Multiple craniotomies in the management of multifocal and multicentric glioblastoma

Clinical article

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Object

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.

Methods

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.

Results

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.

Conclusions

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. rsawaya@mdanderson.org.

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.

Headings

Figures

  • 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.

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