Tag: Incidental tumor

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Patients with incidental WHO grade II glioma frequently suffer from neuropsychological disturbances

Plastic relocation of motor cortex in a patient with LGG (low grade glioma) confirmed by NBS (navigated brain stimulation)

Acta Neurochir (2016) 158:305–312

WHO grade II gliomas (low-grade glioma, LGG) are increasingly diagnosed in patients undergoing MRI for many conditions. These patients are classically considered asymptomatic because they do not experience seizures. Although it was previously demonstrated that symptomatic LGG patients frequently have neurocognitive disorders, the literature does not provide data on the neuropsychological status of patients with incidental LGG (iLGG).

Objective Our aim is to investigate whether neurocognitive impairments exist in a homogeneous iLGG population.

Methods We conducted an analysis of pretreatment neuropsychological assessments of patients with iLGG (histologically proven) admitted to our center from 2007 to 2014. We also obtained data on subjective complaints, tumor size and location.

Results Our study focused on 15 iLGG patients. Two thirds reported subjective complaints, mainly tiredness (40 %) and attentional impairment (33 %). Neurocognitive functions were disturbed in 60 % of patients; 53 % had altered executive functions, 20 % had working memory impairment, and 6 % had attentional disturbances. Only one patient with normal preoperative neuropsychological assessment experienced a deficit at the 3-month postoperative examination.

Conclusions For the first time to our knowledge, we suggest that numerous iLGG patients have neuropsychological impairments. Therefore, greater attention should be paid to objective neuropsychological assessment in iLGG because of the high prevalence of insidious cognitive deficits. Moreover, our original findings bring into question the traditional wait-andsee attitude in iLGG, mainly based on the erroneous dogma that these patients have no functional disturbances. Neuropsychological assessment is mandatory to select the best individualized therapeutic management with preservation of quality of life.

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Is there a risk of seizures in “preventive” awake surgery for incidental diffuse low-grade gliomas?

Is there a risk of seizures in “preventive” awake surgery for incidental diffuse low-grade gliomas?

J Neurosurg 122:1397–1405, 2015

Although a large amount of data supports resection for symptomatic diffuse low-grade glioma (LGG), the therapeutic strategy regarding incidental LGG (ILGG) is still a matter of debate. Indeed, early “preventive” surgery has recently been proposed in asymptomatic patients with LGG, after showing that the extent of resection was larger than in symptomatic patients with LGG. However, the quality of life should be preserved by avoiding both neurological deficit and epilepsy. The aim of this study was to determine the risk of seizures related to such a prophylactic surgical treatment in ILGG.

Methods The authors report a prospective series of 21 patients with ILGG who underwent awake surgery with a minimum follow-up of 20 months following resection. Data regarding clinicoradiological features, surgical procedures, and outcomes were collected and analyzed. In particular, the eventual occurrence and type of seizures in the intra- and postoperative periods were studied, as follows: early (< 3 months) and long-term (until last follow-up) periods.

Results There were no intraoperative seizures in this series. During the early postoperative period, the authors observed only a single episode of partial seizures in a patient with no antiepileptic drug (AED) prophylaxis—all other patients were given antiepileptic treatment following resection. The AEDs were discontinued in all cases, with a mean delay of 8 months after surgery (range 3–24 months). No patient had permanent neurological deficits. All 21 patients returned to an active familial, social, and professional life (working full time in all cases). Total or even “supratotal” resection (the latter meaning that a margin around the tumor visible on FLAIR-weighted MRI was removed) was achieved in 14 cases (67%). In 7 patients (33%) subtotal resection was performed, with a mean residual tumor volume of 1.5 ml (range 1–7 ml). No oncological treatment was administered in the postsurgical period. The mean follow-up after surgery was 49 months (range 20–181 months). Only 2 patients had seizures during the long-term follow-up. Indeed, due to tumor progression after incomplete resection, seizures occurred in 2 cases, 39 and 78 months postsurgery, leading to administration of AEDs and adjuvant treatment. So far, all patients are still alive and enjoy a normal life.

Conclusions: The risk of inducing seizures is very low in ILGG, and it does not represent an argument against early surgery. These data strongly support the proposal of a screening policy for LGG that will evolve toward a preventive treatment in a more systematic manner.

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Awake surgery for incidental WHO grade II gliomas involving eloquent areas

Acta Neurochir (2012) 154:575–584.DOI 10.1007/s00701-011-1216-x
WHO grade II glioma (G2G) is a premalignant tumor, usually revealed by seizures in young patients living normal lives. G2G grows constantly and will inevitably become anaplastic. Surgical resection significantly increases the overall survival by delaying malignant transformation. Recently, a similar natural history was demonstrated in a patient with incidental G2G, with continuous growth and risk of anaplasia. Here, the aim was to study for the first time the functional results and extent of resection in a prospective series of patients who underwent resection for incidental G2G within eloquent areas.
Method G2G involving functional regions in the left dominant hemisphere was incidentally diagnosed in 11 asymptomatic patients. Resection was achieved in all cases after demonstration of a volumetric increase on serial MRIs. Intraoperative awake mapping was performed in the 11 patients.
Findings There were no cases of mortality or permanent postoperative deficit. A subtotal, total or even “supratotal” resection was achieved in the 11 cases, with no partial resections. All patients resumed normal social and professional lives, with no seizures (KPS 100). Due to slow tumor re-growth in three patients with subtotal resection, adjuvant chemotherapy was administrated in two cases and radiotherapy in one. With a mean follow-up of 40 months since surgery, there was no anaplastic transformation.
Conclusion These results show that surgery can be considered in incidental G2G, even in critical areas, with a minimal risk and optimal resection, thanks to intraoperative mapping. Such findings raise the question of an early detection.

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