A personal consecutive series of surgically treated 51 cases of insular WHO Grade II glioma: advances and limitations

Clinical article

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Object

Few experiences of insular surgery have been reported. Moreover, there are no large surgical studies with long-term follow-up specifically dedicated to WHO Grade II gliomas involving the insula. In this paper, the author describes a personal consecutive series of 51 cases in which patients underwent surgery for an insular Grade II glioma. On the basis of the functional and oncological results, advances and limitations of this challenging surgery are discussed.

Methods

Fifty-one patients harboring an insular Grade II glioma (revealed by seizures in 50 cases) underwent surgery. Findings on preoperative neurological examination were normal in 45 patients (88%). All surgeries were conducted under cortico-subcortical stimulation, and in the case of 16 patients while awake.

Results

Despite an immediate postoperative worsening in 30 cases (59%), the condition of all but 2 patients (96%) returned to baseline or better. Postoperative MR imaging demonstrated that 77% of resections were total or subtotal. Ten patients underwent a second or third surgery, with no additional deficit. Forty-two patients (82%) are alive with a median follow-up of 4 years.

Conclusions

This is the largest reported experience with insular Grade II glioma surgery. The better knowledge of the insular pathophysiology and the use of intraoperative functional mapping allow the risk of permanent deficit to be minimized (and even enable improvement in quality of life) while increasing the extent of resection and thus the impact on the course of the disease. Therefore, surgical removal must always be considered for insular Grade II glioma. However, this surgery remains challenging, especially within the anterior perforating substance and the posterior part of the (dominant) insula. Additional surgery can be suggested in cases in which the first resection is not complete.

Abbreviation used in this paper: KPS = Karnofsky Performance Scale.

Article Information

Address correspondence to: Hugues Duffau, M.D., Ph.D., Department of Neurosurgery, Hôpital Gui de Chauliac, CHU Montpellier, 80 Avenue Augustin Fliche, 34295 Montpellier, France. email: h-duffau@chu-montpellier.fr.

Please include this information when citing this paper: published online January 9, 2009; DOI: 10.3171/2008.8.JNS08741.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Preoperative MR images. Axial FLAIR-weighted image (upper left), and axial (upper right), coronal (lower left), and sagittal (lower right) T1-weighted images showing a right paralimbic Grade II glioma without involvement of the anterior perforating substance (see coronal slice).

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    Postoperative MR images from the same case as Fig. 1. Axial FLAIR image (upper left), and axial (upper right), coronal (lower left), and sagittal (lower right) T1-weighted images, showing complete tumor removal. There was no recurrence during 6 years of follow-up, with neither chemotherapy nor radiotherapy. Such total resection was possible without inducing permanent deficit, despite the substantial volume of the glioma, because: 1) there was no involvement of the anterior perforating substance (see coronal slice), and 2) a removal of the right frontal operculum was performed to permit a good exposure of the posterior part of the insula, which was thus removed.

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    Preoperative MR images. Coronal enhanced T1-weighted (upper) and T2-weighted (center) images, and axial enhanced T1-weighted images (lower) showing a right frontoinsulotemporal Grade II glioma, with involvement of the anterior perforating substance (see coronal slices).

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    Postoperative MR images from the same case as Fig. 3. Enhanced T1-weighted coronal (upper) and axial (middle) images, and T2-weighted axial images (lower) showing a subtotal resection with a residue within the anterior perforating substance (see coronal slices) that was intentionally left to avoid damage to the lenticulostriate arteries. The patient had an immediate transient hemiparesis and completely recovered within 6 weeks.

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    Preoperative (upper row) and postoperative (lower row) axial MR images. Preoperative enhanced T1-weighted (upper left) and FLAIR (upper right) images showing a large left insular Grade II glioma without involvement of the anterior perforating substance. Postoperative enhanced T1-weighted (lower left) and FLAIR (lower right) images showing a subtotal resection with a residue within the posterior part of the dominant insula. The residual tumor was unintentionally left due to the following difficulties exposing this portion: 1) a venous bifurcation on the surface of the posterior sylvian fissure, preventing opening at this level; and 2) rolandic operculum essential for language, as revealed by intraoperative stimulation, preventing a posterior transopercular approach. The patient had no postoperative deficit.

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    Kaplan-Meier estimates of survival since the first surgery.

  • View in gallery

    Kaplan-Meier estimates of survival since the first symptom.

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