Independent association of extent of resection with survival in patients with malignant brain astrocytoma

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With recent advances in the adjuvant treatment of malignant brain astrocytomas, it is increasingly debated whether extent of resection affects survival. In this study, the authors investigate this issue after primary and revision resection of these lesions.


The authors retrospectively reviewed the cases of 1215 patients who underwent surgery for malignant brain astrocytomas (World Health Organization [WHO] Grade III or IV) at a single institution from 1996 to 2006. Patients with deep-seated or unresectable lesions were excluded. Based on MR imaging results obtained < 48 hours after surgery, gross-total resection (GTR) was defined as no residual enhancement, near-total resection (NTR) as having thin rim enhancement of the resection cavity only, and subtotal resection (STR) as having residual nodular enhancement. The independent association of extent of resection and subsequent survival was assessed via a multivariate proportional hazards regression analysis.


Magnetic resonance imaging studies were available for review in 949 cases. The mean age and mean Karnofsky Performance Scale (KPS) score at time of surgery were 51 ± 16 years and 80 ± 10, respectively. Surgery consisted of primary resection in 549 patients (58%) and revision resection for tumor recurrence in 400 patients (42%). The lesion was WHO Grade IV in 700 patients (74%) and Grade III in 249 (26%); there were 167 astrocytomas and 82 mixed oligoastrocytoma. Among patients who underwent resection, GTR, NTR, and STR were achieved in 330 (35%), 388 (41%), and 231 cases (24%), respectively. Adjusting for factors associated with survival (for example, age, KPS score, Gliadel and/or temozolomide use, and subsequent resection), GTR versus NTR (p < 0.05) and NTR versus STR (p < 0.05) were independently associated with improved survival after both primary and revision resection of glioblastoma multiforme (GBM). For primary GBM resection, the median survival after GTR, NTR, and STR was 13, 11, and 8 months, respectively. After revision resection, the median survival after GTR, NTR, and STR was 11, 9, and 5 months, respectively. Adjusting for factors associated with survival for WHO Grade III astrocytoma (age, KPS score, and revision resection), GTR versus STR (p < 0.05) was associated with improved survival. Gross-total resection versus NTR was not associated with an independent survival benefit in patients with WHO Grade III astrocytomas. The median survival after primary resection of WHO Grade III (mixed oligoastrocytomas excluded) for GTR, NTR, and STR was 58, 46, and 34 months, respectively.


In the authors' experience with both primary and secondary resection of malignant brain astrocytomas, increasing extent of resection was associated with improved survival independent of age, degree of disability, WHO grade, or subsequent treatment modalities used. The maximum extent of resection should be safely attempted while minimizing the risk of surgically induced neurological injury.

Abbreviations used in this paper: AA = anaplastic astrocytoma; CI = confidence interval; GBM = glioblastoma multiforme; GTR = gross-total resection; KPS = Karnofsky Performance Scale; NTR = near-total resection; RR = relative risk; STR = subtotal resection; WHO = World Health Organization.

Article Information

Address correspondence to: Alfredo Quiñones-Hinojosa, M.D., Brain Tumor Stem Cell Laboratory, Department of Neurosurgery and Oncology, 1550 Orleans Street, Cancer Research Building II, Room 253, Baltimore, Maryland 21231. email:

Please include this information when citing this paper: publishedonline October 10, 2008; DOI: 10.3171/2008.4.17536.

© AANS, except where prohibited by US copyright law."



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    Estimated Kaplan–Meier plot of survival after primary (upper) and revision resection (lower) of GBM. In both primary and secondary resection, patients who underwent NTR experienced an independent survival benefit compared with patients who underwent STR (p < 0.002). Patients who received GTR experienced an independent survival benefit compared with patients receiving NTR (p < 0.05). After primary GBM resection, the median survival after GTR, NTR, or STR was 13, 11, and 8 months, respectively. For revision surgery, median survival after GTR, NTR, and STR was 11, 9, and 5 months, respectively, from time of revision surgery. (GTR = no residual enhancement on MR; NTR = rim enhancement of resection cavity on MR imaging; STR = residual nodular enhancement).

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    Estimated Kaplan–Meier plot of survival after primary resection of AAs (mixed oligoastrocytoma excluded). Both GTR and NTR were associated with a survival benefit versus STR. Gross-total resection versus NTR was not associated with improved survival. After GTR, NTR, or STR, median survival was 58, 46, and 34 months, respectively. The 5-year survival for patients undergoing GTR, NTR, and STR was 42, 41, and 12%, respectively.



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