Sodium Fluorescein-guided Resection of Brain Metastases: A Systematic Review And single-arm Meta-analysis

Introduction: Brain metastases (BM) affect a significant percentage of cancer patients and represent a major treatment challenge. Increased resection rates improve overall survival (OS) and reduce recurrence. Recent studies explored sodium fluorescein-guided (SFg) surgery as a promising tool for achieving these outcomes. This study aims to evaluate the existing evidence on the effectiveness of SFg in enhancing the resection rate of brain metastases.

Methods: We conducted a systematic review, following Cochrane and PRISMA guidelines, using Medline, Embase, and Web of Science databases. Studies reporting SFg in BM were included for a single-arm analysis of the outcome of Complete Resection (CR). CR was defined as (1) all patients included in the “no residual group” of the RANO-BM criteria and (2) all patients included in the “GTR group” on the contrast-enhanced T1-weighted MRI analysis. We pooled proportions with 95% confidence intervals under random effects and applied I² statistics and leave-one-out sensitivity analysis to assess heterogeneity. I² > 40% was considered significant for heterogeneity.

Results: Of 1436 articles, 9 studies involving 546 patients were included for analysis, with 178 singular and 147 multiple brain lesions. The patient population had an average age of 59 years, and 50,5% (n= 384) were male. CR was achieved in 84% of the patients (Proportion (P)=84; 95% CI 81-87; I²=18%). For the sensitivity analysis of the complete resection endpoint, the leave-one-out plot indicated that the I² value only reached 0% when the study by Kofoed et al. (2021) was removed, increasing the proportion to 86% (P=86; 95% CI 0.81-0.87; I²=0%).

Conclusion : This analysis demonstrates that SFg surgery results in a high CR rate of 84% in patients with BM. Furthermore, while these findings support the effectiveness of SFg surgery in improving resection outcomes for brain metastases, more studies are needed to further validate these results and refine the surgical approach.