PO-0738 Extent of resection is potent prognostic factor next to molecular 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.

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SURG-15. A NOVEL RISK MODEL TO DEFINE THE RELATIVE BENEFIT OF MAXIMAL EXTENT OF RESECTION WITHIN PROGNOSTIC GROUPS IN NEWLY DIAGNOSED DIFFUSE LOW-GRADE GLIOMA

Neuro-Oncology ◽

10.1093/neuonc/noaa215.862 ◽

2020 ◽

Vol 22 (Supplement_2) ◽

pp. ii206-ii206

Author(s):

Shawn Hervey-Jumper ◽

Annette Molinaro ◽

Joanna Phillips ◽

Ramin Morshed ◽

Jacob Young ◽

...

Keyword(s):

Cytoreductive Surgery ◽

Risk Model ◽

Molecular Subtype ◽

Prognostic Significance ◽

Extent Of Resection ◽

Low Grade Glioma ◽

Interactive Effects ◽

Low Grade ◽

Newly Diagnosed ◽

Relative Benefit

Abstract BACKGROUND The overall prognostic significance of maximal surgical resection in patients with diffuse low-grade glioma has been well established. Nonetheless, prior studies omit the combined importance of molecular subclass, patient characteristics, and chemoradiation. Similar to findings recently published in newly diagnosed glioblastoma, incorporation of these interactive factors may redefine the relative benefit of cytoreductive surgery. METHODS We examine the interactive effects of volumetric extent of resection with molecular and clinical factors to develop a new roadmap for cytoreductive surgery. Based on a 20-year retrospective cohort of 556 patients with WHO II diffuse low-grade glioma treated with surgery at UCSF 444 had complete records for survival modeling and recursive partitioning (RPA) to investigate multivariate relationships of overall and progression free survival. RESULTS Regardless of molecular subtype, patients with tumor volume under 55cm3 and postoperative volume of residual under 1.9cm3 experience the longest OS (median OS: not reached). Patients with volume of residual over 1.9cm3 experience a OS similar to that of patients with large (over 55cm3) oligodendrogliomas (median OS: not reached). Patients faring worst have large (over 55cm3) astrocytic gliomas (median OS: 84.8 months). Patients not treated with chemotherapy and either ATRX wild-type tumors or ATRX-mutant tumors with small (under 1cm3) volume of residual have the longest PFS together with chemotherapy treated patients who receive either no radiation or radiation for p53-mutant tumors under 30cm3 (median PFS 119 months). Patients with the shortest PFS are under 32-years with larger volume of residual (>1cm3), who receive no chemotherapy for ATRX-mutant tumors together with patients who receive both chemoradiation for larger (>30cm3) p53 mutant tumors (median PFS 30.8 months). CONCLUSION This is the first study to combine extent of resection with molecular and clinical information which paves the way for rethinking surgical strategies for individual patients with newly diagnosed low-grade gliomas.

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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.

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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.

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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.

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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.

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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.

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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.

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Abstract 3201: Molecular subtype specific biomarkers improve prediction of temozolomide therapy in low grade glioma

10.1158/1538-7445.am2020-3201 ◽

2020 ◽

Author(s):

Feng Jia ◽

Feilong Zhao ◽

Xiaoyan Zhang ◽

Jiao Feng ◽

Tonghui Ma ◽

...

Keyword(s):

Molecular Subtype ◽

Low Grade Glioma ◽

Low Grade

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