Comparing Utility of Intraoperative Magnetic Resonance Imaging and 5-Aminolevulinic Acid in High-Grade Glioma Resection Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: High-grade glioma has a poor prognosis despite advancements in histopathological classifications and treatments. Various intraoperative modalities are used to maximize extent of resection (EoR) and intraoperative detection of residual tumor, including 5-aminolevulinic acid (5-ALA) and intraoperative MRI (iMRI). We conducted a systematic review with meta-analysis investigating the efficacy of iMRI vs 5-ALA in maximizing EoR and improving survival outcomes. METHODS: A systematic review with meta-analysis was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed, Embase, Scopus, and ClinicalTrials.gov databases, identifying randomized clinical trials (RCTs) and prospective studies comparing the use of 5-ALA and iMRI in high-grade glioma resection. The primary end points were EoR and survival outcomes. Quality assessment was conducted using the ROBINS-I risk of bias assessment and Jadad scale. Meta-analysis was performed using gross total resection rates, tumor detection sensitivity, and specificity. RESULTS: Five RCTs and 5 prospective studies were identified. Five RCTs lacked published data, thus only 5 prospective studies were included in the data extraction. Combined 5-ALA with iMRI (100%) was superior to 5-ALA alone (61.7%; P < .002) in maximizing EoR. Gross total resection did not differ significantly between 5-ALA alone (78%) and iMRI alone (81%; P = .79). One study showed that specificity was higher with iMRI alone (0.70) than with 5-ALA alone (0.43; P < .001); however, this was not replicated by 2 other studies (iMRI vs 5-ALA: 0.60 vs 0.80, P < .001; 1.00 vs 1.00, P not significant). Two studies reported sensitivity; only 1 found lower sensitivity with iMRI vs 5-ALA with a significant difference (iMRI vs 5-ALA: 0.66 vs 0.90, P < .001). CONCLUSION: There is no clear evidence to suggest iMRI is superior to 5-ALA in maximizing EoR and improving survival. However, combined use of 5-ALA and iMRI may be more effective compared with either modality alone. Larger RCTs are needed to confirm any differences in efficacy between the 2 modalities.