Perioperative outcomes following reoperation for recurrent insular gliomas

Restricted access

OBJECTIVE

Greater extent of resection (EOR) improves overall survival and progression-free survival for patients with low- and high-grade glioma. While resection for newly diagnosed insular gliomas can be performed with minimal morbidity, perioperative morbidity is not clearly defined for patients undergoing a repeat resection for recurrent insular gliomas. In this study the authors report on tumor characteristics, tumor EOR, and functional outcomes in patients undergoing reoperation for recurrent insular glioma.

METHODS

Adult patients with insular gliomas (WHO grades II–IV) who underwent index resection followed by reoperation were identified through the University of California San Francisco Brain Tumor Center. Treatment history and functional outcomes were collected retrospectively from the electronic medical record. Pre- and postoperative tumor volumes were quantified using software with region-of-interest analysis based on FLAIR and T1-weighted postgadolinium sequences from pre- and postoperative MRI.

RESULTS

Forty-four patients (63.6% male, 36.4% female) undergoing 49 reoperations for recurrent insular tumors were identified with a median follow-up of 741 days. Left- and right-sided tumors comprised 52.3% and 47.7% of the cohort, respectively. WHO grade II, III, and IV gliomas comprised 46.9%, 28.6%, and 24.5% of the cohort, respectively. Ninety-five percent (95.9%) of cases involved language and/or motor mapping. Median EOR of the insular component of grade II, III, and IV tumors were 82.1%, 75.0%, and 94.6%, respectively. EOR during reoperation was not impacted by Berger-Sanai insular zone or tumor side. At the time of reoperation, 44.9% of tumors demonstrated malignant transformation to a higher WHO grade. Ninety-day postoperative assessment confirmed that 91.5% of patients had no new postoperative deficit attributable to surgery. Of those with new deficits, 3 (6.4%) had a visual field cut and 1 (2.1%) had hemiparesis (strength grade 1–2/5). The presence of a new postoperative deficit did not vary with EOR.

CONCLUSIONS

Recurrent insular gliomas, regardless of insular zone and pathology, may be reoperated on with an overall acceptable degree of resection and safety despite their anatomical and functional complexities. The use of intraoperative mapping utilizing asleep or awake methods may reduce morbidity to acceptable rates despite prior surgery.

ABBREVIATIONS DVT = deep vein thrombosis; DWI = diffusion-weighted imaging; EOR = extent of resection; MCA = middle cerebral artery; MRC = Medical Research Council; RT = radiation therapy; UCSF = University of California, San Francisco.

Article Information

Correspondence Mitchel S. Berger: University of California, San Francisco, CA. mitchel.berger@ucsf.edu.

INCLUDE WHEN CITING Published online September 21, 2018; DOI: 10.3171/2018.4.JNS18375.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Preoperative (A) and postoperative (B) axial and sagittal MR FLAIR images from the case of a 42-year-old man who had previously undergone two resections of a grade II oligoastrocytoma and subsequently underwent repeat resection after presenting with gradual tumor progression on imaging. Pathology demonstrated a grade II diffuse glioma with 95% of the insular component resected during the operation.

  • View in gallery

    Preoperative (A) and postoperative (B) axial T1-weighted MR images without and with contrast from the case of a 47-year-old man who had previously undergone two resections of a grade II oligoastrocytoma and subsequently underwent repeat resection after presenting a new contrast-enhancing portion on imaging. Pathology demonstrated a grade III anaplastic oligodendroglioma with 100% of the contrast-enhancing insular component resected during the operation.

References

  • 1

    Benet AHervey-Jumper SLSánchez JJLawton MTBerger MS: Surgical assessment of the insula. Part 1: surgical anatomy and morphometric analysis of the transsylvian and transcortical approaches to the insula. J Neurosurg 124:4694812016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Bloch OHan SJCha SSun MZAghi MKMcDermott MW: Impact of extent of resection for recurrent glioblastoma on overall survival: clinical article. J Neurosurg 117:103210382012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Duffau HMoritz-Gasser SGatignol P: Functional outcome after language mapping for insular World Health Organization Grade II gliomas in the dominant hemisphere: experience with 24 patients. Neurosurg Focus 27(2):E72009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Hervey-Jumper SLBerger MS: Reoperation for recurrent high-grade glioma: a current perspective of the literature. Neurosurgery 75:4914992014

  • 5

    Hervey-Jumper SLLi JOsorio JALau DMolinaro AMBenet A: Surgical assessment of the insula. Part 2: validation of the Berger-Sanai zone classification system for predicting extent of glioma resection. J Neurosurg 124:4824882016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Ius TPauletto GCesselli DIsola MTurella LBudai R: Second surgery in insular low-grade gliomas. Biomed Res Int 2015:4976102015

  • 7

    Ius TPauletto GIsola MGregoraci GBudai RLettieri C: Surgery for insular low-grade glioma: predictors of postoperative seizure outcome. J Neurosurg 120:12232014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Lang FFOlansen NEDeMonte FGokaslan ZLHolland ECKalhorn C: Surgical resection of intrinsic insular tumors: complication avoidance. J Neurosurg 95:6386502001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Martino JTaillandier LMoritz-Gasser SGatignol PDuffau H: Re-operation is a safe and effective therapeutic strategy in recurrent WHO grade II gliomas within eloquent areas. Acta Neurochir (Wien) 151:4274362009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Moshel YAMarcus JDParker ECKelly PJ: Resection of insular gliomas: the importance of lenticulostriate artery position. J Neurosurg 109:8258342008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Pallud JAudureau EBlonski MSanai NBauchet LFontaine D: Epileptic seizures in diffuse low-grade gliomas in adults. Brain 137:4494622014

  • 12

    Ringel FPape HSabel MKrex DBock HCMisch M: Clinical benefit from resection of recurrent glioblastomas: results of a multicenter study including 503 patients with recurrent glioblastomas undergoing surgical resection. Neuro Oncol 18:961042016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Sanai NPolley MYBerger MS: Insular glioma resection: assessment of patient morbidity, survival, and tumor progression. J Neurosurg 112:192010

  • 14

    Skrap MMondani MTomasino BWeis LBudai RPauletto G: Surgery of insular nonenhancing gliomas: volumetric analysis of tumoral resection, clinical outcome, and survival in a consecutive series of 66 cases. Neurosurgery 70:108110942012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Southwell DGHervey-Jumper SLPerry DWBerger MS: Intraoperative mapping during repeat awake craniotomy reveals the functional plasticity of adult cortex. J Neurosurg 124:146014692016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Sughrue MESheean TBonney PAMaurer AJTeo C: Aggressive repeat surgery for focally recurrent primary glioblastoma: outcomes and theoretical framework. Neurosurg Focus 38(3):E112015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Uppstrom TJSingh RHadjigeorgiou GFMagge RRamakrishna R: Repeat surgery for recurrent low-grade gliomas should be standard of care. Clin Neurol Neurosurg 151:18–232016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Wang DDDeng HHervey-Jumper SLMolinaro AAChang EFBerger MS: Seizure outcome after surgical resection of insular glioma. Neurosurgery [epub ahead of print] 2017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Wu ASWitgert MELang FFXiao LBekele BNMeyers CA: Neurocognitive function before and after surgery for insular gliomas. J Neurosurg 115:111511252011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 56 56 56
Full Text Views 23 23 23
PDF Downloads 33 33 33
EPUB Downloads 0 0 0

PubMed

Google Scholar