Comparative Analysis of Clinical Outcomes in High-Grade Glioma Patients: 5-ALA Fluorescence-Guided Surgery vs. Conventional White-Light Resection

Background High-grade gliomas (HGGs) are aggressive brain tumors with poor prognoses. Maximizing the extent of resection (EOR) is a critical surgical goal. Fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) has been proposed to enhance tumor visualization and resection. MethodsWe retrospectively analyzed 141 patients with histologically confirmed HGGs who underwent either 5-ALA-guided (<i>n</i> = 71) or conventional white-light (<i>n</i> = 70) resection between 2018 and 2023. Propensity score matching and multivariate Cox regression models were used to assess the impact of 5-ALA on surgical outcomes and survival. Results: Gross total resection (GTR) was significantly more common in the 5-ALA group than the conventional white-light group (28.17% vs. 12.86%, <i>p</i> = 0.0245). Kaplan-Meier analysis showed no statistically significant difference in overall survival between groups after matching (log-rank <i>p</i> = 0.6371). However, patients with GTR had significantly improved survival compared to those with subtotal resection (log-rank <i>p</i> = 0.0423). Multivariate Cox regression identified radiotherapy (HR = 0.291, 95% CI: 0.166-0.513, <i>p</i> < 0.001), higher Karnofsky Performance Status (HR = 0.962, 95% CI: 0.942-0.982, <i>p</i> = 0.0003), and GTR (HR = 0.476, 95% CI: 0.272-0.834, <i>p</i> = 0.0091) as independent predictors of improved survival. 5-ALA usage was not an independent predictor (HR = 0.885, 95% CI: 0.554-1.413, <i>p</i> = 0.612). Radiotherapy and chemotherapy were more frequently administered in the conventional white-light group (<i>p</i> = 0.0404 and <i>p</i> = 0.0085, respectively). Conclusions 5-ALA fluorescence-guided surgery significantly increases the rate of gross total resection in high-grade glioma patients but does not independently confer a survival advantage. Survival outcomes are primarily influenced by the extent of resection, adjuvant therapy, and functional status. Integration of 5-ALA within a comprehensive oncological framework may enhance its clinical utility.