Fluorescein-guided Surgery in Brain Tumors: A Systematic Review and Meta-analysis
Sadeen Eid1, Yousef Al-Bojoq2, Amer Alomari2, Luciano Mastronardi3, Omar Bushnaq2, Mohamed Al-Khateeb2, Heba Aboeqab2, Neveen Muqbel4, Reem Alwahsh2, Bashar Abualsebaa1, Bara M. Hammadeh5
1Jordan University of Science and Technology, 2Mutah University, 3San Filippo Neri Hospital, 4University of Jordan, 5Al-Balqa’ Applied University
Objective:
Fluorescein sodium (FS) has become increasingly popular in neurosurgery as a low-cost intraoperative fluorophore to improve tumor margin visualization and achieve maximum resection (EOR) in the brain tumor resection. Even with its growing adoption, evidence is still mixed on its efficacy, safety and optimal use.
Background:
The purpose of this systematic review and meta-analysis was to assess the clinical effectiveness, safety, and utility of SF-guided surgery in brain tumors with emphasis on the resection rates, dosage, the time of administration, and the adverse outcomes.
Design/Methods:
Using PRISMA and JBI recommendations, PubMed, Scopus, and Google Scholar have been thoroughly searched. Eighty-eight clinical trials, cohort and case series and reports were analysed. Independent reviewers carried out data extraction and critical appraisal, and meta-analysis was done on EOR outcomes.
Results:
The results of the resection between 22 clinical trials and cohort studies (2509 SF patients and 2642 controls) reported pooled odds ratio of 1.28 (95% CI: 0.88-1.86) with high heterogeneity. Subtotal resections supported SF (OR: 0.39, 95% CI: 0.25-0.63) whereas, controls led in total resections. General usefulness was 97.3%. Increase in SF doses (10-20mg/kg) caused significant differences in total resection rates (88.2% vs.77.1%, χ²=21.11, p<0.001).
Dural incision timing was found to provide better EOR in comparison to timing at anesthesia induction (86.1% vs. 83.8%, p=0.034). In 5,421 patients, the most frequent use of SFs was in the case of glioblastomas and metastases, where 82.3% of all patients who received an intervention had undergone total resection compared with 72.5% who did not. The number of adverse events was low and mostly mild (93.8%).
Conclusions:
Neurosurgery guided by SF improves the visualization and increase the conversion of subtotal to total resection and dose and timing had significant effects. It is safe, can be used in a broad range of tumor types and locations.
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