Effectiveness of neuronavigation in resecting solitary intracerebral contrast-enhancing tumors: a randomized controlled trial

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Object

The goal of this study was to assess the impact of neuronavigation on the cytoreductive treatment of solitary contrast-enhancing intracerebral tumors and outcomes of this treatment in cases in which neuronavigation was preoperatively judged to be redundant.

Methods

The authors conducted a prospective randomized study in which 45 patients, each harboring a solitary contrast-enhancing intracerebral tumor, were randomized for surgery with or without neuronavigation. Peri- and postoperative parameters under investigation included the following: duration of the procedure; surgeon’s estimate of the usefulness of neuronavigation; quantification of the extent of resection, determined using magnetic resonance imaging; and the postoperative course, as evaluated by neurological examinations, the patient’s quality-of-life self-assessment, application of the Barthel index and the Karnofsky Performance Scale score, and the patient’s time of death.

The mean amount of residual tumor tissue was 28.9% for standard surgery (SS) and 13.8% for surgery involving neuronavigation (SN). The corresponding mean amounts of residual contrast-enhancing tumor tissue were 29.2 and 24.4%, respectively. These differences were not significant. Gross-total removal (GTR) was achieved in five patients who underwent SS and in three who underwent SN. Median survival was significantly shorter in the SN group (5.6 months compared with 9 months, unadjusted hazard ratio = 1.6); however, this difference may be attributable to the coincidental early death of three patients in the SN group. No discernible important effect on the patients’ 3-month postoperative course was identified.

Conclusions

There is no rationale for the routine use of neuronavigation to improve the extent of tumor resection and prognosis in patients harboring a solitary enhancing intracerebral lesion when neuronavigation is not already deemed advantageous because of the size or location of the lesion.

Abbreviations used in this paper: ACC = Anderson Cancer Center; BI = Barthel index; GBM = glioblastoma multiforme; GTR = gross-total removal; HR = hazards ratio; KPS = Karnofsky Performance Scale; MR = magnetic resonance; QOL = quality of life; SD = standard deviation; SN = surgery involving neuronavigation; SS = standard surgery.

Article Information

Address reprint requests to: Peter W. A. Willems, M.D., Heidel-berglaan 10, 3584 CX Utrecht, The Netherlands. email: p.willems@neuro.azu.nl.

Dr. Willems is financially supported by the Schumacher-Kramer and Vanderes Foundations, both located in The Netherlands.

Disclaimer

None of the authors has any personal or institutional financial interest in the devices described in this manuscript.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Illustration of the segmentation process performed using in-house software. Left: Image of the user interface showing a representative case. Window width and level, image zoom, and slice orientation are adjustable, enabling accurate segmentation in all orthogonal planes. Two volumes are determined: the tumor volume and the contrast-enhancing volume. In many cases, the latter is derived by subtracting the nonenhancing volume from the total volume. No distinction is made between homogeneous or heterogeneous contrast enhancement. Right: Images illustrating the four steps used in each volumetric assessment: the axial slice located approximately through the tumor after delineating the total tumor volume in every fifth coronal slice (I); the same axial slice after delineating the total tumor volume in every fifth sagittal slice (II); the same axial slice after delineating the total tumor volume in every axial slice (III); and a three-dimensional reconstruction of the segmented volume (IV). The volume is automatically quantified based on the known voxel dimensions (1.1 mm3).

  • View in gallery

    Bar graph showing the duration (in minutes) of preparation and surgery. Preparation was measured from the time of anesthesia inductiong until skin incision and surgery from skin incision until skin closure. The numbers of cases (N) that were analyzed and the probability values (p) are provided below the bars.

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    Pie graph showing evaluations by surgeons of the usefulness of neuronavigation during the procedures, as indicated immediately postoperatively. The category “disadvantageous” was not used in any case. The category “neutral” is used to indicate that neuronavigation is neither experienced as a burden nor as beneficial.

  • View in gallery

    Bar graph showing the difference between preoperative and early postoperative tumor volumes and contrast-enhancing volumes for each treatment group. Not all cases are represented by the bars because reliable measurements could not be performed in a number of cases. The numbers of cases that were analyzed and the probability values resulting from the unadjusted analysis are provided below the bars.

  • View in gallery

    Bar graph demonstrating the difference between the patients’ preoperative and 3-month postoperative BI and KPS scores. Both scales range from 100 (for BI independent; for KPS no symptoms) to 0 (for BI extremely dependent; for KPS dead). Negative values for the difference indicate worsening of the patients’ conditions. The numbers of cases analyzed and the probability values resulting from the unadjusted analysis are provided below the bars. Lines represent SDs.

  • View in gallery

    Bar graphs showing the difference between preoperative and 3-month postoperative QOL results. Individual values can vary from 0 to 100 and can be subdivided into functional scales (100 being optimal) and symptom scales (0 being-optimal). For a qualitative comparison, all results are displayed with favorable changes shown in the same direction.

  • View in gallery

    Graph depicting the findings of the Kaplan–Meier survival analysis.

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