Biopsy versus resection in the management of malignant gliomas: a systematic review and meta-analysis

A review

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The aim of this study was to answer the question whether quality of life and progression-free and overall survival are increased in adults with supratentorial malignant glioma who are treated with cytoreductive resection as compared with those who only undergo biopsy.


A literature search of the electronic databases MEDLINE, EMBASE, and CENTRAL was performed to identify relevant studies published before May 2008. Hand-searching of reference lists of the identified studies and relevant review articles was also performed. A study was considered eligible, regardless of study design (prospective or retrospective), if: 1) quality of life and/or progression-free and/or overall survival was compared among adult patients undergoing biopsy or resection, and 2) patient age and Karnofsky Performance Scale scores were not significantly different among the 2 groups compared.


One randomized controlled trial and 4 retrospective studies (involving a total of 1111 patients) were found eligible for this systematic review. A meta-analysis of the eligible studies demonstrated a significant increase in overall survival in the patients treated with resection instead of biopsy (hazard ratio 0.61, 95% CI 0.52–0.71, p < 0.0001, fixed-effect model). Although statistical pooling was not feasible, the available data suggest that quality of life was increased in patients treated with resection rather than biopsy, while there did not seem to be any significant difference in progression-free survival between the 2 groups.


Based on the best available evidence, it appears that cytoreductive resection in adults with supratentorial malignant glioma is associated with improved overall survival as compared with biopsy. However, well-designed prospective studies are needed for more solid conclusions to be drawn.

Abbreviations used in this paper: CENTRAL = Cochrane Central Register of Controlled Trials; HR = hazard ratio; ICP = intracranial pressure; KPS = Karnofsky Performance Scale; QOL = quality of life.

Article Information

Address correspondence to: Abraham Tsitlakidis, M.D., M.Sc., First Department of Neurosurgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Stilponos Kyriakidi 1, 54636, Thessaloniki, Greece. email:

Please include this information when citing this paper: published online September 11, 2009; DOI: 10.3171/2009.7.JNS09758.

© AANS, except where prohibited by US copyright law.



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    Flowchart illustrating the steps of the systematic review and meta-analysis. n = number of studies.

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    Forest plot of quantitative synthesis of HRs with all the studies that were included in the meta-analysis. The position of the rectangles corresponds to the value of the effect measure for each study, their size to its respective weight, and the horizontal lines correspond to the 95% CI. The position of the diamond (dashed line) corresponds to the value of the resultant effect measure and its left and right angles to its 95% CI. An HR < 1 favors resection. An HR > 1 favors biopsy (inverse variance fixed-effect model).

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    Funnel plot for the evaluation of publication bias. The vertical line corresponds to the resultant effect measure and the sloping lines to its confidence limits. Asymmetry in the allocation of the studies is an indication of publication bias (inverse variance fixed-effect model).

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    Trim-and-fill funnel plot for the evaluation of the influence of publication bias in the results of the quantitative synthesis. The vertical continuous line corresponds to the meta-analysis outcome with (only) the original studies included, the empty circle to the hypothetical study that counterbalances the publication bias, and the vertical dashed line the meta-analysis outcome after the imputation of this study.

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    Forest plots of quantitative synthesis of HR with the exclusion of the studies in which the influence of performance bias was dubious and/or the only outcome data were the Kaplan-Meier curves (A), and of HRs of studies with Grade 4/IV gliomas (B), Grade III and IV gliomas (inverse variance fixed effect model) (C), elderly patients (D), and wide range of ages (E). Inverse variance fixed-effect model (A, C, and E), and inverse variance random effects model (B and D).



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