LF OU a FN Ostrava 1;  LF OU v Ostravě 2;  Ústav patologie, FN Ostrava 3;  Radiodiagnostický ústav, FN Ostrava 4;  Neurochirurgická klinika LF MU a FN Brno 5
Published in: Cesk Slov Neurol N 2016; 79/112(3): 300-306
Category: Original Paper


To ascertain correlation between histological findings and the intensity of intraoperative fluorescence. During 5-aminolevulinic acid fluorescence-guided glioblastoma resection, three different levels of fluorescence intensity of the examined tissue can be distinguished in the operative field: 1. red, highly intensive fluorescence zone; 2. pink, moderately intensive fluorescence zone; 3. none, tissue without fluorescence.

Groups and methods:
A prospective study of 13 patients who underwent fluorescence-guided glioblastoma surgery. Representative specimens of the corresponding levels of fluorescence intensity were collected for histological examination. The semi-quantitative method was used to evaluation relative proportion of malignant cells in the tissue.

The histological examination from the highly intensive fluorescence zone biopsy samples revealed 75–100% proportion of malignant cells in the tissue. The infiltration reached 50–75% of the examined tissue in the moderately intensive fluorescence zone, and co-existence of glioblastoma and low grade glioma was noted in two cases. In six cases, there were no malignant cells in the negative fluorescence zone. However, seven specimens were positive for malignant cells, with the infiltration rate around 25% of the tissue. The correlation between the fluorescence intensity and the relative proportion of malignant cells in the tissue was statistically significant (p value < 0.001), and high positive predictive value of the fluorescence for the presence of malignant cells (PPV = 92%) was observed.

The intensity of intraoperative fluorescence correlates with the relative proportion of malignant cells in the tissue. The presence of malignant cells beyond observable fluorescence was confirmed in more than a half of the biopsy samples.

Key words:
glioblastoma – 5-aminolevulinic acid – fluorescence-guided resection – fluorescence intensity – histopathology

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.


1. McGirt MJ, Chaichana KL, Gathinji M, et al. Independent as­sociation of extent of resection with survival in patients with malignant brain astrocytoma. J Neurosurg 2009;110(1):156–62. doi: 10.3171/2008.4.17536.

2. Sanai N, Pol­ley MY, McDermott MW, et al. An extent of resection threshold for newly dia­gnosed glioblastomas. J Neurosurg 2011;115(1):3–8. doi: 10.3171/2011.2.JNS10998.

3. Vecht CJ, Avezaat CJ, van Putten WL, et al. The influence of the extent of surgery on the neurological function and survival in malignant glioma. A retrospective analysis in 243 patients. J Neurol Neurosurg Psychiatry 1990;53(6):466–71.

4. Lacroix M, Abi-Said D, Fourney DR, et al. A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 2001;95(2):190–8.

5. Stum­mer W, Stocker S, Wagner S, et al. Intraoperative detection of malignant gliomas by 5-aminolevulinic acid-induced porphyrin fluorescence. Neurosurgery 1998;42(3):518–25.

6. Stum­mer W, Stocker S, Novotny A, et al. In vitro and in vivo porphyrin accumulation by C6 glioma cel­ls after exposure to 5-aminolevulinic acid. J Photochem Photobio­l B 1998;45(2–3):160–9.

7. Krčík T, Lipina R, Paleček T, et al. Fluorescencí navigovaná resekce vysokostupňových gliomů mozku. Cesk Slov Neurol N 2014;77/110(3):308–13.

8. Stum­mer W, Pichlmeier U, Meinel T, et al. Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomized control­led multicentre phase III trial. Lancet Oncol 2006;7(5):392–401.

9. Col­laud S, Juzeniene A, Moan J, et al. On the selectivity of 5-aminolevulinic acid-induced protoporphyrin IX formation. Curr Med Chem Anticancer Agents 2004;4(3):301–16.

10. Kitai R, Takeuchi H, Miyoshi N, et al. Determin­ing the tumor-cell density required for macroscopic observation of 5-ALA-induced fluorescence of protoporphyrin IX in cultured glioma cel­ls and clinical cases. No Shinkei Geka 2014;42(6):531–6.

11. Roberts DW, Valdés PA, Har­ris BT, et al. Coregistered fluorescence-enhanced tumor resection of malignant glioma: relationships between δ-aminolevulinic acid-induced protoporphyrin IX fluorescence, magnetic resonance imag­ing enhancement, and neuropathological parameters. J Neurosurg 2011;114(3):595–603. doi: 10.3171/2010.2.JNS091322.

12. Stum­mer W, Tonn JC, Goetz C, et al. 5-Aminolevulinic acid-derived tumor fluorescence: the dia­g­nostic accuracy of visible fluorescence qualities as cor­roborated by spectrometry and histology and postoperative imaging. Neurosurgery 2014;74(3):310–9. doi: 10.1227/NEU.0000000000000267.

13. Lee J, Kotliarova S, Kotliarov Y, et al. Tumor stem cel­lsderived from glioblastomas cultured in bFGF and EGF more closely mir­ror the phenotype and genotype of primary tumors than do serum-cultured cell lines. Cancer Cell 2006;9(5):391–403.

14. Picciril­lo SG, Dietz S, Madhu B, et al. Fluorescence-guided surgical sampl­ing of glioblastoma identifies phenotypical­ly distinct tumour-initiat­ing cell populations in the tumour mass and margin. Br J Cancer 2012;107(3):462–8. doi: 10.1038/bjc.2012.271.

15. Nowell PC. The clonal evolution of tumor cell populations. Science 1976;194(4260):23–8.

16. van der Valk P, Lindeman J, Kamphorst W. Growth factor profiles of human gliomas. Do non-tumour cellscontribute to tumour growth in glioma? Ann Oncol 1997;8(10):1023–9.

17. Schittenhelm J, Mittelbronn M, Nguyen TD, et al. WT1 expres­sion distinguishes astrocytic tumor cel­lsfrom normal and reactive astrocytes. Brain Pathol 2008;18(3):344– 53. doi: 10.1111/j.1750-3639.2008.00127.x.

18. Per­ry A, Brat DJ. Practical surgical neuropathology: a dia­gnostic approach. Churchill Livingstone, Edinburg, UK 2010:63–100.

19. Rivera-Zengotita M, Yachnis AT. Gliosis versus glioma?: don‘t grade until you know. Adv Anat Pathol 2012;19(4):239– 49. doi: 10.1097/PAP.0b013e31825c6a04.

20. Šteňo A, Il­léš R, Rychlý B, et al. Detection of anaplastic foci within infiltrative gliomas with nonsignificant contrast enhancement us­ing 5-aminolevulic acid –  a report of five cases. Cesk Slov Neurol N 2012;75/108(2):227– 32.

Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 3

2016 Issue 3

Most read in this issue

This topic is also in:

Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account