Surgery for IDH1/2 wild-type glioma invading the corpus callosum

Abstract Background Glioblastoma of the corpus callosum (ccGBM) are rare tumors, with a dismal prognosis marked by a rapid clinical deterioration. For a long time, surgical treatment was not considered beneficial for most patients with such tumors. Recent studies claimed an improved survival for patients undergoing extensive resection, albeit without integration of the molecular profile of the lesions. The purpose of this study was to investigate the effect of biopsy and surgical resection on oncological and functional outcomes in patients with IDH wild-type ccGBM. Methods We performed a retrospective analysis of our institution’s database of patients having been treated for high-grade glioma between 2005 and 2017. Inclusion criteria were defined as follows: patients older than 18 years, histopathological, and molecularly defined IDH wild-type glioma, major tumor mass (at least 2/3) invading the corpus callosum in the sagittal plane with a uni- or bilateral infiltration of the adjacent lobules. Surgical therapy (resection vs. biopsy), extent of resection according to the remaining tumor volume and adjuvant treatment as well as overall survival and functional outcome using the Karnofsky Performance Score (KPS) were analyzed. Results Fifty-five patients were included in the study, from which the mean age was 64 years and men (n = 34, 61.8%) were more often affected than women (n = 21, 38.2%). Thirty (54.5%) patients were treated with stereotactic biopsy alone, while 25 patients received tumor resection resulting in 14.5% (n = 8) gross-total resections and 30.9% (n = 17) partial resections. The 2-year survival rate after resection was 30% compared to 7% after biopsy (p = 0.047). The major benefit was achieved in the group with gross-total resection, while partial resection failed to improve survival. Neurological outcome measured by KPS did not differ between both groups either pre- or postoperatively. Conclusions Our study suggests that in patients with corpus callosum glioblastoma, gross-total resection prolongs survival without negatively impacting neurological outcome as compared to biopsy.

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ETMR-10. EARLY FOCAL RADIOTHERAPY AND TEMOZOLOMIDE FOLLOWING COMPLETE RESECTION APPEAR SUPERIOR TO INTENSIVE CHEMOTHERAPY AND DELAYED RADIOTHERAPY IN CHILDREN WITH EMBRYONAL TUMORS WITH MULTILAYERED ROSETTES (ETMR)

Neuro-Oncology ◽

10.1093/neuonc/noaa222.214 ◽

2020 ◽

Vol 22 (Supplement_3) ◽

pp. iii324-iii325

Author(s):

Lisa Mayr ◽

Johannes Gojo ◽

Andreas Peyrl ◽

Amedeo Azizi ◽

Karin Dieckmann ◽

...

Keyword(s):

Intensive Therapy ◽

Tumor Resection ◽

High Dose Chemotherapy ◽

Gross Total Resection ◽

Definitive Treatment ◽

High Dose ◽

Central Nervous System Tumor ◽

Intensive Chemotherapy ◽

Total Resection ◽

Dismal Prognosis

Abstract BACKGROUND Embryonal tumor with multilayered rosettes (ETMR) is a rare, aggressive embryonal central nervous system tumor characterized by LIN28A expression and alterations in the C19MC locus. ETMRs predominantly occur in young children, have a dismal prognosis, and no definitive treatment guidelines have been established. We report on our experience in nine consecutive patients. METHODS Between 2006 and 2017, nine patients were diagnosed with ETMR. Median age was 25 months (5–38), seven were treated for primary diagnosis, two referred with progressing tumors, seven diagnosed prospectively, two retrospectively, five were located supratentorially, three pineal, one in the brainstem. RESULTS Seven patients had a gross total resection, one a partial resection and one a biopsy at initial diagnosis, followed by second resections at progression. Six patients were treated with intensive chemotherapy regimens including high-dose chemotherapy in three patients and all recurred after a median of 6 months (range 2–11) and all except one patient who died after high-dose chemotherapy, succumbed to their disease after a median of 13 months (range 7–28). Two patients were treated with gross total tumor resection, early focal radiotherapy and concomitant temozolomide followed by temozolomide and intrathecal therapy for one year and both are in continuous complete remission 51 and 46 months after diagnosis. CONCLUSION Gross total resection followed by early focal radiotherapy, temozolomide, and intrathecal chemotherapy seem to be superior to intensive chemotherapy including high-dose chemotherapy. Steady progression was observed in both patients with initial biopsy and PR only despite intensive therapy. Radiotherapy at recurrence/progression was not successful.

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Transcavernous Approach for Gross Total Resection of a Dumbbell-Shaped Giant Trigeminal Schwannoma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1729995 ◽

2021 ◽

Author(s):

Sima Sayyahmelli ◽

Emel Avci ◽

Burak Ozaydin ◽

Mustafa K. Başkaya

Keyword(s):

Skull Base ◽

Cavernous Sinus ◽

Tumor Resection ◽

Mass Effect ◽

World Health ◽

Gross Total Resection ◽

Petrous Apex ◽

Total Resection ◽

Who Grade ◽

Trigeminal Schwannoma

AbstractTrigeminal schwannomas are rare nerve sheet tumors that represent the second most common intracranial site of occurrence after vestibular nerve origins. Microsurgical resection of giant dumbbell-shaped trigeminal schwannomas often requires complex skull base approaches. The extradural transcavernous approach is effective for the resection of these giant tumors involving the cavernous sinus.The patient is a 72-year-old man with headache, dizziness, imbalance, and cognitive decline. Neurological examination revealed left-sided sixth nerve palsy, a diminished corneal reflex, and wasting of temporalis muscle. Magnetic resonance imaging (MRI) showed a giant homogeneously enhancing dumbbell-shaped extra-axial mass centered within the left cavernous sinus, Meckel's cave, and the petrous apex, with extension to the cerebellopontine angle. There was a significant mass effect on the brain stem causing hydrocephalus. Computed tomography (CT) scan showed erosion of the petrous apex resulting in partial anterior autopetrosectomy (Figs. 1 and 2).The decision was made to proceed with tumor resection using a transcavernous approach. Gross total resection was achieved. The surgery and postoperative course were uneventful, and the patient woke up the same as in the preoperative period. MRI confirmed gross total resection of the tumor. The histopathology was a trigeminal schwannoma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence at 15-month follow-up.This video demonstrates important steps of the microsurgical skull base techniques for resection of these challenging tumors.The link to the video can be found at https://youtu.be/TMK5363836M

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

Journal of Neurosurgery ◽

10.3171/2020.10.jns203366 ◽

2021 ◽

pp. 1-8

Author(s):

Tito Vivas-Buitrago ◽

Ricardo A. Domingo ◽

Shashwat Tripathi ◽

Gaetano De Biase ◽

Desmond Brown ◽

...

Keyword(s):

Significant Influence ◽

Karnofsky Performance Status ◽

Performance Status ◽

Gross Total Resection ◽

Inclusion Criteria ◽

Wild Type ◽

Total Resection ◽

Contrast Enhanced ◽

Observational Cohort ◽

Supramarginal Resection

OBJECTIVE 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.

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Extent of resection in glioblastoma: a 10-year local survival analysis

Neuro-Oncology ◽

10.1093/neuonc/noab195.049 ◽

2021 ◽

Vol 23 (Supplement_4) ◽

pp. iv19-iv19

Author(s):

Theodore Hirst ◽

Patrick McAleavey ◽

Tom Flannery

Keyword(s):

Neurological Deficit ◽

Survival Benefit ◽

Extent Of Resection ◽

Cox Proportional Hazards ◽

Partial Resection ◽

Gross Total Resection ◽

Molecular Profile ◽

Total Resection ◽

Local Survival ◽

The Impact

Abstract Aims The impact on extent of resection (EOR) in glioblastoma has been well documented. It is clear that gross-total resection (GTR) confers best overall survival (OS), however the minimum EOR required to confer a survival benefit over biopsy is debated. Recent studies favour partial resection (PR) over biopsy for IDH-wildtype, MGMT-unmethylated tumours. We describe our experiences locally with these principles in mind. Method Retrospective evaluation of a single surgeon cohort. All patients over 18 years old, undergoing a surgical treatment for histologically confirmed GBM in the stated period were included. We collected information on demographics, tumour volume, EOR, complications, adjuvant therapies, molecular profile, and OS. We used log rank tests and Cox Proportional Hazards Models to identify factors associated with OS. Results The patient and tumour characteristics of our cohort were similar to those documented in the literature. The mean age was 56.6 years. 72 patients underwent biopsy and 202 had debulking surgery. Median OS was 11 months. Of those debulked, gross-total resection was achieved in 41 patients (20%); associated median OS was 29 months. Patients receiving partial resection (defined as EOR <80%) had no clear survival benefit over patients undergoing biopsy (median OS 6 vs 5 months) but had a higher rate of post-op neurological deficit (3% vs 12%). Tumour molecular profile appeared to influence survival outcome in a manner comparable to worldwide experience. Conclusion In our experience, partial resection is not a justifiable surgical aim in the typical glioblastoma cohort. The limited benefit that it may confer over biopsy appears to be outweighed by the risk of neurological deficit that affects quality and probably quantity of life. This finding applies to our glioblastoma population in general as well as those specifically with an MGM-unmethylated tumour.

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Microsurgical Resection of Cervical Intradural Juxtamedullary Solitary Fibrous Tumor: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa232 ◽

2020 ◽

Vol 19 (5) ◽

pp. E532-E532

Author(s):

Paolo Perrini ◽

Davide Tiziano Di Carlo ◽

Nicola Montemurro ◽

Nicola Benedetto ◽

Valerio Ortenzi ◽

...

Keyword(s):

Spinal Cord ◽

Nerve Root ◽

Tumor Resection ◽

Gross Total Resection ◽

Total Resection ◽

Neurophysiologic Monitoring ◽

Intramedullary Lesion ◽

Dural Attachment ◽

Fibrous Tumor ◽

Nerve Root Involvement

Abstract Solitary fibrous tumors (SFTs) are uncommon mesenchymal lesions originally described as pleura-based neoplasms. Intradural juxtamedullary SFTs are rare, hard, and scarcely vascularized and generally present a conspicuous extramedullary exophytic component without dural attachment and nerve root involvement. Gross-total resection is the mainstay of treatment, although the absence of an arachnoidal plane and the firm adherence to the spinal cord make resection challenging. We describe the case of a 74-yr-old female patient presenting with a history of progressive spastic tetraparesis due to a cervical juxtamedullary SFT. The patient was not able to walk and magnetic resonance imaging (MRI) of the cervical spine demonstrated a possible intramedullary lesion at C2-C3 with homogeneous enhancement after gadolinium injection. Given the progressive nature of symptoms, the patient elected to have surgical resection of the tumor. The patient underwent C2-C3 laminoplasty and tumor resection under neurophysiologic monitoring. The tumor presented extremely hard without dural attachment or nerve root involvement and was progressively debulked using microsurgical techniques and ultrasonic aspirator. The identification of a plane between the mass and the spinal cord white matter allowed for a gross total resection. Permanent pathological analysis eventually demonstrated SFT. The patient's neurological condition was unchanged postoperatively. MRI performed 2 mo after the operation demonstrated gross total resection of the lesion. At the 6-mo follow-up visit, the patient was able to walk with assistance. The patient signed the Institutional Consent Form to undergo the surgical procedure and to allow the use of her images and videos for any type of medical publications.

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Does extent of resection of glioblastoma multiforme affect survival?

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e14514 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e14514-e14514

Author(s):

Emad Eldin Nabil ◽

Ashraf Elyamany

Keyword(s):

Glioblastoma Multiforme ◽

Eastern Cooperative Oncology Group ◽

Tumor Resection ◽

Extent Of Resection ◽

Complete Resection ◽

University Hospital ◽

Gross Total Resection ◽

Cancer Center ◽

Total Resection ◽

Imaging Results

e14514 Background: Glioblastoma Multiforme (GBM) is the most common primary intracranial tumor. The effect on survival of extent of tumor resection for GBM tumors remains controversial. Our study aims to detect the role of extent of tumor resection in improvement of survival in patients with GBM. Methods: A prospective study for 84 patients with GBM, was conducted between March 2013 and September 2016 in Sohag University Hospital and Sohag Cancer Center. For all of them surgery was done. Either biopsy (stereotactic or open), debulking or gross total resection (complete). All patients received radical radiotherapy concurrent with Temozolomide chemotherapy followed by six to eight cycles of Temozolomide. All patients were followed by clinical examination and brain imaging. Results: 59% of our patients were males and 41% were females. About 78% of the patients had either Eastern Cooperative Oncology Group (ECOG) Performance Status 1 or 2. Median age was 51years with a range (25-70 years). In 38 patients (45.8%) debulking was done, while complete resection was done in 20 patients (24.1%). only biopsy was done in 30% of patients. We found a statistically significant effect for the extent of resection on overall survival (OS)(22 vs 19.5 months) and progression free survival (PFS)(18.25 vs17.42 months) for patients with complete resection vs patients with debulking only. In addition younger age patients had a statistically significant longer survival. Conclusions: Gross total resection (complete resection) of intracranial GBM was associated with longer survival. Gross total resection should be performed whenever possible.

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Early outcomes of endoscopic transsphenoidal surgery for adult craniopharyngiomas

Neurosurgical FOCUS ◽

10.3171/2010.1.focus09319 ◽

2010 ◽

Vol 28 (4) ◽

pp. E9 ◽

Cited By ~ 66

Author(s):

John A. Jane ◽

Erin Kiehna ◽

Spencer C. Payne ◽

Stephen V. Early ◽

Edward R. Laws

Keyword(s):

Mr Imaging ◽

Transsphenoidal Surgery ◽

Tumor Resection ◽

Imaging Study ◽

High Rate ◽

Transsphenoidal Approach ◽

Gross Total Resection ◽

Csf Leak ◽

Total Resection ◽

Endoscopic Transsphenoidal Surgery

Object Although the transsphenoidal approach for subdiaphragmatic craniopharyngiomas has been performed for many years, there are few reports describing the role of the endoscopic transsphenoidal technique for suprasellar craniopharyngiomas. The purpose of this study was to report the outcomes of the endoscopic transsphenoidal approach for adults with craniopharyngiomas in whom the goal was gross-total resection. Methods Twelve patients were identified who were older than 18 years at the time of their pure endoscopic transsphenoidal surgery. Their medical records and imaging studies were retrospectively reviewed. Results Gross-total resection was achieved in 42% of cases when assessed by intraoperative impression alone and in 75% when assessed by the first postoperative MR imaging study. However, 83% of patients achieved at least a 95% resection when assessed by both intraoperative impression and the first postoperative MR imaging study. Permanent diabetes insipidus occurred postoperatively in 44% of patients. Six (67%) of 9 patients who had a functioning hypothalamic-pituitary axis preoperatively developed panhypopituitarism after surgery. Visual improvement or normalization occurred in 78% of patients with preoperative visual deficits. Although no patient experienced a postoperative CSF leak, 1 patient was treated for meningitis. Conclusions The authors have achieved a high rate of radical resection and symptomatic improvement with the endoscopic transsphenoidal technique for both subdiaphragmatic (sellar/suprasellar) and supradiaphragmatic (suprasellar) craniopharyngiomas. However, this is also associated with a high incidence of new endocrinopathy. Endoscopic assessment of tumor resection may be more sensitive for residual tumor than the first postoperative MR imaging study.

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Microsurgical resection of giant T11/T12 conus cauda equine schwannoma

Bosnian Journal of Basic Medical Sciences ◽

10.17305/bjbms.2020.5153 ◽

2020 ◽

Author(s):

Alisa Arnautovic ◽

Mirza Pojskic ◽

Kenan Arnautovic

Keyword(s):

Motor Evoked Potentials ◽

Tumor Resection ◽

Cauda Equina ◽

Sensory Nerve ◽

Gross Total Resection ◽

Nerve Roots ◽

Total Resection ◽

Who Grade ◽

Extramedullary Tumor ◽

Microsurgical Resection

In this video, we highlight the anatomy involved with microsurgical resection of a giant T11/T12 conus cauda equine schwannoma. Spinal schwannoma remains the third most common intradural spinal tumor. Tumors undergoing gross total resection usually do not recur. To our knowledge, this is the first video case report of giant cauda equina schwannoma resection. A 55-year-old female presented with paraparesis and urinary retention. Lumbar spine MRI revealed contrast-enhancing intradural extramedullary tumor at the T11/T12 level. Surgery was performed in a prone position with intraoperative neurophysiology monitoring (somatosensory and motor evoked potentials - SSEP and MEP). T11/T12 laminectomies were performed. After opening the dura and arachnoid, the tumor was found covered with cauda equina nerve roots. We delineated the inferior pole of the tumor, followed by opening of the capsule and debulking the tumor. Subsequently, the cranial pole was dissected from the corresponding cauda equina nerve roots. Finally, the tumor nerve origin was identified and divided after nerve stimulation confirmed the tumor arose from a sensory nerve root. The tumor was removed; histological analysis revealed a schwannoma (WHO Grade I). Postoperative MRI revealed complete resection. The patient fully recovered her neurological function. This case highlights the importance of careful microsurgical technique and gross total resection of the tumor in the view of favorable postoperative neurological recovery of the patient. Intraoperative use of ultrasound is helpful to delineate preoperatively tumor extension and confirm postoperative tumor resection.

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P14.116 Lack of correlation between incidental ipsilateral subventricular zone radiation dose and overall survival in glioblastoma patients

Neuro-Oncology ◽

10.1093/neuonc/noz126.351 ◽

2019 ◽

Vol 21 (Supplement_3) ◽

pp. iii95-iii96

Author(s):

G Hallaert ◽

H Pinson ◽

D Vanhauwaert ◽

L Staelens ◽

C Vandenbroecke ◽

...

Keyword(s):

Overall Survival ◽

Radiation Dose ◽

Subventricular Zone ◽

Cox Regression ◽

Extent Of Resection ◽

Gross Total Resection ◽

Karnofsky Performance Score ◽

Mgmt Methylation ◽

Gene Methylation ◽

Total Resection

Abstract BACKGROUND The role of the subventricular zone (SVZ) in glioblastoma (GBM) is controversial. The past decade, several retrospective studies were published concerning the potential correlation between incidental radiation of the SVZ and survival in GBM patients. Although these publications showed conflicting results, a large study claimed an overall survival (OS) benefit for GBM patients after gross total resection if the ipsilateral SVZ received a higher dose than 40 Gy. We investigated this finding in our own population of GBM patients. MATERIAL AND METHODS A multicenter retrospective study was conducted including all adult patients treated for histologically proven GBM from 2003–2014. All patients received 60 Gy radiation therapy after surgery and concomitant temozolomide. Exclusion criteria were: infratentorial GBM; presence of other neoplasm(s); known previous history of low grade glioma; incomplete radiotherapy data. Demographic data were collected from the patient charts. O6-methylguanin-DNA-methyltransferase-promotor-gene (MGMT) methylation was determined on stored tumor samples using semi quantitative methylation-specific polymerase chain reaction (qMSP). SVZs (ipsilateral, contralateral and bilateral) were contoured on radiotherapy treatment plans. Multivariate Cox regression analysis was used to study the correlation between incidental SVZ radiation dose and OS. Age (cut-off 65 years), Karnofsky Performance Score (KPS; cut-off 70), methylation of the MGMT-promotor gene and extent of resection (biopsy; subtotal resection, groos total resection) were used as covariates. Patients alive at time of database closure were censored for analysis. RESULTS 183 patients were eligible for analysis. Mean age at diagnosis was 62 years, with an average KPS of 70. In 34% of patients, gross total resection (GTR) was achieved, while in 28% only a biopsy was taken. MGMT-promoter gene methylation was present in 39% of cases. Median ipsilateral, contralateral and bilateral SVZ doses were 46.1 Gy, 25.35 Gy and 34.8 Gy resp. In multivariate Cox regression, all covariates (age, P = 0.011; KPS, P = 0.001; MGMT methylation, P = 0.000; extent of resection, P = 0.000) were significantly associated with OS. Mean OS was 23 months, but median OS 13 months. There was no correlation between incidental radiation dose of the ipsilateral SVZ and OS for 46 Gy or 40 Gy (hazard ratio 0.82 (0.6–1.1), P = 0.225 and 0.89 (0.63–1.23), P = 0.52 resp.) for the whole group nor for the subgroup of gross total resection. CONCLUSION In this group of GBM patients, age, KPS, extent of resection and methylation of the MGMT-promotor gene were significantly correlated with OS, but not incidental ipsilateral SVZ radiation dose. The previously published positive results may result from bias, possibly arising from lack of inclusion of MGMT-promotor gene methylation as an important independent prognostic factor.

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Effect of the Extent of Surgical Resection on Survival and Quality of Life in Patients with Supratentorial Glioblastomas and Anaplastic Astrocytomas

Neurosurgery ◽

10.1227/00006123-198708000-00012 ◽

1987 ◽

Vol 21 (2) ◽

pp. 201-206 ◽

Cited By ~ 324

Author(s):

Mario Ammirati ◽

Nicholas Vick ◽

Liao Youlian ◽

Ciric Ivan ◽

Michael Mikhael

Keyword(s):

Surgical Resection ◽

Pathological Condition ◽

Tumor Resection ◽

Gross Total Resection ◽

Subtotal Resection ◽

Total Resection ◽

Postoperative Radiation Therapy ◽

Resection Group ◽

Extent Of Surgical Resection

Abstract Thirty-one patients operated upon for supratentorial glioblastomas or anaplastic astrocytomas were studied to evaluate the effect of the extent of surgical resection on the length and quality of survival. The median age was 50 years and the median preoperative Karnofsky rate was 80. Twenty-one patients (68%) had glioblastoma multiforme, and 10 patients (32%) had anaplastic astrocytoma. Early postoperative enhanced computed tomography was used to determine the extent of tumor resection. Gross total tumor resection was accomplished in 19 patients (61%), and subtotal resection was performed in 12 patients (39%). The two groups were comparable regarding age, sex, pathological condition, preoperative Karnofsky rating, tumor location, postoperative radiation therapy, and postoperative chemotherapy (P > 0.05). The gross total resection group lived longer than the subtotal resection group by life table analysis (P < 0.001; median survival of 90 and 43 weeks, respectively). Postoperatively, the mean functional ability measured by the Karnofsky rating was significantly increased in the gross total resection group (P = 0.006), but not in the subtotal resection group (P > 0.05). The difference in degree of change between preoperative and postoperative Karnofsky rating in the two groups was statistically significant (P = 0.002). The gross total resection group spent significantly more time after the operation in an independent status (Karnofsky rating ≥ 80) compared to the subtotal resection group (P = 0.007; median time of 185 and 12.5 weeks, respectively). Gross total resection of supratentorial glioblastomas and anaplastic astrocytomas is feasible and is directly associated with longer and better survival when compared to subtotal resection.

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