5‑ALA vs. fluorescein guided resection for high‑grade gliomas: A systematic review and meta‑analysis

High-grade gliomas (HGGs) are characterized by aggressive biological behavior and dismal prognosis. Both 5-aminolevulinic acid (5-ALA) and other fluorescence-guided surgery (FGS) techniques are used to maximize tumor resection while preserving neurological function. The present study synthesizes current evidence and compares these two approaches in the neurosurgical management of HGGs. A systematic literature search was conducted to identify clinical studies evaluating 5-ALA-guided resection and alternative FGS techniques in patients with HGGs. A total of 41 studies were included, comprising 36 in the qualitative review and 5 in the quantitative meta-analysis. Data were extracted regarding study characteristics, patient demographics, tumor type, median progression-free survival, overall survival (OS), pre- and postoperative Karnofsky Performance Status (KPS ≥70 within 30 days), and postoperative neurological deficits (defined as a newly developed decrease in Glasgow Coma Scale score of ≥2 points, hemiparesis, or aphasia). The pooled population consisted of 732 patients, with 503 (68.7%) undergoing 5-ALA-guided resection and 229 (31.3%) treated with FGS. The mean patient age across studies was 57.9 years. The present meta-analysis demonstrated that 5-ALA-guided surgery was associated with improved outcomes in terms of postoperative neurological deficits, maintenance of KPS ≥70, and OS compared with other FGS techniques. However, the presence of publication bias and the heterogeneity of the underlying data limit the strength of these findings and underscores the need for further high-quality comparative trials before definitive conclusions can be drawn regarding the superiority of one method over the other.