Outcomes after Combined Use of Intraoperative MRI and 5-Aminolevulinic Acid in High-Grade Glioma Surgery

Aims: Previous studies have shown the individual benefits of 5-aminolevulinic acid (5-ALA) and intraoperative magnetic resonance imaging (iMRI) in enhancing survival for patients with high-grade glioma. In this retrospective study, we compare rates of progression-free and overall survival between patients who underwent surgical resection with the combination of 5-ALA and iMRI and a control group without iMRI. Methods: In 200 consecutive patients with high-grade gliomas, we recorded age, sex, World Health Organization (WHO) grade of the tumor, and pre- and postoperative Karnofsky performance status (KPS; good ≥80 and poor <80). A 0.15-T magnet was used for iMRI; all patients operated with iMRI received 5-ALA. Overall and progression-free survival rates were compared using multivariable regression analysis. Results: Median overall survival (OS) was 13.8 months in the non-iMRI group and 17.9 months in the iMRI group (p = 0.043). However, on identifying confounding variables (i.e., KPS and resection status) in this univariate analysis, we adjusted for these cofounders in multivariate analysis and eliminated this distinction in overall survival (HR 1.23, p = 0.34, 95% CI 0.81–1.86). Although 5-ALA enhanced the achievement of gross total resection (OR 3.19, p = 0.01) (95% CI 1.28–7.93), it offered no effect on overall or progression-free survival when adjusted for resection status. Conclusions: Gross total resection is the key surgical variable that influences progression and survival in patients with high-grade glioma and more likely when surgical adjuncts, such as iMRI in combination with 5-ALA, are used to enhance resection.