Progress in Malignant Glioma
Surgery and radiotherapy compared with gamma knife radiosurgery in the treatment of solitary single cerebral metastases of small diameter
Alexander Muacevic, Friedrich W. Kreth, Gerhard A. Horstmann, Robert Schmid-Elsaesser, Berndt Wowra, Hans J. Steiger, and Hans J. Reulen
Object. The aim of this retrospective study was to compare treatment results of surgery plus whole-brain radiation therapy (WBRT) with gamma knife radiosurgery alone as the primary treatment for solitary cerebral metastases suitable for radiosurgical treatment.
Methods. Patients who had a single circumscribed tumor that was 3.5 cm or smaller in diameter were included. Treatment results were compared between microsurgery plus WBRT (52 patients, median tumor dose 50 Gy) and radiosurgery alone (56 patients, median prescribed tumor dose 22 Gy). In case of local/distant tumor recurrence in the radiosurgery group, additional radiosurgical treatment was administered in patients with stable systemic disease. Survival time was analyzed using the Kaplan—Meier method, and prognostic factors were obtained from the Cox model. The patient groups did not differ in terms of age, gender, pretreatment Karnofsky Performance Scale (KPS) score, duration of symptoms, tumor location, histological findings, status of the primary tumor, time to metastasis, and cause of death. Patients who suffered from larger lesions underwent surgery (p < 0.01). The 1-year survival rate (median survival) was 53% (68 weeks) in the surgical group and 43% (35 weeks) in the radiosurgical group (p = 0.19). The 1-year local tumor control rates after surgery and radiosurgery were 75% and 83%, respectively (p = 0.49), and the 1-year neurological death rates in these groups were 37% and 39% (p = 0.8). Shorter overall survival time in the radiosurgery group was related to higher systemic death rates. A pretreatment KPS score of less than 70 was a predictor of unfavorable survival. Perioperative morbidity and mortality rates were 7.7% and 1.6% in the resection group, and 8.9% and 1.2% in the radiosurgery group, respectively. Four patients presented with transient radiogenic complications after radiosurgery.
Conclusions. Radiosurgery alone can result in local tumor control rates as good as those for surgery plus WBRT in selected patients. Radiosurgery should not be routinely combined with radiotherapy.
Resection of Malignant Gliomas of Childhood
Stereotactic Biopsy and Hemorrhage
Tumors of the Insula
Surgery or Radiosurgery?
Stereotactic Biopsy for Nonpilocytic Astrocytomas
Interstitial radiosurgery of low-grade gliomas
Friedrich W. Kreth, Michael Faist, Peter C. Warnke, Reinhard Roβner, Benedikt Volk, and Christoph B. Ostertag
✓ The treatment of patients with low-grade gliomas remains a subject of controversy, especially with respect to new treatment modalities such as interstitial radiosurgery (brachytherapy), radiosurgery, and stereotactic radiotherapy. In a retrospective analysis conducted between 1979 and 1991, the authors studied the results of interstitial radiosurgery in 455 patients with low-grade gliomas (World Health Organization (WHO) Grade I + WHO Grade II) with regard to survival time, quality of life, the risk of malignant transformation, and the risk profile of the treatment concept. Interstitial radiosurgery with iodine-125 was performed using permanent (1979–1985) or temporary implants (after 1985) with low-dose rates (≤ 10 cGy/hr) and a reference dose of 60 to 100 Gy calculated to the outer rim of the tumor.
The 5- and 10-year survival rates in patients with pilocytic astrocytomas (97 patients) were 84.9% and 83%, and in patients with WHO Grade II astrocytomas (250 patients) 61% and 51%, respectively. Five-year survival rates for patients with oligoastrocytomas (60 patients), oligodendrogliomas (27 patients), and gemistocytic astrocytomas (21 patients) were 49%, 50%, and 32%, respectively. In the group with WHO Grade II gliomas, young age and a good performance status were associated with a better prognosis. Unfavorable factors were midline shift, enhancement on computerized tomography (CT) scan, and tumor recurrence after previous radiotherapy or surgery. Tumor location had no influence on the prognosis (247 patients in this series had deep-seated tumors). Malignant transformation was the major cause of death. Important risk factors for malignancy were the patient's age, tumor enhancement in CT scan, and tumor recurrence after previous surgery or radiotherapy. Perioperative mortality was 0.9% and perioperative morbidity was 1.7%. Radiogenic complications were observed in 2.7% of all patients, most often in larger tumors and after using permanent implants. The authors conclude that interstitial radiosurgery represents a specific treatment modality for selected patients with unifocal circumscribed low-grade gliomas with a diameter of less than 4 cm in any location. The efficacy of this treatment lies in the same range as the best results after surgery and radiotherapy.
Surgical resection and radiation therapy versus biopsy and radiation therapy in the treatment of glioblastoma multiforme
Friedrich W. Kreth, Peter C. Warnke, Rudolf Scheremet, and Christoph B. Ostertag
✓ There has been considerable controversy over the concept of treating glioblastoma multiforme with cytoreductive surgery. Therefore, a retrospective study of cases treated between 1986 and 1991 was conducted to analyze and compare the results of stereotactic biopsy followed by radiation therapy performed in 58 patients with those of surgical resection plus radiation therapy in 57 patients. In both groups, conventionally fractionated radiation (1.7 to 2.0 Gy/day) was delivered, with a total dose of 50 to 60 Gy. Biopsy was performed only in patients with tumors judged to be inoperable. These patients carried a higher surgical risk and were in worse neurological condition than the patients in the resection group.
The median survival time for the resection group was 39.5 weeks, as compared with 32 weeks for the biopsy group. This difference was not significant. The most important prognostic factor was the patient's age. The treatment variable biopsy versus resection did not reach prognostic relevance. In patients with midline shift who underwent biopsy, the Karnofsky Performance Scale score decreased in more patients during radiation therapy. The clinical status 6 weeks after surgery, however, showed no significant differences between the two groups. The comparable survival times for the two groups place doubt on the concept of treating glioblastoma multiforme with cytoreductive surgery. Presently, radiation therapy is the most effective treatment for patients with glioblastoma. There is no question that decompressive surgery followed by radiation therapy should be performed whenever necessary for severe space-occupying lesions and when it will not cause new neurological deficits.