Tag: extent of resection

Posted on

Prediction of Diffuse High-Grade Glioma Survival Outcomes Using Preoperative Whole-Brain Tractography–Based Resectability Metrics

Neurosurgery 98:836–847, 2026

This study presents novel whole-brain tractography (WBT)–derived resectability metrics—resectability index (RI) and unresectable tumor volume (UTV), plus modified versions mRI and mUTV—calculated from preoperative diffusion imaging to estimate how much of diffuse high-grade gliomas (HGG) can be safely resected. Metrics are derived by quantifying tumor overlap with critical white-matter tracts and deep structures, and compared with conventional postoperative measures.

Using retrospective data from 146 tumors (84 with WBT), mRI and mUTV strongly predicted biopsy versus resection and correlated with extent of resection, residual tumor, and overall survival. Accelerated failure time models incorporating mUTV/mRI provided accurate preoperative survival predictions, outperforming conventional metrics in postoperative models.

Problem: Extent of resection (EOR) predicts survival in diffuse high-grade glioma but is only measurable postoperatively, limiting preoperative decision-making.

Approach: Preoperative whole-brain tractography (WBT) was used to quantify tumor overlap with eloquent tracts and deep structures to estimate resectability before surgery.

Metrics: Unresectable tumor volume (UTV) = tumor overlap with eloquent tracts + deep structures; Resectability index (RI) = (preop tumor volume − UTV) / preop tumor volume.

Modified metrics: mUTV/mRI focused only on corticospinal tract and left arcuate fasciculus, and performed better than unmodified metrics in several analyses.

Surgical decision prediction: mRI (AUROC 0.953) and mUTV (AUROC 0.854) accurately predicted biopsy vs resection, with optimal cutoffs mRI 0.75 and mUTV 2.5 cm³.

Survival separation: Tumors with mRI > 0.65 vs ≤ 0.65 showed the largest median overall survival difference (not reached vs 82 days, P < .0001).

Best preop survival model: A log-logistic accelerated failure time (AFT) model using only preoperative covariates achieved validated C-index 0.788, with mUTV an independent predictor of overall survival (P = .008).

Overall conclusion: Preoperative WBT-based resectability metrics approximate postoperative EOR/residual tumor volume and can strongly predict survival outcomes after biopsy or resection.

Posted on

Integrated insular phenotype (IIP) versus Berger–Sanai and Yasargil classifications: comparative prognostic value in surgery of insular gliomas

Acta Neurochirurgica (2025) 167:324

This study compares the Integrated Insular Phenotype (IIP), a three-level ordinal topographic classification of insular gliomas, with Berger–Sanai and Yasargil systems to evaluate prognostic performance for extent of resection, seizure control, and persistent neurological deficit at 90 days. Using retrospective analysis of 167 surgically treated patients, logistic regression and model metrics (AUC, AIC, LR χ2) assessed associations between classification complexity and outcomes.

Results show increasing IIP complexity strongly predicted lower resectability, poorer seizure control, and higher persistent deficit risk; IIP produced more stable odds ratios, lower AIC, and higher LR χ2 than traditional systems. The authors propose IIP as a practical risk-stratification tool to balance oncological radicality and functional safety, recommending multicenter prospective validation and integration with molecular and intraoperative technologies.

Integrated Insular Phenotype (IIP): An ordinal classification system for insular gliomas that incorporates tumor topographic complexity and multizonal involvement, outperforming traditional Berger–Sanai and Yasargil systems in prognostic accuracy for surgical outcomes.

Prognostic Value: IIP demonstrates superior and more stable associations with key surgical outcomes—extent of resection, seizure control, and persistent neurological deficit at 90 days—compared to Berger–Sanai and Yasargil classifications, as shown by higher informativeness, lower AIC, and more reproducible odds ratios.

Surgical Complexity: Higher IIP complexity (IIP-M) is linked to reduced likelihood of total/subtotal resection, poorer seizure control, and increased risk of persistent neurological deficits, while simpler phenotypes (IIP-L) are associated with more favorable outcomes.

Traditional Classifications: Berger–Sanai and Yasargil systems provide limited prognostic value; Berger–Sanai yields high but unstable odds ratios with wide confidence intervals, while Yasargil offers consistent but less discriminative results.

Clinical Implications: IIP can guide individualized surgical strategies by balancing oncological radicality against functional safety, supporting the principle of maximal safe resection and informing risk stratification.

Seizure Outcomes: Multizonal and widespread IIP phenotypes (IIP-M) are associated with poorer postoperative seizure control, reflecting the challenge of eliminating diffuse epileptogenic networks.

Study Limitations: The findings are based on a single-center retrospective cohort; external validation and integration with molecular, histopathological, and neurocognitive factors are needed for broader applicability.

Future Directions: Prospective multicenter validation, integration with intraoperative technologies, and use of AI/ML for risk stratification and personalized planning are recommended to enhance the utility of IIP in clinical practice

Posted on

Is FLAIRectomy Directly Correlated with Prolonged Survival in Glioblastoma? A Prospective National Multicenter Study on Correlation Between Extent of Tumor Resection and Clinical Outcome

Neurosurgery 97:489–500, 2025

This multicenter prospective study shows that the extent of FLAIRectomy (resection of FLAIR-positive areas) in glioblastoma is a stronger predictor of survival than traditional resection, with higher EOFR significantly improving progression-free and overall survival, especially in IDH-mutant tumors, without increasing neurological complications.

• FLAIRectomy, or resection of FLAIR-MRI hyperintense regions beyond the contrast-enhancing tumor, was studied in a prospective multicenter cohort of 150 glioblastoma patients.

• A higher extent of FLAIR resection (EOFR) was associated with significantly improved overall survival (OS) and progression-free survival (PFS), more so than resection of contrast-enhancing tumor alone.

• Each 1% increase in EOFR correlated with a 6.8% reduction in mortality risk for IDH-wildtype and 12.1% for IDH-mutant tumors.

• Mean OS was 28.4 months and mean PFS was 16.3 months in the study cohort.

• IDH1 mutation status was also associated with longer survival, but EOFR remained an independent predictor after adjustment.

• AI analysis confirmed that patients with higher EOFR clustered with longer survival.

• Neurological safety was addressed with intraoperative neuromonitoring and careful planning; permanent deficits occurred in 9/150 patients.

• The study concludes that FLAIR-based supramarginal resection may be a more reliable predictor of survival in glioblastoma than conventional imaging-guided resection.

Posted on

Prognostic value of manual versus automatic methods for assessing extents of resection and residual tumor volume in glioblastoma

J Neurosurg 142:1298–1306, 2025

This study compares manual and automatic methods for assessing tumor resection extent and residual volume in glioblastoma patients. It finds that both methods have comparable prognostic value, suggesting that automatic segmentation with Raidionics is a viable alternative for future studies.

• Objective: The study compares the prognostic value of manual versus automatic methods for assessing the extent of resection (EOR) and residual tumor (RT) volume in glioblastoma patients.

• Methods: Patients from 12 hospitals in Europe and North America underwent glioblastoma resection and were included in the study. Data were collected from local tumor registries and patient medical records.

• Results: Both manual and automatic RT volumes were negative prognostic factors for overall survival. Automatic segmentation with Raidionics showed comparable prognostic properties to manual measurements.

• Automatic Segmentation: Raidionics, an open-access software, performed automatic segmentation using pretrained deep learning models, which showed high quality and robustness.

• Survival Analysis: Cox regression models indicated that patients with gross-total resection had significantly longer overall survival compared to those with subtotal resection.

• Advantages of Automatic Methods: Automatic segmentation offers fast, quantitative image assessments and reduces interobserver variability, making it suitable for clinical trials.

• Limitations: Some cases showed a mismatch between manual and automatic segmentation, often due to poor-quality MR images or heterogeneous tumors.

• Conclusion: Automatic segmentation is a viable alternative to manual methods for evaluating tumor remnants, with similar prognostic value for survival in glioblastoma patients.

Posted on

Effect of pituitary stalk preservation during craniopharyngioma removal on pituitary function, extent of resection, and recurrence: systematic review and meta-analysis

J Neurosurg 142:741–755, 2025

The meta-analysis evaluates the impact of pituitary stalk preservation during craniopharyngioma surgery on pituitary function, resection extent, and recurrence. Preservation reduces diabetes insipidus risk but may increase incomplete resection risk in pediatric patients. Results are cautious due to small study sizes and reporting biases.

• Pituitary stalk preservation reduces risk of postoperative diabetes insipidus (DI) and anterior pituitary dysfunction.

• Preservation shows no significant impact on tumor recurrence or extent of resection.

• Pediatric patients face higher risk of incomplete resection with stalk preservation.

• Meta-analysis included 33 studies with 2366 patients.

• Significant heterogeneity observed in DI and recurrence risk across studies.

• Stalk preservation benefits posterior pituitary function long-term, not anterior.

• High risk of bias in individual studies; findings should be interpreted cautiously.

• Subgroup analysis highlights higher recurrence risk in pediatric stalk preservation.

• Egger’s test indicates publication bias in DI analysis.

• Previous meta-analysis by Li et al. lacked age stratification and EEA cases.

• Authors recommend careful consideration of stalk preservation in pediatric cases.

• Lack of age-stratified data limits analysis and may increase bias.

• Study methods followed PRISMA guidelines, with data extracted from eligible studies

Posted on

Evaluation of the extent of resection of intracranial tumors with virtual intraoperative MRI

J Neurosurg 141:695–701, 2024

Intraoperative MRI (iMRI) is the gold-standard technique for intraoperative evaluation of the extent of resection in brain tumor surgery. Unfortunately, it is currently available at only a few neurosurgical centers. A commercially available software, Virtual iMRI Cranial, provides an elastic fusion between preoperative MRI and intraoperative CT (iCT). The aim of this study was to evaluate the accuracy of this software in determining the presence of residual tumor.

METHODS Virtual iMRI was performed in patients who underwent iCT after intracranial tumor resection. The results of the software in terms of presence or absence of tumor residual were then compared with postoperative MRI performed within 48 hours after surgery to evaluate the diagnostic accuracy of virtual iMRI.

RESULTS Sixty-six patients were included in the present study. The virtual iMRI findings were concordant with the postoperative MRI data in 35 cases (53%) in the detection of tumor residual (p = 0.006). No false-negative findings (i.e., presence of residual on postoperative MRI and absence of residual on virtual iMRI) were encountered. Virtual iMRI had a sensitivity of 1 (95% CI 0.86–1), specificity of 0.26 (95% CI 0.14–0.42), positive predictive value of 0.44 (95% CI 0.3–0.58), and negative predictive value of 1 (95% CI 0.72–1). Subgroup analysis revealed that the virtual iMRI findings were concordant with postoperative MRI findings in all cases (n = 9) of lower-grade glioma (LGG) with a sensitivity of 1 (95% CI 0.59–1) and a specificity of 1 (95% CI 0.16–1) (p = 0.003); a statistically significant association was also found for grade 4 gliomas with a sensitivity of 1 (95% CI 0.69–1) and a specificity of 0.33 (95% CI 0.08–0.7) (p = 0.046) (19 patients). No significant association was found when considering meningiomas or metastases.

CONCLUSIONS The commercially available virtual iMRI can predict the presence or absence of tumor residual with high sensitivity. The diagnostic accuracy of this method was higher in LGGs and much lower for meningiomas or metastases; these findings must be evaluated in prospective studies in a larger population.

Posted on

Use of 5-ALA fluorescence–guided surgery versus white-light conventional microsurgery for the resection of newly diagnosed glioblastomas (RESECT study): a French multicenter randomized phase III study

J Neurosurg 140:987–1000, 2024

Only one phase III prospective randomized study, published in 2006, has assessed the performance of 5-aminolevulinic acid (5-ALA) fluorescence–guided surgery (FGS) for glioblastoma resection. The aim of the RESECT study was to compare the onco-functional results associated with 5-ALA fluorescence and with white-light conventional microsurgery in patients with glioblastoma managed according to the current standards of care.

METHODS This was a phase III prospective randomized single-blinded study, involving 21 French neurosurgical centers, comparing 5-ALA FGS with white-light conventional microsurgery in patients with glioblastoma managed according to the current standards of care, including neuronavigation use and postoperative radiochemotherapy. Randomization was performed in a 1:1 ratio stratified by institution. 5-ALA (20 mg/kg) or placebo (ascorbic acid) was administered orally 3–5 hours before the incision. The primary endpoint was the rate of gross-total resection (GTR) blindly assessed by an independent committee. Patients without a confirmed pathological diagnosis of glioblastoma or with unavailable postoperative MRI studies were excluded from the per-protocol analysis.

RESULTS Between March 2013 and August 2016, a total of 171 patients were assigned to the 5-ALA fluorescence group (n = 88) or to the placebo group (n = 83). Twenty-four cases were excluded because the WHO histological criteria of grade 4 glioma were not met. The proportion of GTR was significantly higher in the 5-ALA fluorescence group (53/67, 79.1%) than in the placebo group (33/69, 47.8%; p = 0.0002). After adjustment for age, preoperative Karnofsky Performance Scale score, and tumor location, GTR was still associated with 5-ALA fluorescence (OR 4.13 [95% CI 1.94–8.79]). The mean 7-day postoperative Karnofsky Performance Scale score (≥ 80% in 49/71, 69.0% [5-ALA group]; 50/71, 70.4% [placebo group], p = 0.86) and the proportion of patients with a worsened neurological status 3 months postoperatively (9/68, 13.2% [5-ALA group]; 9/70, 12.9% [placebo group], p = 0.95) were similar between groups. Adverse events related to 5-ALA intake were rare and consisted of photosensitization in 4/87 (4.6%) patients and hepatic cytolysis in 1/87 (1.1%) patients. The 6-month PFS (70.2% [95% CI 57.7%–79.6%] and 68.4% [95% CI 55.7%–78.1%]; p =0.39) and 24-month OS (30.1% [95% CI 18.9%–42.0%] and 37.7% [95% CI 25.8%–49.5%]; p = 0.89) did not significantly differ. In multivariate analysis, GTR was an independent predictor of PFS (hazard ratio 0.56 [95% CI 0.36–0.86], p =0.008) and OS (hazard ratio 0.65 [95% CI 0.42–1.01], p = 0.05). The use of 5-ALA FGS generates a significant extra cost of 2732.36€ (95% CI 1658.40€–3794.11€).

CONCLUSIONS The authors found that 5-ALA FGS is an easy-to-use, cost-effective, and minimally time-consuming technique that safely optimizes the extent of resection in patients harboring glioblastoma amenable to a large resection.

Posted on

Surgical, functional, and oncological considerations regarding awake resection for giant diffuse lower-grade glioma of more than 100 cm3

J Neurosurg 139:934–943, 2023

Surgery for giant diffuse lower-grade gliomas (LGGs) is challenging, and very few data have been reported on this topic in the literature. In this article, the authors investigated surgical, functional, and oncological aspects in patients who underwent awake resection for large LGGs with a volume > 100 cm3.

METHODS The authors retrospectively reviewed a consecutive cohort of patients who underwent surgery in an awake condition for an LGG (WHO grade 2 with possible foci of grade 3 transformation) with a volume > 100 cm3.

RESULTS A total of 108 patients were included, with a mean age of 36.1 ± 8.5 years. The mean presurgical LGG volume was 136.7 ± 34.5 cm3. In all but 2 patients a disconnection resective surgery up to functional boundaries was possible thanks to active patient collaboration during the awake period. At 3 months of follow-up, all but 1 patient had a normal neurological examination, with a mean Karnofsky Performance Status (KPS) score of 89.8 ± 10.36. In all patients with preoperative epilepsy, there was postoperative control or significant reduction of seizure events. Moreover, 85.1% of patients returned to work. The mean extent of resection (EOR) was 88.9% ± 7.0%, with a mean residual tumor volume (RTV) of 16.3 ± 12.0 cm3 (median RTV 15 cm3). Pathological examination revealed 73 grade 2 gliomas (67.6%; 26 oligodendrogliomas and 47 astrocytomas) and 35 gliomas with foci of grade 3 (32.4%; 19 oligodendrogliomas and 16 astrocytomas). During the postoperative period, 93.6% of patients underwent adjuvant chemotherapy with a median interval between surgery and first chemotherapy of 14 months (IQR 2–26 months), and 55% of patients had radiotherapy with a median interval of 38.5 months (IQR 18–59.8 months). At the last follow-up, 69.7% of patients were still alive with a median follow-up of 62 months (IQR 36–99 months). Overall survival (OS) rates at 1, 5, and 10 years were 100% (95% CI 0.99–1), 80% (95% CI 0.72–0.9), and 58% (95% CI 0.45–0.73), respectively. The median OS was 138 months. In multivariable Cox regression analysis, RTV was established as the only independent prognostic factor for survival.

CONCLUSIONS With the application of rigorous surgical methodology based on functional-guided resection, resection of giant LGGs (volume > 100 cm3) can be reproducibly achieved during surgery with patients under awake mapping with both favorable functional results (< 1% permanent neurological worsening) and favorable long-term oncological outcomes (median OS > 11 years, with a more significant benefit when the RTV is < 15 cm3).

Posted on

Brain metastasis resection: the impact of fluorescence guidance (MetResect study)

Neurosurg Focus 55(2):E10, 2023

Maximal resection of brain metastases (BMs) improves both progression-free survival and overall survival (OS). Fluorescein sodium (FL) in combination with the YELLOW 560-nm filter is a safe and feasible method for visualizing residual tumor tissue during BM resection. The authors of this study aimed to show that use of FL would positively influence the volumetric extent of resection (EOR) and thus the survival outcome in patients undergoing BM resection.

METHODS Analyzing their institution’s prospective brain tumor registry, the authors identified 539 consecutive patients with BMs (247 women, mean age 62.8 years) by using preoperative high-quality MR images for volumetric analysis. BMs were resected under white light (WL) in 293 patients (54.4%; WL group) and under FL guidance in 246 patients (45.6%; FL group). Sex, age, presurgical Karnofsky Performance Status (KPS), recursive partitioning analysis class, and adjuvant treatment modalities were well balanced between the two groups. Volumetric analysis was performed in a blinded fashion by quantifying pre- and postoperative tumor volume based on gadolinium-enhanced T1-weighted sequences.

RESULTS In the FL group, the postoperative tumor volume was significantly smaller (p = 0.01), and hence the quantitative EOR was significantly larger (p = 0.024) and OS was significantly longer (p = 0.0001) (log-rank testing). Multivariate Cox regression modeling showed that age, presurgical KPS, metastasis status, and FL-guided resection are independent prognostic factors for survival.

CONCLUSIONS Compared with WL resection, FL-guided BM resection increased resection quality, significantly improved EOR, and prolonged OS.

Posted on

Management strategies in clival and craniovertebral junction chordomas: a 29-year experience

J Neurosurg 138:1640–1652, 2023

Chordomas represent one of the most challenging subsets of skull base and craniovertebral junction (CVJ) tumors to treat. Despite extensive resection followed by proton-beam radiation therapy, the recurrence rate remains high, highlighting the importance of developing efficient treatment strategies. In this study, the authors present their experience in treating clival and CVJ chordomas over a 29-year period.

METHODS The authors conducted a retrospective study of clival and CVJ chordomas that were surgically treated at their institution from 1991 to 2020. This study focuses on three aspects of the management of these tumors: the factors influencing the extent of resection (EOR), the predictors of survival, and the outcomes of the endoscopic endonasal approaches (EEAs) compared with open approaches (OAs).

RESULTS A total of 265 surgical procedures were performed in 210 patients, including 123 OAs (46.4%) and 142 EEAs (53.6%). Tumors that had an intradural extension (p = 0.03), brainstem contact (p = 0.005), cavernous sinus extension (p = 0.004), major artery encasement (p = 0.01), petrous apex extension (p = 0.003), or high volume (p = 0.0003) were significantly associated with a lower EOR. The 5-year progression-free survival (PFS) and overall survival (OS) rates were 52.1% and 75.1%, respectively. Gross-total resection and Ki-67 labeling index < 6% were considered to be independent prognostic factors of longer PFS (p = 0.0005 and p = 0.003, respectively) and OS (p = 0.02 and p = 0.03, respectively). Postoperative radiation therapy correlated independently with a longer PFS (p = 0.006). Previous surgical treatment was associated with a lower EOR (p = 0.01) and a higher rate of CSF leakage after EEAs (p = 0.02) but did not have significantly lower PFS and OS compared with primary surgery. Previously radiation therapy correlated with a worse outcome, with lower PFS and OS (p = 0.001 and p = 0.007, respectively). EEAs were more frequently used in patients with upper and middle clival tumors (p = 0.002 and p < 0.0001, respectively), had a better rate of EOR (p = 0.003), and had a lower risk of de novo neurological deficit (p < 0.0001) compared with OAs. The overall rate of postoperative CSF leakage after EEAs was 14.8%.

CONCLUSIONS This large study showed that gross-total resection should be attempted in a multidisciplinary skull base center before providing radiation therapy. EEAs should be considered as the gold-standard approach for upper/middle clival lesions based on the satisfactory surgical outcome, but OAs remain important tools for large complex chordomas.

Posted on

Circumferential sulcus-guided resection technique for improved outcomes of low-grade gliomas

J Neurosurg 137:1015–1025, 2022

Many neurosurgeons resect nonenhancing low-grade gliomas (LGGs) by using an inside-out piecemeal resection (PMR) technique. At the authors’ institution they have increasingly used a circumferential, perilesional, sulcusguided resection (SGR) technique. This technique has not been well described and there are limited data on its effectiveness. The authors describe the SGR technique and assess the extent to which SGR correlates with extent of resection and neurological outcome.

METHODS The authors identified all patients with newly diagnosed LGGs who underwent resection at their institution over a 22-year period. Demographics, presenting symptoms, intraoperative data, method of resection (SGR or PMR), volumetric imaging data, and postoperative outcomes were obtained. Univariate analyses used ANOVA and Fisher’s exact test. Multivariate analyses were performed using multivariate logistic regression.

RESULTS Newly diagnosed LGGs were resected in 519 patients, 208 (40%) using an SGR technique and 311 (60%) using a PMR technique. The median extent of resection in the SGR group was 84%, compared with 77% in the PMR group (p = 0.019). In multivariate analysis, SGR was independently associated with a higher rate of complete (100%) resection (27% vs 18%) (OR 1.7, 95% CI 1.1–2.6; p = 0.03). SGR was also associated with a statistical trend toward lower rates of postoperative neurological complications (11% vs 16%, p = 0.09). A subset analysis of tumors located specifically in eloquent brain demonstrated SGR to be as safe as PMR.

CONCLUSIONS The authors describe the SGR technique used to resect LGGs and show that SGR is independently associated with statistically significantly higher rates of complete resection, without an increase in neurological complications, than with PMR. SGR technique should be considered when resecting LGGs.

Posted on

Functional outcomes after resection of middle frontal gyrus diffuse gliomas

J Neurosurg 137:1–8, 2022

The clinical outcomes for patients undergoing resection of diffuse glioma within the middle frontal gyrus (MFG) are understudied. Anatomically, the MFG is richly interconnected to known language areas, and nearby subcortical fibers are at risk during resection. The goal of this study was to determine the functional outcomes and intraoperative mapping results related to resection of MFG gliomas. Additionally, the study aimed to evaluate if subcortical tract disruption on imaging correlated with functional outcomes.

METHODS The authors performed a retrospective review of 39 patients with WHO grade II–IV diffuse gliomas restricted to only the MFG and underlying subcortical region that were treated with resection and had no prior treatment. Intraoperative mapping results and postoperative neurological deficits by discharge and 90 days were assessed. Diffusion tensor imaging (DTI) tractography was used to assess subcortical tract integrity on pre- and postoperative imaging.

RESULTS The mean age of the cohort was 37.9 years at surgery, and the median follow-up was 5.1 years. The mean extent of resection was 98.9% for the cohort. Of the 39 tumors, 24 were left sided (61.5%). Thirty-six patients (92.3%) underwent intraoperative mapping, with 59% of patients undergoing an awake craniotomy. No patients had positive cortical mapping sites overlying the tumor, and 12 patients (33.3%) had positive subcortical stimulation sites. By discharge, 8 patients had language dysfunction, and 5 patients had mild weakness. By 90 days, 2 patients (5.1%) had persistent mild hand weakness only. There were no persistent language deficits by 90 days. On univariate analysis, preoperative tumor size (p = 0.0001), positive subcortical mapping (p = 0.03), preoperative tumor invasion of neighboring subcortical tracts on DTI tractography (p = 0.0003), and resection cavity interruption of subcortical tracts on DTI tractography (p < 0.0001) were associated with an increased risk of having a postoperative deficit by discharge. There were no instances of complete subcortical tract transections in the cohort.

CONCLUSIONS MFG diffuse gliomas may undergo extensive resection with minimal risk for long-term morbidity. Partial subcortical tract interruption may lead to transient but not permanent deficits. Subcortical mapping is essential to reduce permanent morbidity during resection of MFG tumors by avoiding complete transection of critical subcortical tracts.

 

Posted on

Impact of awake mapping on overall survival and extent of resection in patients with adult diffuse gliomas within or near eloquent areas

Acta Neurochirurgica (2022) 164:395–404

Awake craniotomy (AC) with intraoperative mapping is the best approach to preserve neurological function for glioma surgery in eloquent or near eloquent areas, but whether AC improves the extent of resection (EOR) and overall survival (OS) is controversial. This study aimed to compare the long-term clinical outcomes of glioma resection under AC with those under general anesthesia (GA).

Methods Data of 335 patients who underwent surgery with intraoperative magnetic resonance imaging for newly diagnosed gliomas of World Health Organization (WHO) grades II-IV between 2000 and 2013 were reviewed. EOR and OS were quantitatively compared between the AC and GA groups after 1:1 propensity score matching. The two groups were matched for age, preoperative Karnofsky performance status (KPS), tumor location, and pathology.

Results After propensity score matching, 91 pairs were obtained. The median EOR was 96.1% (interquartile range [IQR] 7.3) and 97.4% (IQR 14.4) in the AC and GA groups, respectively (p = 0.31). Median KPS score 3 months after surgery was 90 (IQR 20) in both groups (p = 0.384). The median survival times were 163.3 months (95% confidence interval [CI] 77.9–248.7) and 143.5 months (95% CI 94.4–192.7) in the AC and GA groups, respectively (p = 0.585).

Conclusion Even if the glioma was within or close to the eloquent area, AC was comparable with GA in terms of EOR and OS. In case of difficulties in randomizing patients with eloquent or near eloquent glioma, our propensity score-matched analysis provides retrospective evidence that AC can obtain EOR and OS equivalent to removing glioma under GA.

Posted on

Influence of supramarginal resection on survival outcomes after gross-total resection of IDH–wild-type glioblastoma

J Neurosurg 136:1–8, 2022

The authors’ goal was to use a multicenter, observational cohort study to determine whether supramarginal resection (SMR) of FLAIR-hyperintense tumor beyond the contrast-enhanced (CE) area influences the overall survival (OS) of patients with isocitrate dehydrogenase–wild-type (IDH-wt) glioblastoma after gross-total resection (GTR).

METHODS The medical records of 888 patients aged ≥ 18 years who underwent resection of GBM between January 2011 and December 2017 were reviewed. Volumetric measurements of the CE tumor and surrounding FLAIR-hyperintense tumor were performed, clinical variables were obtained, and associations with OS were analyzed.

RESULTS In total, 101 patients with newly diagnosed IDH-wt GBM who underwent GTR of the CE tumor met the inclusion criteria. In multivariate analysis, age ≥ 65 years (HR 1.97; 95% CI 1.01–2.56; p < 0.001) and contact with the lateral ventricles (HR 1.59; 95% CI 1.13–1.78; p = 0.025) were associated with shorter OS, but preoperative Karnofsky Performance Status ≥ 70 (HR 0.47; 95% CI 0.27–0.89; p = 0.006), MGMT promotor methylation (HR 0.63; 95% CI 0.52–0.99; p = 0.044), and increased percentage of SMR (HR 0.99; 95% CI 0.98–0.99; p = 0.02) were associated with longer OS. Finally, 20% SMR was the minimum percentage associated with beneficial OS (HR 0.56; 95% CI 0.35–0.89; p = 0.01), but > 60% SMR had no significant influence (HR 0.74; 95% CI 0.45–1.21; p = 0.234).

CONCLUSIONS SMR is associated with improved OS in patients with IDH-wt GBM who undergo GTR of CE tumor. At least 20% SMR of the CE tumor was associated with beneficial OS, but greater than 60% SMR had no significant influence on OS.

Posted on

Is There a Role for Surgical Resection of Multifocal Glioblastoma? A Retrospective Analysis of 100 Patients

Neurosurgery 89:1042–1051, 2021

Glioblastoma with multiple localizations (mGBMs) can be defined as multifocal, where enhancing lesions present a connection visible on magnetic resonance imaging fluid-attenuated inversion recovery imaging, or multicentric, in the absence of a clear dissemination pathway.

OBJECTIVE: To evaluate the role of the extent of resection (EOR) in the treatment of mGBMs and its correlation with overall survival (OS) and progression free survival (PFS).

METHODS: One hundred patients with mGBMs were treated at our Institution between 2009 and 2019. Clinical, radiological, and follow-up datawere collected. EOR of the contrastenhancing part of lesions was classified as gross total resection (GTR, absence of tumor remnant), subtotal resection (STR, residual tumor < 30% of the initial mass), partial resection (PR, residual tumor>30% of the initialmass), and needle or open biopsy (residual tumor > 75% of the initial mass).

RESULTS: Approximately 15% of patients underwent GTR, 14% STR, 32% PR, and 39% biopsy. Median OS was 17 mo for GTR, 11 mo for STR, 7 mo for PR, and 5 mo for biopsy. Greater EOR was associated with a significantly longer OS than biopsy. GTR and STR were associated with a longer PFS in Kaplan-Meier survival analyses. After adjusting for age, Karnofsky performance status (KPS), number of lesions, and adjunctive therapy in multivariable Cox regression analyses, GTR, STR, and PR were still associated with OS, but only GTR remained associated with PFS.

CONCLUSION: Our study suggests that EOR may positively influence survival of patients with mGBM. Surgical resection can be a reasonable option when performance and access to adjuvant treatment can be preserved.

Posted on

Improved outcomes associated with maximal extent of resection for butterfly glioblastoma

Acta Neurochirurgica (2021) 163:1883–1894

Butterfly glioblastomas (bGBMs) are grade IV gliomas that infiltrate the corpus callosum and spread to bilateral cerebral hemispheres. Due to the rarity of cases, there is a dearth of information in existing literature. Herein, we evaluate clinical and genetic characteristics, associated predictors, and survival outcomes in an institutional series and compare them to a national cohort.

Methods We identified all adult patients with bGBM treated at Brigham & Women’s Hospital (2008–2018). The National Cancer Database (NCDB) was also queried for bGBM patients. Survival was analyzed with Kaplan–Meier methods, and Cox models were built to assess for predictive factors.

Results Of 993 glioblastoma patients, 62 cases (6.2%) of bGBM were identified. Craniotomy for resection was attempted in 26 patients (41.9%), with a median volumetric extent of resection (vEOR) of 72.3% (95% confidence interval [95%CI] 58.3–82.1). The IDH1 R132H mutation was detected in two patients (3.2%), and MGMT promoter was methylated in 55.5% of the assessed cases. In multivariable regression, factors predictive of longer OS were increased vEOR, MGMT promoter methylation, and receipt of adjuvant therapy. Median OS for the resected cases was 11.5 months (95%CI 7.7–18.8) vs. 6.3 (95%CI 5.1–8.9) for the biopsied. Of 21,353 GBMs, 719 (3.37%) bGBM patients were identified in the NCDB. Resection was more likely to be pursued in recent years, and GTR was independently associated with prolonged OS (p < 0.01).

Conclusion Surgical resection followed by adjuvant chemoradiation is associated with significant survival gains and should be pursued in carefully selected bGBM patients.

Posted on

Impact of Intraoperative Magnetic Resonance Imaging and Other Factors on Surgical Outcomes for Newly Diagnosed Grade II Astrocytomas and Oligodendrogliomas: A Multicenter Study

Neurosurgery 88 (1) 2021: 63–73,

Few studies use large, multi-institutional patient cohorts to examine the role of intraoperative magnetic resonance imaging (iMRI) in the resection of grade II gliomas.

OBJECTIVE: To assess the impact of iMRI and other factors on overall survival (OS) and progression-free survival (PFS) for newly diagnosed grade II astrocytomas and oligodendrogliomas.

METHODS: Retrospective analyses of a multicenter database assessed the impact of patient-, treatment-, and tumor-related factors on OS and PFS.

RESULTS: A total of 232 resections (112 astrocytomas and 120 oligodendrogliomas) were analyzed. Oligodendrogliomas had longer OS (P < .001) and PFS (P = .01) than astrocytomas. Multivariate analyses demonstrated improved OS for gross total resection (GTR) vs subtotal resection (STR; P = .006, hazard ratio [HR]: .23) and near total resection (NTR; P = .02, HR: .64). GTR vs STR (P = .02, HR: .54), GTR vs NTR (P = .04, HR: .49), and iMRI use (P = .02, HR: .54) were associated with longer PFS. Frontal (P = .048, HR: 2.11) and occipital/parietal (P = .003, HR: 3.59) locations were associated with shorter PFS (vs temporal). Kaplan-Meier analyses showed longer OS with increasing extent of surgical resection (EOR) (P=.03) and 1p/19q gene deletions (P=.02). PFS improved with increasing EOR (P = .01), GTR vs NTR (P = .02), and resections above STR (P = .04). Factors influencing adjuvant treatment (35.3% of patients) included age (P=.002, odds ratio [OR]: 1.04) and EOR (P=.003,OR: .39) but not glioma subtype or location. Additional tumor resection after iMRI was performed in 105/159 (66%) iMRI cases, yielding GTR in 54.5% of these instances.

CONCLUSION: EOR is a major determinant of OS and PFS for patients with grade II astrocytomas and oligodendrogliomas. Intraoperative MRI may improve EOR and was associated with increased PFS.

Posted on

Contemporary assessment of extent of resection in molecularly defined categories of diffuse low-grade glioma: a volumetric analysis

J Neurosurg 133:1291–1301, 2020

While the effect of increased extent of resection (EOR) on survival in diffuse infiltrating low-grade glioma (LGG) patients is well established, there is still uncertainty about the influence of the new WHO molecular subtypes. The authors designed a retrospective analysis to assess the interplay between EOR and molecular classes.

METHODS The authors retrospectively reviewed the records of 326 patients treated surgically for hemispheric WHO grade II LGG at Brigham and Women’s Hospital and Massachusetts General Hospital (2000–2017). EOR was calculated volumetrically and Cox proportional hazards models were built to assess for predictive factors of overall survival (OS), progression-free survival (PFS), and malignant progression–free survival (MPFS).

RESULTS There were 43 deaths (13.2%; median follow-up 5.4 years) among 326 LGG patients. Median preoperative tumor volume was 31.2 cm3 (IQR 12.9–66.0), and median postoperative residual tumor volume was 5.8 cm3 (IQR 1.1–20.5). On multivariable Cox regression, increasing postoperative volume was associated with worse OS (HR 1.02 per cm3; 95% CI 1.00–1.03; p = 0.016), PFS (HR 1.01 per cm3; 95% CI 1.00–1.02; p = 0.001), and MPFS (HR 1.01 per cm3; 95% CI 1.00–1.02; p = 0.035). This result was more pronounced in the worse prognosis subtypes of IDH-mutant and IDH-wildtype astrocytoma, for which differences in survival manifested in cases with residual tumor volume of only 1 cm3. In oligodendroglioma patients, postoperative residuals impacted survival when exceeding 8 cm3. Other significant predictors of OS were age at diagnosis, IDH-mutant and IDH-wildtype astrocytoma classes, adjuvant radiotherapy, and increasing preoperative volume.

CONCLUSIONS The results corroborate the role of EOR in survival and malignant transformation across all molecular subtypes of diffuse LGG. IDH-mutant and IDH-wildtype astrocytomas are affected even by minimal postoperative residuals and patients could potentially benefit from a more aggressive surgical approach.

Posted on

Resection of tumors within the primary motor cortex using high-frequency stimulation

J Neurosurg 133:642–654, 2020

Brain mapping techniques allow one to effectively approach tumors involving the primary motor cortex (M1). Tumor resectability and maintenance of patient integrity depend on the ability to successfully identify motor tracts during resection by choosing the most appropriate neurophysiological paradigm for motor mapping. Mapping with a highfrequency (HF) stimulation technique has emerged as the most efficient tool to identify motor tracts because of its versatility in different clinical settings. At present, few data are available on the use of HF for removal of tumors predominantly involving M1.

METHODS The authors retrospectively analyzed a series of 102 patients with brain tumors within M1, by reviewing the use of HF as a guide. The neurophysiological protocols adopted during resections were described and correlated with patients’ clinical and tumor imaging features. Feasibility of mapping, extent of resection, and motor function assessment were used to evaluate the oncological and functional outcome to be correlated with the selected neurophysiological parameters used for guiding resection. The study aimed to define the most efficient protocol to guide resection for each clinical condition.

RESULTS The data confirmed HF as an efficient tool for guiding resection of M1 tumors, affording 85.3% complete resection and only 2% permanent morbidity. HF was highly versatile, adapting the stimulation paradigm and the probe to the clinical context. Three approaches were used. The first was a “standard approach” (HF “train of 5,” using a monopolar probe) applied in 51 patients with no motor deficit and seizure control, harboring a well-defined tumor, showing contrast enhancement in most cases, and reaching the M1 surface. Complete resection was achieved in 72.5%, and 2% had permanent morbidity. The second approach was an “increased train approach,” that is, an increase in the number of pulses (7–9) and of pulse duration, using a monopolar probe. This second approach was applied in 8 patients with a long clinical history, previous treatment (surgery, radiation therapy, chemotherapy), motor deficit at admission, poor seizure control, and mostly high-grade gliomas or metastases. Complete resection was achieved in 87.5% using this approach, along with 0% permanent morbidity. The final approach was a “reduced train approach,” which was the combined use of train of 2 or train of 1 pulses associated with the standard approach, using a monopolar or bipolar probe. This approach was used in 43 patients with a long clinical history and poorly controlled seizures, harboring tumors with irregular borders without contrast enhancement (low or lower grade), possibly not reaching the cortical surface. Complete resection was attained in 88.4%, and permanent morbidity was found in 2.3%.

CONCLUSIONS Resection of M1 tumors is feasible and safe. By adapting the stimulation paradigm and probe appropriately to the clinical context, the best resection and functional results can be achieved.

Posted on

Awake vs. asleep motor mapping for glioma resection: a systematic review and meta-analysis

Acta Neurochirurgica (2020) 162:1709–1720

Intraoperative stimulation (IS) mapping has become the preferred standard treatment for eloquent tumors as it permits a more accurate identification of functional areas, allowing surgeons to achieve higher extents of resection (EOR) and decrease postoperative morbidity. For lesions adjacent to the perirolandic area and descending motor tracts, mapping can be done with both awake craniotomy (AC) and under general anesthesia (GA). Objective We aimed to determine which anesthetic protocol—AC vs. GA—provides better patient outcomes by comparing EOR and postoperative morbidity for surgeries using IS mapping in gliomas located near or in motor areas of the brain.

Methods A systematic literature search was carried out to identify relevant studies from 1983 to 2019. Seven databases were screened. A total of 2351 glioma patients from 17 studies were analyzed.

Results A random-effects meta-analysis revealed a trend towards a higher mean EOR in AC [90.1% (95% C.I. 85.8–93.8)] than with GA [81.7% (95% C.I. 72.4–89.7)] (p = 0.06). Neurological deficits were divided by timing and severity for analysis. There was no significant difference in early neurological deficits [20.9% (95% C.I. 4.1–45.0) vs. 25.4% (95% C.I. 13.6–39.2)] (p = 0.74), late neurological deficits [17.1% (95% C.I. 0.0–50.0) vs. 3.8% (95% C.I. 1.1–7.6)] (p = 0.06), or in non-severe [28.4% (95% C.I. 0.0–88.5) vs. 20.1% (95% C.I. 7.1–32.2)] (p = 0.72), and severe morbidity [2.6% (95% C.I. 0.0–15.5) vs. 4.5% (95% C.I. 1.1–9.6)] (p = 0.89) between patients who underwent AC versus GA, respectively.

Conclusion Mapping during resection of gliomas located in or near the perirolandic area and descending motor tracts can be safely carried out with both AC and GA.

Proudly powered by WordPress