Multiple craniotomies in the management of multifocal and multicentric glioblastoma

Clinical article

Restricted access


Multiple craniotomies have been performed for resection of multiple brain metastases in the same surgical session with satisfactory outcomes, but the role of this procedure in the management of multifocal and multicentric glioblastomas is undetermined, although it is not the standard approach at most centers.


The authors performed a retrospective analysis of data prospectively collected between 1993 and 2008 in 20 patients with multifocal or multicentric glioblastomas (Group A) who underwent resection of all lesions via multiple craniotomies during a single surgical session. Twenty patients who underwent resection of solitary glioblastoma (Group B) were selected to match Group A with respect to the preoperative Karnofsky Performance Scale (KPS) score, tumor functional grade, extent of resection, age at time of surgery, and year of surgery. Clinical and neurosurgical outcomes were evaluated.


In Group A, the median age was 52 years (range 32–78 years); 70% of patients were male; the median preoperative KPS score was 80 (range 50–100); and 9 patients had multicentric glioblastomas and 11 had multifocal glioblastomas. Aggressive resection of all lesions in Group A was achieved via multiple craniotomies in the same session, with a median extent of resection of 100%. Groups A and B were comparable with respect to all the matching variables as well as the amount of tumor necrosis, number of cysts, and the use of intraoperative navigation. The overall median survival duration was 9.7 months in Group A and 10.5 months in Group B (p = 0.34). Group A and Group B (single craniotomy) had complication rates of 30% and 35% and 30-day mortality rates of 5% (1 patient) and 0%, respectively.


Aggressive resection of all lesions in selected patients with multifocal or multicentric glioblastomas resulted in a survival duration comparable with that of patients undergoing surgery for a single lesion, without an associated increase in postoperative morbidity. This finding may indicate that conventional wisdom of a minimal role for surgical treatment in glioblastoma should at least be questioned.

Abbreviation used in this paper: KPS = Karnofsky Performance Scale.

Article Information

Address correspondence to: Raymond Sawaya, M.D., Department of Neurosurgery—Unit 442, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, email.

Please include this information when citing this paper: published online August 6, 2010; DOI: 10.3171/2010.6.JNS091326.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Sagittal contrast-enhanced T1-weighted MR images of the brain in a patient with multicentric glioblastoma, showing right frontal and right parietal ring-enhancing lesions before (A) and after (C) resection. Gross-total resection was achieved via 2 craniotomies in the same surgical session with the aid of cortical mapping and intraoperative MR imaging. A preoperative axial FLAIR image of these same lesions (B) shows no connections between them.

  • View in gallery

    Graph showing Kaplan-Meier estimates of overall survival after resection in patients with multifocal or multicentric glioblastoma (Group A) and patients with solitary glioblastoma (Group B).

  • View in gallery

    Graph showing Kaplan-Meier estimates of overall survival after resection in patients who presented with new or recurrent lesions at diagnosis. Patients in Group A1 had multicentric glioblastoma, those in Group A2 had multifocal glioblastoma, and those in Group B had a solitary glioblastoma.

  • View in gallery

    Graph showing Kaplan-Meier estimates of overall survival after resection in patients who presented with new lesions at diagnosis.



Ampil FBurton GVGonzalez-Toledo ENanda A: Do we need whole brain irradiation in multifocal or multicentric high-grade cerebral gliomas? Review of cases and the literature. J Neurooncol 85:3533552007


Benveniste RJManzano GPetito CK: Multifocal glioblastoma multiforme with synchronous spontaneous hemorrhage: case report. J Neurooncol 89:55582008


Bindal RKSawaya RLeavens MELee JJ: Surgical treatment of multiple brain metastases. J Neurosurg 79:2102161993


Brown PDMaurer MJRummans TAPollock BEBallman KVSloan JA: A prospective study of quality of life in adults with newly diagnosed high-grade gliomas: the impact of the extent of resection on quality of life and survival. Neurosurgery 57:4955042005


Buckner JC: Factors influencing survival in high-grade gliomas. Semin Oncol 30:6 Suppl 1910142003


Buckner JCSchomberg PJMcGinnis WLCascino TLScheithauer BWO'Fallon JR: A phase III study of radiation therapy plus carmustine with or without recombinant interferon-alpha in the treatment of patients with newly diagnosed high-grade glioma. Cancer 92:4204332001


Chadduck WMRoycroft DBrown MW: Multicentric glioma as a cause of multiple cerebral lesions. Neurosurgery 13:1701751983


Djalilian HRShah MVHall WA: Radiographic incidence of multicentric malignant gliomas. Surg Neurol 51:5545581999


Hegi MEDiserens ACGorlia THamou MFde Tribolet NWeller M: MGMT gene silencing and benefit from temozolomide in glioblastoma. N Engl J Med 352:99710032005


Jawahar AWeilbaecher CShorter CStout NNanda A: Multicentric glioblastoma multiforme determined by positron emission tomography: a case report. Clin Neurol Neurosurg 106:38402003


Kyritsis APBondy MLXiao MBerman ELCunningham JELee PS: Germline p53 gene mutations in subsets of glioma patients. J Natl Cancer Inst 86:3443491994


Kyritsis APLevin VAYung WKLeeds NE: Imaging patterns of multifocal gliomas. Eur J Radiol 16:1631701993


Kyritsis APYung WKLeeds NEBruner JGleason MJLevin VA: Multifocal cerebral gliomas associated with secondary malignancies. Lancet 339:122912301992


Lacroix MAbi-Said DFourney DRGokaslan ZLShi WDeMonte F: A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 95:1901982001


Lamborn KRChang SMPrados MD: Prognostic factors for survival of patients with glioblastoma: recursive partitioning analysis. Neuro Oncol 6:2272352004


Laperriere NZuraw LCairncross G: Radiotherapy for newly diagnosed malignant glioma in adults: a systematic review. Radiother Oncol 64:2592732002


Law MCha SKnopp EAJohnson GArnett JLitt AW: High-grade gliomas and solitary metastases: differentiation by using perfusion and proton spectroscopic MR imaging. Radiology 222:7157212002


Laws ERParney IFHuang WAnderson FMorris AMAsher A: Survival following surgery and prognostic factors for recently diagnosed malignant glioma: data from the Glioma Outcomes Project. J Neurosurg 99:4674732003


McGirt MJChaichana KLGathinji MAttenello FJThan KOlivi A: Independent association of extent of resection with survival in patients with malignant brain astrocytoma. J Neurosurg 110:1561622009


Mishra HBHaran RPSingh JPJoseph T: Multicentric gliomas: two case reports and a review of the literature. Br J Neurosurg 4:5355391990


Nomiya TNemoto KKumabe TTakai YYamada S: Prognostic significance of surgery and radiation therapy in cases of anaplastic astrocytoma: retrospective analysis of 170 cases. J Neurosurg 106:5755812007


Nunez OMSeol HJRutka JT: The role of surgery in the management of intracranial gliomas: current concepts. Indian J Cancer 46:1201262009


Ozawa YMachida TNoda MHarada MAkahane MKiryu S: MRI findings of multiple malignant gliomas: differentiation from multiple metastatic brain tumors. Radiat Med 16:69741998


Pathak ASharma BSKak VKVasista RKBanerjee AK: Multicentric gliomas: report of 2 cases. Indian J Cancer 30:2052081993


Pell MFRevesz TThomas DG: Multicentric malignant glioma. Br J Neurosurg 5:6316341991


Prather JLLong JMvan Heertum RHardman J: Multicentric and isolated multifocal glioblastoma multiforme simulating metastatic disease. Br J Radiol 48:10151975


Salvati MCervoni LCelli PCaruso RGagliardi FM: Multicentric and multifocal primary cerebral tumours. Methods of diagnosis and treatment. Ital J Neurol Sci 18:17201997


Salvati MOppido PAArtizzu SFiorenza FPuzzilli FOrlando ER: Multicentric gliomas. Report of seven cases. Tumori 77:5185221991


Santiago PSilbergeld LDMalignant gliomas: anaplastic astrocytoma, glioblastoma multiforme, gliosarcoma, malignant oligodendroglioma. Winn HR: Youmans Neurological Surgery ed 5PhiladelphiaSaunders2004. 1:969980


Sawaya RHammoud MSchoppa DHess KRWu SZShi WM: Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 42:104410561998


Showalter TNAndrel JAndrews DWCurran WJ JrDaskalakis CWerner-Wasik M: Multifocal glioblastoma multiforme: prognostic factors and patterns of progression. Int J Radiat Oncol Biol Phys 69:8208242007


Sridhar TGore ABoiangiu IMachin DSymonds RP: Concomitant (without adjuvant) temozolomide and radiation to treat glioblastoma: a retrospective study. Clin Oncol (R Coll Radiol) 21:19222009


Stark AMNabavi AMehdorn HMBlömer U: Glioblastoma multiforme—report of 267 cases treated at a single institution. Surg Neurol 63:1621692005


Stuckey SLWijedeera R: Multicentric/multifocal cerebral lesions: can fluid-attenuated inversion recovery aid the differentiation between glioma and metastases?. J Med Imaging Radiat Oncol 52:1341392008


Stupp RHegi MEMason WPvan den Bent MJTaphoorn MJJanzer RC: Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol 10:4594662009


Stupp RMason WPvan den Bent MJWeller MFisher BTaphoorn MJ: Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:9879962005


Synowitz Mvon Eckardstein KBrauer CHoch HHKiwit JC: Case history: multicentric glioma with involvement of the optic chiasm. Clin Neurol Neurosurg 105:66682002


Ushio YKochi MHamada JKai YNakamura H: Effect of surgical removal on survival and quality of life in patients with supratentorial glioblastoma. Neurol Med Chir (Tokyo) 45:4544612005


Walker MDGreen SBByar DPAlexander E JrBatzdorf UBrooks WH: Randomized comparisons of radiotherapy and nitrosoureas for the treatment of malignant glioma after surgery. N Engl J Med 303:132313291980


Wang SKim SChawla SWolf RLZhang WGO'Rourke DM: Differentiation between glioblastomas and solitary brain metastases using diffusion tensor imaging. Neuroimage 44:6536602009


Wang WSteward CEDesmond PM: Diffusion tensor imaging in glioblastoma multiforme and brain metastases: the role of p, q, L, and fractional anisotropy. AJNR Am J Neuroradiol 30:2032082009


Willis RA: Pathology of the Tumors ed 4LondonButterworth1967


Zamponi NRychlicki FDucati ARegnicolo LSalvolini URicciuti RA: Multicentric glioma with unusual clinical presentation. Childs Nerv Syst 17:1011052001


Zülch KJ: Brain Tumors: Their Biology and Pathology New YorkSpringer1957


Cited By



All Time Past Year Past 30 Days
Abstract Views 150 150 55
Full Text Views 171 171 6
PDF Downloads 151 151 7
EPUB Downloads 0 0 0


Google Scholar