Extent of Resection Is Potent Prognostic Factor Next to Molecular Pathologic Subtype in Low-Grade Glioma

AbstractAvailable data imply that extent of resection (EOR) improves progression free survival (PFS) in patients harboring a low-grade glioma (LGG). Intraoperative high-field magnetic resonance imaging (iMRI) is an established diagnostic tool that can detect residual tumors in LGG surgery. We conducted a retrospective study to evaluate the extent of resection, clinical outcome and PFS in conventional and iMRI-based LGG resection.A total of 69 patients was assessed. Only World Health Organization (WHO) grade II LGGs were evaluated. Thirty-three patients had surgery using iMRI (2008–2013). Thirty-six patients underwent surgery before introduction of iMRI at our center (2000–2008). Demographic data, extent of resection (EOR), complication rate, overall time of surgery and progression free survival were evaluated.The majority of patients were treated for a diffuse astrocytoma in both cohorts (iMRI: 46.9%, historical (hist.): 61.1%). Extent of resection was a positive prognostic factor for longer PFS according to Cox regression multivariate analysis controlled by eloquent location, tumor recurrence and histological subtype [P<0.001, hazard ratio (HR) 0.247]. Additionally, the Cox regression showed the advantage and longer PFS of iMRI-assisted resections using the same settings (P=0.038, HR=0.378). Permanent neurological deficits (PND) after surgery were found in 12.5% (n=4) of the iMRI group and in 22.2% (n=8) of the historical group. Duration of surgery was significantly higher in the iMRI group (iMRI: 6.3 h, hist.: 4.3 h, P<0.036). However, there was no significant increase of postoperative surgical complications. Gross total resection (GTR) was achieved in 63.6% (n=21) of iMRI patients and 27.8% (n=10, P<0.0069) in the historical control, respectively. Binary logistic regression showed that iMRI has a significant impact on tumor remnants (P<0.001).In our study we have confirmed EOR to be an important positive prognostic factor for PFS. At our center, compared to a historical group, the routine use of iMRI increases EOR and was associated with a decrease in complications. Due to a selection bias no final conclusion can be drawn as to whether the use of iMRI increases PFS.

Download Full-text

Profound hearing loss following surgery in pediatric patients with posterior fossa low-grade glioma

Neuro-Oncology Practice ◽

10.1093/nop/npx025 ◽

2017 ◽

Vol 5 (2) ◽

pp. 96-103 ◽

Cited By ~ 1

Author(s):

Yahya Ghazwani ◽

Ibrahim Qaddoumi ◽

Johnnie K Bass ◽

Shengjie Wu ◽

Jason Chiang ◽

...

Keyword(s):

Hearing Loss ◽

Posterior Fossa ◽

Extent Of Resection ◽

Tumor Location ◽

Low Grade Glioma ◽

Gross Total Resection ◽

Subtotal Resection ◽

Low Grade ◽

Total Resection ◽

Profound Hearing Loss

Abstract Background Hearing loss may occur in patients with posterior fossa low-grade glioma who undergo surgery. Methods We retrospectively reviewed 217 patients with posterior fossa low-grade glioma, including 115 for whom results of hearing tests performed after surgery and before chemotherapy or radiation therapy were available. We explored the association of UHL with age at diagnosis, sex, race, tumor location, extent of resection, posterior fossa syndrome, ventriculoperitoneal shunt placement, and histology. Results Of the 115 patients, 15 (13.0%: 11 male, 6 black, 8 white, 1 multiracial; median age 7 years [range, 1.3–17.2 years]) had profound UHL after surgery alone or before receiving ototoxic therapy. Median age at tumor diagnosis was 6.8 years (range, 0.7–14.1 years), and median age at surgery was 6.8 years (range, 0.7–14.1 years). Patients with UHL had pathology characteristic of pilocytic astrocytoma (n = 10), ganglioglioma (n = 4), or low-grade astrocytoma (n = 1). Of these 15 patients, 4 underwent biopsy, 1 underwent gross total resection, 1 underwent near-total resection, and 9 underwent subtotal resection. UHL was more frequent in black patients than in white patients (OR 7.3, P = .007) and less frequent in patients who underwent gross total resection or near-total resection than in those who underwent subtotal resection (OR 0.11, P = .02). Conclusions Children undergoing surgery for posterior fossa low-grade glioma are at risk for UHL, which may be related to race or extent of resection. These patients should receive postoperative audiologic testing, as earlier intervention may improve outcomes.

Download Full-text

SURG-32. THE USE OF 5-AMINOLEVULINIC ACID IN LOW-GRADE GLIOMA RESECTION: A SYSTEMATIC REVIEW

Neuro-Oncology ◽

10.1093/neuonc/noz175.1032 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi246-vi246

Author(s):

Ahmad Almekkawi ◽

Tarek El Ahmadieh ◽

Karl Abi-Aad ◽

Salah Aoun ◽

Najib EL Tecle ◽

...

Keyword(s):

Systematic Review ◽

Quality Index ◽

Aminolevulinic Acid ◽

High Grade Glioma ◽

Extent Of Resection ◽

Low Grade Glioma ◽

Low Grade ◽

High Grade ◽

Visualization Technology ◽

Glioma Resection

Abstract BACKGROUND 5-aminolevulinic acid is a reliable tool for optimizing high-grade glioma resection. However, its efficacy in low-grade glioma resection remains unclear. OBJECTIVE To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and effect on the extent of resection. METHODS A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. Quality index of the selected papers using the Downs and Black criteria checklist was provided. RESULTS Twelve articles met the selection criteria with 244 histologically-confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n=60/244; 24.5%) demonstrated visual intra-operative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies, however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10–17) which correlated with an overall good quality. CONCLUSION There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.

Download Full-text

Surgery for low-grade glioma infiltrating the central cerebral region: location as a predictive factor for neurological deficit, epileptological outcome, and quality of life

Journal of Neurosurgery ◽

10.3171/2013.5.jns122235 ◽

2013 ◽

Vol 119 (2) ◽

pp. 318-323 ◽

Cited By ~ 37

Author(s):

Philippe Schucht ◽

Fadi Ghareeb ◽

Hugues Duffau

Keyword(s):

Quality Of Life ◽

Return To Work ◽

Seizure Control ◽

Extent Of Resection ◽

Low Grade Glioma ◽

Neurological Deficits ◽

Main Concern ◽

Low Grade ◽

Who Grade

Object A main concern with regard to surgery for low-grade glioma (LGG, WHO Grade II) is maintenance of the patient's functional integrity. This concern is particularly relevant for gliomas in the central region, where damage can have grave repercussions. The authors evaluated postsurgical outcomes with regard to neurological deficits, seizures, and quality of life. Methods Outcomes were compared for 33 patients with central LGG (central cohort) and a control cohort of 31 patients with frontal LGG (frontal cohort), all of whom had had medically intractable seizures before undergoing surgery with mapping while awake. All surgeries were performed in the period from February 2007 through April 2010 at the same institution. Results For the central cohort, the median extent of resection was 92% (range 80%–97%), and for the frontal cohort, the median extent of resection was 93% (range 83%–98%; p = 1.0). Although the rate of mild neurological deficits was similar for both groups, seizure freedom (Engel Class I) was achieved for only 4 (12.1%) of 33 patients in the central cohort compared with 26 (83.9%) of 31 patients in the frontal cohort (p < 0.0001). The rate of return to work was lower for patients in the central cohort (4 [12.1%] of 33) than for the patients in the frontal cohort (28 [90.3%] of 31; p < 0.0001). Conclusions Resection of central LGG is feasible and safe when appropriate intraoperative mapping is used. However, seizure control for these patients remains poor, a finding that contrasts markedly with seizure control for patients in the frontal cohort and with that reported in the literature. For patients with central LGG, poor seizure control ultimately determines quality of life because most will not be able to return to work.

Download Full-text

Awake Mapping Optimizes the Extent of Resection for Low-Grade Gliomas in Eloquent Areas

Neurosurgery ◽

10.1227/01.neu.0000369514.74284.78 ◽

2010 ◽

Vol 66 (6) ◽

pp. 1074-1084 ◽

Cited By ~ 149

Author(s):

Alessandro De Benedictis ◽

Sylvie Moritz-Gasser ◽

Hugues Duffau

Keyword(s):

Extent Of Resection ◽

Low Grade Glioma ◽

Awake Surgery ◽

Low Grade ◽

Functional Sites ◽

Social Lives ◽

Eloquent Areas ◽

Functional Regions ◽

First Time

Abstract BACKGROUND Awake craniotomy with intraoperative electrical mapping is a reliable method to minimize the risk of permanent deficit during surgery for low-grade glioma located within eloquent areas classically considered inoperable. However, it could be argued that preservation of functional sites might lead to a lesser degree of tumor removal. To the best of our knowledge, the extent of resection has never been directly compared between traditional and awake procedures. OBJECTIVE We report for the first time a series of patients who underwent 2 consecutive surgeries without and with awake mapping. METHODS Nine patients underwent surgery for a low-grade glioma in functional sites under general anesthesia in other institutions. The resection was subtotal in 3 cases and partial in 6 cases. There was a postoperative worsening in 3 cases. We performed a second surgery in the awake condition with intraoperative electrostimulation. The resection was performed according to functional boundaries at both the cortical and subcortical levels. RESULTS Postoperative magnetic resonance imaging showed that the resection was complete in 5 cases and subtotal in 4 cases (no partial removal) and that it was improved in all cases compared with the first surgery (P = .04). There was no permanent neurological worsening. Three patients improved compared with the presurgical status. All patients returned to normal professional and social lives. CONCLUSION Our results demonstrate that awake surgery, known to preserve the quality of life in patients with low-grade glioma, is also able to significantly improve the extent of resection for lesions located in functional regions.

Download Full-text

Predictors of stimulation-induced seizures during perirolandic glioma resection using intraoperative mapping techniques

Surgical Neurology International ◽

10.25259/sni_873_2020 ◽

2021 ◽

Vol 12 ◽

pp. 117

Author(s):

Ahmed A. Morsy ◽

Ayman M. Ismail ◽

Yasser M. Nasr ◽

Salwa H. Waly ◽

Esam A. Abdelhameed

Keyword(s):

Neurological Status ◽

Extent Of Resection ◽

Low Grade Glioma ◽

Low Grade ◽

Motor Responses ◽

Intraoperative Mapping ◽

Subcortical Stimulation ◽

The Mean ◽

Mapping Techniques ◽

Glioma Resection

Background: Intraoperative mapping techniques maximize safety and efficacy during perirolandic glioma resection but may induce seizures and limit the procedure. We aim to report the incidence and predictors of stimulation-induced seizures during mapping either patient is awake or under general anesthesia (GA). Methods: Retrospective analysis of 64 patients (40 awake and 24 GA) with perirolandic glioma underwent resection using intraoperative mapping techniques between 2014 and 2019. Preoperative data, operative details, postoperative neurological status, and extent of resection (EOR) were analyzed. Predictors of intraoperative seizures were assessed. Results: The mean cortical and subcortical stimulation intensities needed to evoke motor responses were significantly lower in awake cases than in GA patients (4.9 ± 0.42 vs. 8.9 ± 1.2 mA) and (8.3 ± 0.62 vs. 12.1 ± 1.1 mA), respectively (P = 0.01). Incidence of intraoperative seizures was lower but statistically non-significant in awake cases (10% vs. 12.5%) (P = 0.76). Preoperative multiple antiepileptic drugs (AEDs) (P = 0.03) and low-grade glioma (P = 0.04) were statistically significant predictors for intraoperative seizures. Mean EOR in awake cases was 92.03% and 90.05% in GA cases (P = 0.23). Postoperative deficits were permanent after 3 months only in 5% of awake patients versus 8.3% of GA group (P = 0.59). Conclusion: Awake craniotomy with intraoperative mapping can be done safely for perirolandic gliomas with lower but statistically nonsignificant incidence of intraoperative seizures and this could be attributed to statistically significant lower stimulation intensities required for mapping. Preoperative multiple AEDs and low-grade glioma are significant predictors for intraoperative seizures.

Download Full-text

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

Journal of Neurosurgery ◽

10.3171/2019.6.jns19972 ◽

2020 ◽

Vol 133 (5) ◽

pp. 1291-1301 ◽

Cited By ~ 5

Author(s):

Vasileios K. Kavouridis ◽

Alessandro Boaro ◽

Jeffrey Dorr ◽

Elise Y. Cho ◽

J. Bryan Iorgulescu ◽

...

Keyword(s):

Tumor Volume ◽

Cox Regression ◽

Molecular Subtypes ◽

Progression Free Survival ◽

Residual Tumor ◽

Extent Of Resection ◽

Low Grade Glioma ◽

Low Grade ◽

Who Grade ◽

Free Survival

OBJECTIVEWhile 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.METHODSThe 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).RESULTSThere 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.CONCLUSIONSThe 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.

Download Full-text

The “onco-functional balance” in surgery for diffuse low-grade glioma: integrating the extent of resection with quality of life

Acta Neurochirurgica ◽

10.1007/s00701-013-1653-9 ◽

2013 ◽

Vol 155 (6) ◽

pp. 951-957 ◽

Cited By ~ 84

Author(s):

Hugues Duffau ◽

Emmanuel Mandonnet

Keyword(s):

Quality Of Life ◽

Extent Of Resection ◽

Low Grade Glioma ◽

Low Grade ◽

Functional Balance

Download Full-text

WP1-17 Risk factors and patterns of progression in a surgical cohort of low grade glioma patients

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-abn.18 ◽

2019 ◽

Vol 90 (3) ◽

pp. e6.2-e6

Author(s):

S Acharya ◽

J Lavrador ◽

R Visagan ◽

V Narbad ◽

J Jung ◽

...

Keyword(s):

Risk Factors ◽

Performance Status ◽

Extent Of Resection ◽

Low Grade Glioma ◽

Subtotal Resection ◽

Low Grade ◽

Neurosurgical Procedures ◽

Volumetric Change ◽

Who Grade ◽

Adjusted Analysis

ObjectivesTo understand the risk factors for and patterns of progression of low grade glioma (LGG).DesignSingle centre retrospective cohort study.SubjectsPatients undergoing at least two neurosurgical procedures for LGG, the first being for diffuse LGG (WHO 2). 22 patients included (14M; 8F); mean age at time of first operation 37.7±2.7 years. 20 patients had a Performance Status (PS) 0–1 and 2 patients had a PS 2.MethodsAll patients with LGG diagnosed in between 2009–2018 were retrospectively evaluated. Variables of interest included demographics, staging, performance status, time to re-operation (TTR), extent of resection, molecular genetics (1p19q co-deletion, IDH status). Tumour volumes were estimated from MRI images by the validated ABC/2 equation. Statistical analyses were performed by Stata13.0.ResultsThe tumour progressed in WHO grade in 18 patients (WHO grade 3 (n=15); WHO grade 4 (n=3). Mean time to re-operation after the first surgery was 7.0±1.2 years following gross total resection (GTR) and 3.2±0.7 years following subtotal resection (STR). Non-adjusted analysis of risk factors for time to re-operation (TTR) showed absence of 1p19q co-deletion as a risk factor (p=0.021). Adjusted analysis revealed that GTR, 1p19q mutation, PS 0 at 1 st surgery and tumour volumetric change decrease the risk for re-intervention (p<0.05). Chemo-radiotherapy was not associated with TTR.ConclusionsIn our cohort, TTR in LGG was influenced by the amount of initial resection, 1p19q deletion, PS and post-operative volumetric change.

Download Full-text