Background: Malignant glioma represents a relevant therapeutic issue and the value of extensive surgical resection remains debated; recent evidence suggests that radical removal is associated with better survival. An interesting tool for identifying tumor tissue and increasing the extent of surgery is represented by fluorescence-guided resection, taking advantage of metabolic and structural changes induced by a natural precursor of heme biosynthetic pathway, 5-amino-levulinic acid (ALA). Methods: The present experience is related to 32 patients affected by malignant glioma (18 newly diagnosed: 16 glioblastoma (GBM), 2 anaplastic oligodendroglioma; and 14 recurrent GBM) eligible for fluorescence-guided resection, operated on in our Institute since fall of 2009. All patients underwent preoperative and early postoperative MRI, showing contrast enhancing lesions. An oral dose of 20 mg 5-ALA /kg bw was administered to each patient. Microsurgical resection was performed by an operating microscope enabled to visualize the fluorescence. All the patients, as first line treatment, have been submitted to radiotherapy and chemotherapy; second and in some cases third line treatments were utilized in recurrent cases. The patients follow-up ranged from 2 years to 6 months. Results: In more than 90% of patients tumor tissue showed intraoperative red fluorescence; mainly in recurrent GBM, when MRI documented heterogeneous lesions with enhancing areas mixed with non enhancing gliotic scars, fluorescence-guided surgery allowed a better definition of active tumor, with net margins from perilesional “healthy” brain. Early postoperative MRI confirmed gross total resection without contrast enhancement in 80 % of patients. In the present experience the procedure did not determine any relevant additional neurological deficit. Considering overall survival of recurrent patients we obtained a median extension of at least 9.0 months (3 – 16+ months). Conclusions: Fluorescence-guided surgery improves tumor detection and allows extended resection of malignant glioma, without any relevant impact on neurological status, resulting helpful mainly in the recurrent setting with a consistent effect on overall survival.