Insular gliomas: the case for surgical management

2009 ◽  
Vol 110 (4) ◽  
pp. 685-695 ◽  
Author(s):  
Matthias Simon ◽  
Georg Neuloh ◽  
Marec von Lehe ◽  
Bernhard Meyer ◽  
Johannes Schramm
Keyword(s):  
Scale Score ◽  
Functional Outcomes ◽  
Good Survival ◽  
Karnofsky Performance Scale ◽  
Complication Rates ◽  
Who Grade ◽  
Histological Features ◽  
Oligodendroglial Tumors ◽  
Karnofsky Performance Scale Score ◽  
Performance Scale

Object Treatment for insular (paralimbic) gliomas is controversial. In this report the authors summarize their experience with microsurgical resection of insular tumors. Methods The authors analyzed complications, functional outcomes, and survival in a series of 101 operations performed in 94 patients between 1995 and 2005. Results A > 90% resection was achieved in 42%, and 70–90% tumor removal was accomplished in 51% of cases. Functional outcomes varied considerably between patient subgroups. For example, in neurologically intact patients ≤ 40 years of age with WHO Grade I–III tumors, good outcomes (Karnofsky Performance Scale Score 80–100) were seen in 91% of cases. Predictors of an unfavorable functional outcome included histological features of glioblastoma, advanced age, and a low preoperative Karnofsky Performance Scale score. One year after surgery, 76% of patients who had presented with epilepsy were seizure free or experienced only isolated, nondebilitating seizures. Surprisingly good survival rates were seen after surgery for anaplastic gliomas. The median survival for patients with anaplastic astrocytomas (WHO Grade III) was 5 years, and the 5-year survival rate for those with anaplastic oligodendroglial tumors was 80%. Independent predictors of survival included younger age, favorable histological features (WHO Grade I and oligodendroglial tumors), Yaşargil Type 5A/B tumors with frontal extensions, and more extensive resections. Conclusions Insular tumor surgery carries substantial complication rates. However, surprisingly similar figures have been reported in large unselected craniotomy series and also after alternative treatment regimens. In view of the oncological benefits of resective surgery, our data would therefore argue for microsurgery as the primary treatment for most patients with a presumed WHO Grade I–III tumor. Patients with glioblastomas and/or age > 60 years require a more cautious approach.

EXTENT OF RESECTION AND SURVIVAL IN GLIOBLASTOMA MULTIFORME

Neurosurgery ◽  
2008 ◽  
Vol 62 (3) ◽  
pp. 564-576 ◽  
Author(s):  
◽  
Walter Stummer ◽  
Hanns-Jürgen Reulen ◽  
Thomas Meinel ◽  
Uwe Pichlmeier ◽  
...  
Keyword(s):  
Glioblastoma Multiforme ◽  
Scale Score ◽  
Aminolevulinic Acid ◽  
Residual Tumor ◽  
Complete Resection ◽  
Karnofsky Performance Scale ◽  
Resonance Imaging ◽  
Treatment Bias ◽  
Karnofsky Performance Scale Score ◽  
Performance Scale

Abstract OBJECTIVE The influence of the degree of resection on survival in patients with glioblastoma multiforme is still under discussion. The highly controlled 5-aminolevulinic acid study provided a unique platform for addressing this question as a result of the high frequency of “complete” resections, as revealed by postoperative magnetic resonance imaging scans achieved by fluorescence-guided resection and homogeneous patient characteristics. METHODS Two hundred forty-three patients with glioblastoma multiforme per protocol from the 5-aminolevulinic acid study were analyzed. Patients with complete and incomplete resections as revealed by early magnetic resonance imaging scans were compared. Prognostic factors that might cause bias regarding resection and influence survival (e.g., tumor size, edema, midline shift, location, age, Karnofsky Performance Scale score, National Institutes of Health Stroke Scale score) were used for analysis of overall survival. Time to reintervention (chemotherapy, reoperation) was analyzed further to exclude bias regarding second-line therapies. RESULTS Treatment bias was identified in patients with complete (n = 122) compared with incomplete resection (n = 121), i.e., younger age and less frequent eloquent tumor location. Other factors, foremost preoperative tumor size, were identical. Patients without residual tumor survived longer (16.7 versus 11.8 mo, P < 0.0001). In multivariate analysis, only residual tumor, age, and Karnofsky Performance Scale score were significantly prognostic. To account for distribution bias, patients were stratified for age (>60 or ≤60 yr) and eloquent location. Survival advantages from complete resection remained significant within subgroups, and age/eloquent location were no longer unevenly distributed. Reinterventions occurred marginally earlier in patients with residual tumor (6.7 versus 9.5 mo, P = 0.0582). CONCLUSION Treatment bias was demonstrated regarding resection and second-line therapies. However, bias and imbalances were controllable in the cohorts available from the 5-aminolevulinic acid study so that the present data now provide Level 2b evidence (Oxford Centre for Evidence-based Medicine) that survival depends on complete resection of enhancing tumor in glioblastoma multiforme.

Age and Radiation Response in Glioblastoma Multiforme

Neurosurgery ◽  
2001 ◽  
Vol 49 (6) ◽  
pp. 1288-1298 ◽  
Author(s):  
Fred G. Barker ◽  
Susan M. Chang ◽  
David A. Larson ◽  
Penny K. Sneed ◽  
William M. Wara ◽  
...  
Keyword(s):  
Scale Score ◽  
Radiation Treatment ◽  
External Beam Radiation Therapy ◽  
Radiation Response ◽  
External Beam Radiation ◽  
Karnofsky Performance Scale ◽  
External Beam ◽  
Beam Radiation ◽  
Karnofsky Performance Scale Score ◽  
Performance Scale

ABSTRACT OBJECTIVE Advanced age is a strong predictor of shorter survival in patients with glioblastoma multiforme (GM), especially for those who receive multimodality treatment. Radiographically assessed tumor response to external beam radiation therapy is an important prognostic factor in GM. We hypothesized that older GM patients might have more radioresistant tumors. METHODS We studied radiographically assessed response to external beam radiation treatment (five-level scale) in relation to age and other prognostic factors in a cohort of 301 GM patients treated on two prospective clinical protocols. A total of 223 patients (74%) were assessable for radiographically assessed radiation response. A proportional odds ordinal regression model was used for univariate and multivariate analysis. RESULTS Younger age (P = 0.006), higher Karnofsky Performance Scale score before radiotherapy (P = 0.027), and more extensive surgical resection (P = 0.028) predicted better radiation response in univariate analyses. Results were similar when clinical criteria were used to classify an additional 61 patients without radiographically assessed radiation response (stable versus progressive disease). In multivariate analyses, age and extent of resection were significant independent predictors of radiation response (P < 0.05); Karnofsky Performance Scale score was of borderline significance (P = 0.07). CONCLUSION Older GM patients are less likely to have good responses to postoperative external beam radiation therapy. Karnofsky Performance Scale score before radiation treatment and extent of surgical resection are additional predictors of radiographically assessed radiation response in GM.

Outcomes in Reoperated Low-Grade Gliomas

Neurosurgery ◽  
2015 ◽  
Vol 77 (2) ◽  
pp. 175-184 ◽  
Author(s):  
Rohan Ramakrishna ◽  
Adam Hebb ◽  
Jason Barber ◽  
Robert Rostomily ◽  
Daniel Silbergeld
Keyword(s):  
Scale Score ◽  
Progression Free Survival ◽  
Residual Tumor ◽  
Extent Of Resection ◽  
Karnofsky Performance Scale ◽  
Low Grade ◽  
Free Survival ◽  
First Recurrence ◽  
Karnofsky Performance Scale Score ◽  
Performance Scale

Abstract BACKGROUND: Low-grade gliomas (LGGs) comprise a diverse set of intrinsic brain tumors that correlate strongly with survival. Data on the effect of reoperation are sparse. OBJECTIVE: To evaluate the effect of reoperation on patients with LGG. METHODS: Fifty-two consecutive patients with reoperated LGGs treated at the University of Washington between 1986 and 2004 were identified and evaluated in a retrospective analysis. RESULTS: The average overall survival (OS) for this cohort was 12.95 ± 0.96 years. The overall 10-year survival rate was 57%. The absence of any residual tumor at either the first or second operation was associated with significantly increased OS. Negative prognostic variables for OS included the use of upfront radiation and pathology at recurrence. The average overall progression-free survival to the first recurrence (PFS1) was 6.23 ± 0.51 years. Positive prognostic factors for improved PFS1 included the use of upfront radiation therapy. Variables not associated with differences in PFS1 included the use of upfront chemotherapy, enhancement, pathology, extent of resection, the presence of residual tumor, and Karnofsky Performance Scale score <80. The average overall progression-free survival to the second recurrence was 2.73 ± 0.39 years. Pathology at recurrence was associated with significant differences in progression-free survival to the second recurrence, as was extent of resection at time of first recurrence, and Karnofsky Performance Scale score <80. CONCLUSION: This is among the largest studies to assess variables associated with outcome in patients with reoperated LGG. Reresection appears to provide significant benefit, and extent of resection remains the strongest predictor of OS.

Radiosurgery alone for 5 or more brain metastases: expert opinion survey

2010 ◽  
Vol 113 (Special_Supplement) ◽  
pp. 84-89 ◽  
Author(s):  
Jonathan P. S. Knisely ◽  
Masaaki Yamamoto ◽  
Cary P. Gross ◽  
William A. Castrucci ◽  
Hidefumi Jokura ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
San Francisco ◽  
Scale Score ◽  
Gamma Knife ◽  
Outcome Variable ◽  
Karnofsky Performance Scale ◽  
Clinical Factors ◽  
Karnofsky Performance Scale Score ◽  
Performance Scale

Object Oligometastatic brain metastases may be treated with stereotactic radiosurgery (SRS) alone, but no consensus exists as to when SRS alone would be appropriate. A survey was conducted at 2 radiosurgery meetings to determine which factors SRS practitioners emphasize in recommending SRS alone, and what physician characteristics are associated with recommending SRS alone for ≥ 5 metastases. Methods All physicians attending the 8th Biennial Congress and Exhibition of the International Stereotactic Radiosurgery Society in June 2007 and the 18th Annual Meeting of the Japanese Society of Stereotactic Radiosurgery in July 2009 were asked to complete a questionnaire ranking 14 clinical factors on a 5-point Likert-type scale (ranging from 1 = not important to 5 = very important) to determine how much each factor might influence a decision to recommend SRS alone for brain metastases. Results were condensed into a single dichotomous outcome variable of “influential” (4–5) versus “not influential” (1–3). Respondents were also asked to complete the statement: “In general, a reasonable number of brain metastases treatable by SRS alone would be, at most, ___.” The characteristics of physicians willing to recommend SRS alone for ≥ 5 metastases were assessed. Chi-square was used for univariate analysis, and logistic regression for multivariate analysis. Results The final study sample included 95 Gamma Knife and LINAC-using respondents (54% Gamma Knife users) in San Francisco and 54 in Sendai (48% Gamma Knife users). More than 70% at each meeting had ≥ 5 years experience with SRS. Sixty-five percent in San Francisco and 83% in Sendai treated ≥ 30 cases annually with SRS. The highest number of metastases considered reasonable to treat with SRS alone in both surveys was 50. In San Francisco, the mean and median numbers of metastases considered reasonable to treat with SRS alone were 6.7 and 5, while in Sendai they were 11 and 10. In the San Francisco sample, the clinical factors identified to be most influential in decision making were Karnofsky Performance Scale score (78%), presence/absence of mass effect (76%), and systemic disease control (63%). In Sendai, the most influential factors were the size of the metastases (78%), the Karnofsky Performance Scale score (70%), and metastasis location (68%). In San Francisco, 55% of respondents considered treating ≥ 5 metastases and 22% considered treating ≥ 10 metastases “reasonable.” In Sendai, 83% of respondents considered treating ≥ 5 metastases and 57% considered treating ≥ 10 metastases “reasonable.” In both groups, private practitioners, neurosurgeons, and Gamma Knife users were statistically significantly more likely to treat ≥ 5 metastases with SRS alone. Conclusions Although there is no clear consensus for how many metastases are reasonable to treat with SRS alone, more than half of the radiosurgeons at 2 international meetings were willing to extend the use of SRS as an initial treatment for ≥ 5 brain metastases. Given the substantial variation in clinicians' approaches to SRS use, further research is required to identify patient characteristics associated with optimal SRS outcomes.

scholarly journals Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for Glioblastoma of the Corpus Callosum

Neurosurgery ◽  
2018 ◽  
Vol 83 (3) ◽  
pp. 556-565 ◽  
Author(s):  
Thomas L Beaumont ◽  
Alireza M Mohammadi ◽  
Albert H Kim ◽  
Gene H Barnett ◽  
Eric C Leuthardt
Keyword(s):  
Corpus Callosum ◽  
Effective Treatment ◽  
Scale Score ◽  
Survival Benefit ◽  
Tumor Volume ◽  
Thermal Therapy ◽  
Karnofsky Performance Scale ◽  
Safety And Efficacy ◽  
Karnofsky Performance Scale Score ◽  
Performance Scale

Abstract BACKGROUND Glioblastoma of the corpus callosum is particularly difficult to treat, as the morbidity of surgical resection generally outweighs the potential survival benefit. Laser interstitial thermal therapy (LITT) is a safe and effective treatment option for difficult to access malignant gliomas of the thalamus and insula. OBJECTIVE To assess the safety and efficacy of LITT for the treatment of glioblastoma of the corpus callosum. METHODS We performed a multicenter retrospective analysis of prospectively collected data. The primary endpoint was the safety and efficacy of LITT as a treatment for glioblastoma of the corpus callosum. Secondary endpoints included tumor coverage at thermal damage thresholds, median survival, and change in Karnofsky Performance Scale score 1 mo after treatment. RESULTS The study included patients with de novo or recurrent glioblastoma of the corpus callosum (n = 15). Mean patient age was 54.7 yr. Mean pretreatment Karnofsky Performance Scale score was 80.7 and there was no significant difference between subgroups. Mean tumor volume was 18.7 cm3. Hemiparesis occurred in 26.6% of patients. Complications were more frequent in patients with tumors >15 cm3 (RR 6.1, P = .009) and were associated with a 32% decrease in survival postLITT. Median progression-free survival, survival postLITT, and overall survival were 3.4, 7.2, and 18.2 mo, respectively. CONCLUSION LITT is a safe and effective treatment for glioblastoma of the corpus callosum and provides survival benefit comparable to subtotal surgical resection with adjuvant chemoradiation. LITT-associated complications are related to tumor volume and can be nearly eliminated by limiting the procedure to tumors of 15 cm3 or less.

Bypass Grafting and Revascularization in the Management of Posterior Circulation Aneurysms

Neurosurgery ◽  
2004 ◽  
Vol 55 (5) ◽  
pp. 1036-1049 ◽  
Author(s):  
James J. Evans ◽  
Laligam N. Sekhar ◽  
Ramin Rak ◽  
Dinko Stimac
Keyword(s):  
Patient Outcome ◽  
Scale Score ◽  
Posterior Fossa ◽  
Clinical Information ◽  
Posterior Circulation ◽  
Karnofsky Performance Scale ◽  
Imaging Data ◽  
Posterior Circulation Aneurysms ◽  
Karnofsky Performance Scale Score ◽  
Performance Scale

Abstract OBJECTIVE: To describe the bypass techniques, cranial base approaches, results of treatment, causes of failure, and lessons that are learned in patients with posterior circulation aneurysms requiring revascularization. METHODS: Retrospectively, 19 patients with posterior fossa aneurysms requiring revascularization procedures operated on between 1991 and 2002 were reviewed. Preoperative and postoperative clinical information, neurological examinations, imaging data, and updated follow-ups were reviewed. Patient outcome is reported as the most current Karnofsky Performance Scale score. RESULTS: A total of 22 arterial bypasses were performed in 19 patients for posterior fossa circulation aneurysms between 1991 and 2002. The mean follow-up was 41 months. Total graft patency rate (including patients requiring reoperation) was 86.4% (before) and 100% (after) salvage procedures. Patient outcome was 84.2% with Karnofsky Performance Scale score 80 to 90, and three deaths occurred perioperatively. Only one death could be attributed to the failure of the radial artery graft because of spasm and subsequent rupture during angioplasty. CONCLUSION: Certain graft selection criteria and technical considerations contribute to the success or failure of bypass grafts in the management of posterior circulation aneurysms. Bypass procedures remain an important method of management of complex posterior circulation aneurysms, in addition to endovascular procedures.

Brain Metastases Treated with Radiosurgery Alone: An Alternative to Whole Brain Radiotherapy?

Neurosurgery ◽  
2003 ◽  
Vol 52 (6) ◽  
pp. 1318-1326 ◽  
Author(s):  
Toshinori Hasegawa ◽  
Douglas Kondziolka ◽  
John C. Flickinger ◽  
Anand Germanwala ◽  
L. Dade Lunsford
Keyword(s):  
Brain Metastases ◽  
Survival Time ◽  
Scale Score ◽  
Median Survival ◽  
Primary Tumor ◽  
Median Survival Time ◽  
Tumor Control ◽  
Karnofsky Performance Scale ◽  
Karnofsky Performance Scale Score ◽  
Performance Scale

Abstract OBJECTIVE Whole brain radiotherapy (WBRT) provides benefit for patients with brain metastases but may result in neurological toxicity for patients with extended survival times. Stereotactic radiosurgery in combination with WBRT has become an important approach, but the value of WBRT has been questioned. As an alternative to WBRT, we managed patients with stereotactic radiosurgery alone, evaluated patients' outcomes, and assessed prognostic factors for survival and tumor control. METHODS One hundred seventy-two patients with brain metastases were managed with radiosurgery alone. One hundred twenty-one patients were evaluable with follow-up imaging after radiosurgery. The median patient age was 60.5 years (age range, 16–86 yr). The mean marginal tumor dose and volume were 18.5 Gy (range, 11–22 Gy) and 4.4 ml (range, 0.1–24.9 ml). Eighty percent of patients had solitary tumors. RESULTS The overall median survival time was 8 months. The median survival time in patients with no evidence of primary tumor disease or stable disease was 13 and 11 months. The local tumor control rate was 87%. At 2 years, the rate of local control, remote brain control, and total intracranial control were 75, 41, and 27%, respectively. In multivariate analysis, advanced primary tumor status (P = 0.0003), older age (P = 0.008), lower Karnofsky Performance Scale score (P = 0.01), and malignant melanoma (P = 0.005) were significant for poorer survival. The median survival time was 28 months for patients younger than 60 years of age, with Karnofsky Performance Scale score of at least 90, and whose primary tumor status showed either no evidence of disease or stable disease. Tumor volume (P = 0.02) alone was significant for local tumor control, whereas no factor affected remote or intracranial tumor control. Eleven patients developed complications, six of which were persistent. Nineteen (16.5%) of 116 patients in whom the cause of death was obtained died as a result of causes related to brain metastasis. CONCLUSION Brain metastases were controlled well with radiosurgery alone as initial therapy. We advocate that WBRT should not be part of the initial treatment protocol for selected patients with one or two tumors with good control of their primary cancer, better Karnofsky Performance Scale score, and younger age, all of which are predictors of longer survival.

Embolization of Spinal Cord Arteriovenous Shunts: Morphological and Clinical Follow-up and Results—Review of 69 Consecutive Cases

Neurosurgery ◽  
2003 ◽  
Vol 53 (1) ◽  
pp. 40-50 ◽  
Author(s):  
Georges Rodesch ◽  
Michel Hurth ◽  
Beatrice Ducot ◽  
Hortensia Alvarez ◽  
Philippe David ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Endovascular Treatment ◽  
Scale Score ◽  
Karnofsky Performance Scale ◽  
Arteriovenous Shunts ◽  
The Mean ◽  
Acrylic Glue ◽  
Karnofsky Performance Scale Score ◽  
Performance Scale

Abstract OBJECTIVE We sought to analyze the results of embolization in patients with intradural spinal cord arteriovenous shunts. METHODS The clinical and radiological files of 69 of a population of 155 patients treated with embolization between 1981 and 1999 were reviewed retrospectively. The patients' clinical status was evaluated according to Karnofsky Performance Scale score. Twenty-one (14%) of 155 patients were treated surgically because they were thought to be poor candidates for embolization. Twenty-four (15%) of 155 patients were considered untreatable with surgery or embolization; in these patients, follow-up was proposed, but only 8 of them were followed appropriately and remained stable after the first consultation. Forty-one (26%) of 155 patients consulted our group, but no follow-up could be obtained. In 69 (45%) of 155 patients, comprising 20 children and 49 adults, endovascular treatment was performed with the patients under general anesthesia and without provocative tests, mainly with acrylic glue, in 99% of these patients. RESULTS The mean number of diagnostic and therapeutic sessions was 3.5 per patient, and the mean number of pure therapeutic sessions was 1.5 per patient. Follow-up ranged between 6 months and 18 years (mean, 5.6 yr). In 16% of patients, anatomic obliteration of spinal cord arteriovenous shunts was obtained. Embolization reduced more than 50% of the spinal cord arteriovenous shunts in 86% of cases. No recanalization was noted on follow-up angiograms. Good clinical outcomes were obtained in 83% of the patients: 15% of them were asymptomatic, 43% were improved, and 25% were stable. In 4% of patients, embolization failed to stabilize the disease. Transient deficits were seen after embolization in 14% of the patients, and permanent severe complications occurred in 4% of the patients (Karnofsky Performance Scale score ≤70). Mild worsening was seen in 9% of the patients (Karnofsky Performance Scale score, 80). No bleeding or rebleeding was seen after endovascular treatment was considered to have been completed. CONCLUSION This study proves that embolization with acrylic glue is a therapeutic option that compares favorably with surgery or embolization with other agents (particles, coils, or balloons). It offers stable long-term clinical results, despite not necessarily achieving total cure. Studies of larger series with longer follow-up are necessary to confirm these encouraging therapeutic data.

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