Extent of resection in patients with glioblastoma: limiting factors, perception of resectability, and effect on survival

Clinical article

Restricted access

Object

The extent of resection (EOR) is a known prognostic factor in patients with glioblastoma. However, gross-total resection (GTR) is not always achieved. Understanding the factors that prevent GTR is helpful in surgical planning and when counseling patients. The goal of this study was to identify demographic, tumor-related, and technical factors that influence EOR and to define the relationship between the surgeon's impression of EOR and radiographically determined EOR.

Methods

The authors performed a retrospective review of the electronic medical records to identify all patients who underwent craniotomy for glioblastoma resection between 2006 and 2009 and who had both preoperative and postoperative MRI studies. Forty-six patients were identified and were included in the study. Image analysis software (FIJI) was used to perform volumetric analysis of tumor size and EOR based on preoperative and postoperative MRI. Using multivariate analysis, the authors assessed factors associated with EOR and residual tumor volume. Perception of resectability was described using bivariate statistics, and survival was described using the log-rank test and Kaplan-Meier curves.

Results

The EOR was less for tumors in eloquent areas (p = 0.014) and those touching ventricles (p = 0.031). Left parietal tumors had significantly greater residual volume (p = 0.042). The average EOR was 91.0% in this series. There was MRI-demonstrable residual tumor in 69.6% of cases (16 of 23) in which GTR was perceived by the surgeon. Expert reviewers agreed that GTR could be safely achieved in 37.0% of patients (17 of 46) in this series. Among patients with safely resectable tumors, radiographically complete resection was achieved in 23.5% of patients (4 of 17). An EOR greater than 90% was associated with a significantly greater 1-year survival (76.5%) than an EOR less than 90% (p = 0.005).

Conclusions

The authors' findings confirm that tumor location affects EOR and suggest that EOR may also be influenced by the surgeon's ability to judge the presence of residual tumor during surgery. The surgeon's ability to judge completeness of resection during surgery is commonly inaccurate. The authors' study confirms the impact of EOR on 1-year survival.

Abbreviations used in this paper:ACE-27 = Adult Comorbidity Evaluation-27; EOR = extent of resection; GTR = gross-total resection.

Article Information

* Dr. Orringer and Mr. Lau contributed equally to this work.

Address correspondence to: Oren Sagher, M.D., Department of Neurosurgery, University of Michigan Health System, 1500 East Medical Center Drive, Room 3552 TC, Ann Arbor, Michigan 48109-5338. email: osagher@umich.edu.

Please include this information when citing this paper: published online September 14, 2012; DOI: 10.3171/2012.8.JNS12234.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Kaplan-Meier survival curve representing patients who underwent craniotomy for glioblastoma stratified by EOR. The EOR was associated with a significant difference in mortality at 1 year (p = 0.043), but not at 2 years (p = 0.350), among the 4 groups.

References

1

Albert FKForsting MSartor KAdams HPKunze S: Early postoperative magnetic resonance imaging after resection of malignant glioma: objective evaluation of residual tumor and its influence on regrowth and prognosis. Neurosurgery 34:45611994

2

Böhringer HJLankenau EStellmacher FReusche EHüttmann GGiese A: Imaging of human brain tumor tissue by near-infrared laser coherence tomography. Acta Neurochir (Wien) 151:5075172009

3

Chaichana KLMcGirt MJFrazier JAttenello FGuerrero-Cazares HQuinones-Hinojosa A: Relationship of glioblastoma multiforme to the lateral ventricles predicts survival following tumor resection. J Neurooncol 89:2192242008

4

Dandy WE: Removal of right cerebral hemisphere for certain tumors with hemiplegia: preliminary report. JAMA 90:8238251928

5

Datema FRFerrier MBvan der Schroeff MPBaatenburg de Jong RJ: Impact of comorbidity on short-term mortality and overall survival of head and neck cancer patients. Head Neck 32:7287362010

6

Ertl-Wagner BBBlume JDPeck DUdupa JKHerman BLevering A: Reliability of tumor volume estimation from MR images in patients with malignant glioma. Results from the American College of Radiology Imaging Network (ACRIN) 6662 Trial. Eur Radiol 19:5996092009

7

Feigl GCRitz RMoraes MKlein JRamina KGharabaghi A: Resection of malignant brain tumors in eloquent cortical areas: a new multimodal approach combining 5-aminolevulinic acid and intraoperative monitoring. Clinical article. J Neurosurg 113:3523572010

8

Hori DKatsuragawa SMurakami RHirai T: Semi-automated segmentation of a glioblastoma multiforme on brain MR images for radiotherapy planning. Nippon Hoshasen Gijutsu Gakkai Zasshi 66:3533622010

9

Kaur GBloch OJian BJKaur RSughrue MEAghi MK: A critical evaluation of cystic features in primary glioblastoma as a prognostic factor for survival. Clinical article. J Neurosurg 115:7547592011

10

Kuhnt DGanslandt OSchlaffer SMBuchfelder MNimsky C: Quantification of glioma removal by intraoperative highfield magnetic resonance imaging: an update. Neurosurgery 69:8528632011

11

Lacroix MAbi-Said DFourney DRGokaslan ZLShi WDeMonte F: A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 95:1901982001

12

Laws ERParney IFHuang WAnderson FMorris AMAsher A: Survival following surgery and prognostic factors for recently diagnosed malignant glioma: data from the Glioma Outcomes Project. J Neurosurg 99:4674732003

13

Moonis GLiu JUdupa JKHackney DB: Estimation of tumor volume with fuzzy-connectedness segmentation of MR images. AJNR Am J Neuroradiol 23:3563632002

14

Nazzaro JMNeuwelt EA: The role of surgery in the management of supratentorial intermediate and high-grade astrocytomas in adults. J Neurosurg 73:3313441990

15

Nimsky CGanslandt OBuchfelder MFahlbusch R: Glioma surgery evaluated by intraoperative low-field magnetic resonance imaging. Acta Neurochir Suppl 85:55632003

16

Ryken TCFrankel BJulien TOlson JJ: Surgical management of newly diagnosed glioblastoma in adults: role of cytoreductive surgery. J Neurooncol 89:2712862008

17

Sanai NBerger MS: Glioma extent of resection and its impact on patient outcome. Neurosurgery 62:7537642008

18

Sanai NPolley MYMcDermott MWParsa ATBerger MS: An extent of resection threshold for newly diagnosed glioblastomas. Clinical article. J Neurosurg 115:382011

19

Senft CBink AFranz KVatter HGasser TSeifert V: Intraoperative MRI guidance and extent of resection in glioma surgery: a randomised, controlled trial. Lancet Oncol 12:99710032011

20

Spetzler RFMartin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:4764831986

21

Stummer WPichlmeier UMeinel TWiestler ODZanella FReulen HJ: Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol 7:3924012006

22

Stummer WReulen HJMeinel TPichlmeier USchumacher WTonn JC: Extent of resection and survival in glioblastoma multiforme: identification of and adjustment for bias. Neurosurgery 62:5645762008

23

Stupp RMason WPvan den Bent MJWeller MFisher BTaphoorn MJ: Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:9879962005

24

Talos IFZou KHOhno-Machado LBhagwat JGKikinis RBlack PM: Supratentorial low-grade glioma resectability: statistical predictive analysis based on anatomic MR features and tumor characteristics. Radiology 239:5065132006

25

Willems PWTaphoorn MJBurger HBerkelbach van der Sprenkel JWTulleken CA: Effectiveness of neuronavigation in resecting solitary intracerebral contrast-enhancing tumors: a randomized controlled trial. J Neurosurg 104:3603682006

26

Wrensch MRice TMiike RMcMillan ALamborn KRAldape K: Diagnostic, treatment, and demographic factors influencing survival in a population-based study of adult glioma patients in the San Francisco Bay Area. Neuro Oncol 8:12262006

27

Wu JSZhou LFTang WJMao YHu JSong YY: Clinical evaluation and follow-up outcome of diffusion tensor imaging-based functional neuronavigation: a prospective, controlled study in patients with gliomas involving pyramidal tracts. Neurosurgery 61:9359492007

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 164 164 41
Full Text Views 206 206 11
PDF Downloads 124 124 5
EPUB Downloads 0 0 0

PubMed

Google Scholar