Does pattern of 5-aminolevulinic acid (5-ALA) residual intra-operatively predict worse outcome in glioblastoma?

Authors

Vishal Manik, Feras Fayez, Gopikrishna Shyam, Dimitrios Kalaitzoglou, Ayesha Sathali, Yasir Chowdhury, Van Sim, Mark MacDonald, Amoolya Mannava, Christos Soumpasis, Prajwal Ghimire, Asfand Baig Mirza, Kazumi Chia, Sean Main, Keyoumars Ashkan, Ranjeev Bhangoo, Richard Gullan, Lucy Brazil, Omar Al-Salihi, Francesco Vergani, Angela Swampillai, Jose Pedro Lavrador

Published in

Brain & spine. Volume 6. Pages 106166. Epub Jul 15, 2026.

Abstract

5-Aminolevulinic acid (5-ALA) guidance helps to maximize surgical resection in Glioblastoma (GBM). It is unclear if the residual 5-ALA pattern can predict the outcome of GBM patients.
Patients with GBM treated at our center between January 2018 - Jun 2022 were included. The pattern of 5-ALA residual was classified as no residue; focal residue (5-ALA in 1-2 walls); or diffuse residue (all walls involved). Pattern of recurrence - focal, diffuse or distal - was classified upon central radiology review.
Total of 120 patients were screened and 46 were included. The majority of patients presented with temporal lesion (50%) and gross total resection was achieved in 56.52%. No 5-ALA residual was seen in 50% of patients; 39% had focal and 11% had diffuse residual. The pattern of 5-ALA residual - none or focal versus diffuse - was predictive of OS 16.4 versus 9.3 months (p = 0.018) and PFS 10.9 versus 4.5 months (p = 0.007). The univariate analysis showed that extent of resection (HR 0.59, 95% CI 0.39-0.88, p = 0.010), adjuvant chemotherapy (HR 0.39, 95% CI 0.18-0.84, p = 0.016), and higher number of cycles (HR 0.85, 95% CI 0.75-0.97, p = 0.012) were also significantly associated with longer survival.
Diffuse 5-ALA residual is a poor prognostic factor for OS and PFS. The absence of a survival benefit of none over focal 5-ALA residual at the end of resection is important for intraoperative decision making.

PMID:
42502369
Bibliographic data and abstract were imported from PubMed on 26 Jul 2026.

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