Surgical efficacy and survival outcomes of fluorescein sodium-guided surgery in glioblastoma: a single-center experience

Introduction: Fluorescence-guided (FG) surgery enhances the extent of resection (EOR) in glioblastoma. While 5-aminolevulinic acid (5-ALA) is the current standard, fluorescein sodium (FS) has emerged as a promising, accessible alternative. This study evaluates the impact of FS-guided resection on surgical outcomes and survival compared to conventional white-light (WL) resection. Research question: Does FS-guided surgery improve EOR, overall survival (OS), and progression-free survival (PFS) compared to WL-guided glioblastoma surgery? Material and methods: In this retrospective single-center analysis, data from patients with newly diagnosed glioblastoma who underwent primary resection with gross total resection (GTR) intent between 2013 and 2023 were evaluated. Based on intraoperative technique, patients were allocated to either FS-guided or WL-guided surgery groups. Logistic and linear regression assessed FS impact on GTR and residual tumor volume. Multivariate Cox regression and Kaplan-Meier analysis were used to assess OS and PFS. Results: Among 128 patients, 85 (66 %) underwent FS-guided surgery. GTR was achieved in 69 % of FS cases versus 36 % with WL (p = 0.0004; OR = 1.379). FS significantly reduced residual tumor volume (1.82 ml vs. 8.83 ml; p = 0.0003). MGMT methylation, GTR, and Stupp-protocol therapy were identified as independent predictors of improved OS and PFS. FS use itself showed no significant association with survival outcomes. Discussion and conclusion: FS-guided surgery significantly improved EOR and reduced residual tumor volume without impacting OS or PFS. It represents a safe, effective alternative to standard WL resection. Prospective studies should explore combining fluorophores for optimal resection strategies.