Cordectomy as final treatment option for diffuse intramedullary malignant glioma using 5-ALA fluorescence-guided resection

Background

We present a case of an anaplastic astrocytoma (WHO-grade III, AA III) in a 27-year-old woman treated by spinal cordectomy. The patient was pretreated by surgery, radiation therapy and temozolomide chemotherapy and repeat surgery at recurrence. Later on, she developed paraplegia and a diffuse severe pain syndrome. MRI demonstrated intramedullar invasion from T12 to T9. To assess tumor invasion intraoperatively, we used tumor fluorescence derived from 5-aminolevulinic acid (5-ALA).

Patients course

The spinal cord was amputated caudally to the root entry zones of the T10 sensory roots. Additional cordectomy was performed because of tumor infiltration at the cut end to T9 as identified by intraoperative tumor fluorescence, and as verified histologically. The final transected level was between T8 and T9, and the cut end did not reveal any tumor invasion intraoperatively by tumor fluorescence and postoperatively by MRI and with regard to the pathological result. After surgery, the patient was unchanged concerning spasticity, motor and sensory function, and showed complete relief of pain. She refused additional adjuvant therapy. The patient is free of recurrence 15 months after surgery.

Conclusion

Our observation suggests 5-ALA fluorescence-guided resections to be useful in the context of malignant spinal cord gliomas. Furthermore, our particular case indicates that palliative spinal cordectomy with a wide margin and intraoperative resection using fluorescence guidance may be a final option for patients with recurrent spinal malignant glioma presenting with complete deficit below the lesion.