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Article Open Access

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

  • Authors:
    • Evangelos Kogias
    • George Fotakopoulos
    • Vasiliki Epameinondas Georgakopoulou
    • Iraklis Kagkouras
    • Demetrios A. Spandidos
    • Nikolaos Trakas
    • Nikolaos Foroglou
  • View Affiliations / Copyright

    Affiliations: Department of Neurosurgery, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece, Department of Pathophysiology, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece, Department of Surgery, Worcestershire Acute Hospital, WR51DD, Worcester, United Kingdom, Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece, Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
    Copyright: © Kogias et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
  • Article Number: 18
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    Published online on: February 3, 2026
       https://doi.org/10.3892/mco.2026.2927
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Abstract

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.
View Figures

Figure 1

Flowchart of the study selection
process.

Figure 2

(A) Forest plot for postoperative
neurological deficit, with the results demonstrated a statistically
significant difference between groups [OR: 0.88, 95% CI:
(0.17,4.57), P<0.00001], but with heterogeneity (P=0.88,
I2=90%). (B) Funnel plots for Postoperative Neurological
deficit in the two groups with heterogeneity (P=0.88,
I2=90%). I2, percentage of total variation
across studies that is due to heterogeneity rather than chance; CI,
confidence interval; OR, odds ratio.

Figure 3

(A) Forest plot for Postoperative KPS
≥70, with the results demonstrated a statistically significant
difference between groups [OR=49.46; 95% CI: (-2.21, 101.13);
P<0.00001] but with heterogeneity (P=0.06 and
I2=100%). (B) Funnel plots for Postoperative KPS≥70 in
the two groups with high heterogeneity (P=0.06 and
I2=100%). I2, percentage of total variation
across studies that is due to heterogeneity rather than chance; CI,
confidence interval; KPS, Karnofsky Performance Scale.

Figure 4

(A) Forest plot for OS, with the
results demonstrated a statistically significant difference between
groups [OR=4.05; 95% CI: (1.33, 6.77); P<0.00001] but a high
heterogeneity was found (P<0.05 and I2=98%). (B)
Funnel plots for OS in the two groups with high heterogeneity
(P<0.05 and I2=98%). I2, percentage of
total variation across studies that is due to heterogeneity rather
than chance; CI, confidence interval; OS, overall survival.
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Spandidos Publications style
Kogias E, Fotakopoulos G, Georgakopoulou VE, Kagkouras I, Spandidos DA, Trakas N and Foroglou N: 5‑ALA vs. fluorescein guided resection for high‑grade gliomas: A systematic review and meta‑analysis. Mol Clin Oncol 24: 18, 2026.
APA
Kogias, E., Fotakopoulos, G., Georgakopoulou, V.E., Kagkouras, I., Spandidos, D.A., Trakas, N., & Foroglou, N. (2026). 5‑ALA vs. fluorescein guided resection for high‑grade gliomas: A systematic review and meta‑analysis. Molecular and Clinical Oncology, 24, 18. https://doi.org/10.3892/mco.2026.2927
MLA
Kogias, E., Fotakopoulos, G., Georgakopoulou, V. E., Kagkouras, I., Spandidos, D. A., Trakas, N., Foroglou, N."5‑ALA vs. fluorescein guided resection for high‑grade gliomas: A systematic review and meta‑analysis". Molecular and Clinical Oncology 24.3 (2026): 18.
Chicago
Kogias, E., Fotakopoulos, G., Georgakopoulou, V. E., Kagkouras, I., Spandidos, D. A., Trakas, N., Foroglou, N."5‑ALA vs. fluorescein guided resection for high‑grade gliomas: A systematic review and meta‑analysis". Molecular and Clinical Oncology 24, no. 3 (2026): 18. https://doi.org/10.3892/mco.2026.2927
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Spandidos Publications style
Kogias E, Fotakopoulos G, Georgakopoulou VE, Kagkouras I, Spandidos DA, Trakas N and Foroglou N: 5‑ALA vs. fluorescein guided resection for high‑grade gliomas: A systematic review and meta‑analysis. Mol Clin Oncol 24: 18, 2026.
APA
Kogias, E., Fotakopoulos, G., Georgakopoulou, V.E., Kagkouras, I., Spandidos, D.A., Trakas, N., & Foroglou, N. (2026). 5‑ALA vs. fluorescein guided resection for high‑grade gliomas: A systematic review and meta‑analysis. Molecular and Clinical Oncology, 24, 18. https://doi.org/10.3892/mco.2026.2927
MLA
Kogias, E., Fotakopoulos, G., Georgakopoulou, V. E., Kagkouras, I., Spandidos, D. A., Trakas, N., Foroglou, N."5‑ALA vs. fluorescein guided resection for high‑grade gliomas: A systematic review and meta‑analysis". Molecular and Clinical Oncology 24.3 (2026): 18.
Chicago
Kogias, E., Fotakopoulos, G., Georgakopoulou, V. E., Kagkouras, I., Spandidos, D. A., Trakas, N., Foroglou, N."5‑ALA vs. fluorescein guided resection for high‑grade gliomas: A systematic review and meta‑analysis". Molecular and Clinical Oncology 24, no. 3 (2026): 18. https://doi.org/10.3892/mco.2026.2927
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