Intravenous Fluorescein Sodium for Resection of Pleomorphic Xanthoastrocytoma: 2-Dimensional Operative Video.

Pleomorphic xanthoastrocytoma (PXA) are rare neoplasms constituting < 1% of astrocy tic tumors.(1) They are characterized by heterogeneous morphology and molecular alterations, conferring high potential to recur and suffer malignant transformation.(2) Although standardized treatment is not well established, gross total resection (GTR) is associated with increased overall survival (OS) and progression-free survival (PFS), making maximal extent of resection crucial .(3) Recently, fluorescence-guided surgery has become widely used to maximize extent of resection.(4) The only approved drug for fluorescence-guided surgery is 5-aminolevulinic acid (ALA), which accumulates in glioma cells and visualized with red-light filter or ultraviolet-headlight/loupe combination.(5 )Previous studies have not identified PXA as a tumor that readily fluoresces after administration of 5-ALA.(6-8) This has led to the rediscovery of alternatives, such as fluorescein sodium (FS), which optimizes surgical resection with high predictive value for identifying pathological tissue,(9) easier management, and favorable impact on survival outcomes.(10,11) It accumulates in tumor regions where the blood-brain barrier is disrupted. Visualization typically requires a yellow microscope filter.(12 )Unlike 5-ALA, FS is not a metabolic marker, but rather a surrogate for contrast enhancement and thus may be a better surgical adjunct for low grade, enhancing tumors compared with 5-ALA. Because GTR is considered the main goal in PXA treatment,(13,14) several FS studies have shown an increase in GTR rates compared with white-light control groups. In addition, FS was associated with improved OS and PFS over other modalities. This improvement in GTR, OS, and PFS was found not only in PXA but also in other pathologies, including highgrade gliomas.(15-17) In this study, we present an operative video for PXA resection using FS. The patient consented to the surgery.