Transcortical insular glioma resection: clinical outcome and predictors

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OBJECTIVE

Insular lobe gliomas continue to challenge neurosurgeons due to their complex anatomical position. Transcortical and transsylvian corridors remain the primary approaches for reaching the insula, but the adoption of one technique over the other remains controversial. The authors analyzed the transcortical approach of resecting insular gliomas in the context of patient tumor location based on the Berger-Sinai classification, achievable extents of resection (EORs), overall survival (OS), and postsurgical neurological outcome.

METHODS

The authors studied 255 consecutive cases of insular gliomas that underwent transcortical tumor resection in their division. Tumor molecular pathology, location, EOR, postoperative neurological outcome for each insular zone, and the accompanying OS were incorporated into the analysis to determine the value of this surgical approach.

RESULTS

Lower-grade insular gliomas (LGGs) were more prevalent (63.14%). Regarding location, giant tumors (involving all insular zones) were most prevalent (58.82%) followed by zone I+IV (anterior) tumors (20.39%). In LGGs, tumor location was an independent predictor of survival (p = 0.003), with giant tumors demonstrating shortest patient survival (p = 0.003). Isocitrate dehydrogenase 1 (IDH1) mutation was more likely to be associated with giant tumors (p < 0.001) than focal tumors located in a regional zone. EOR correlated with survival in both LGG (p = 0.001) and higher-grade glioma (HGG) patients (p = 0.008). The highest EORs were achieved in anterior-zone LGGs (p = 0.024). In terms of developing postoperative neurological deficits, patients with giant tumors were more susceptible (p = 0.038). Postoperative transient neurological deficit was recorded in 12.79%, and permanent deficit in 15.70% of patients. Patients who developed either transient or permanent postsurgical neurological deficits exhibited poorer survival (p < 0.001).

CONCLUSIONS

The transcortical surgical approach can achieve maximal tumor resection in all insular zones. In addition, the incorporation of adjunct technologies such as multimodal brain imaging and mapping of cortical and subcortical eloquent brain regions into the transcortical approach favors postoperative neurological outcomes, and prolongs patient survival.

ABBREVIATIONS ASPI = anterior, superior, posterior, or inferior; CI = confidence interval; DTI = diffusion tensor imaging; EOR = extent of resection; GTR = gross-total resection; HGG = higher-grade glioma; HR = hazard ratio; IDH1 = isocitrate dehydrogenase 1; LGG = lower-grade glioma; MEP = motor evoked potential; OS = overall survival; PFS = progression-free survival; PI = proliferative index; STR = subtotal resection.

Article Information

Correspondence Jinsong Wu: Huashan Hospital, Fudan University, Shanghai, China. wjsongc@126.com; wujinsong@huashan.org.cn.

INCLUDE WHEN CITING Published online October 19, 2018; DOI: 10.3171/2018.4.JNS18424.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A: Tailored frontotemporal craniotomy is performed via the pterion with the size of the bone window dependent on the extent of tumor. B: Following separation of the dura, subdural strip electrodes were placed to locate the central sulcus and then continuously detect the MEPs. C: Language and motor cortical mapping is performed next. Functional cortical areas are labeled with sterile tags (1, 2, 5, speech arrest; 3, dysarthria; M, mouth motor area; 6, 7, 8, 9, anomia) and covered with thin film for both visualization and protection. Under neuronavigation, the tumor border is identified and marked with 4–0 silk (dashed line). D: Cortical incisions are made, avoiding critical areas, and the incisions are made longitudinally away from the sulci to preserve the sulcal vessels. E: The tumor is gradually debunked using the cavitron ultrasonic surgical aspirator, which is set to tissue selection to sense vessels and viable tissue. F: Subcortical bipolar stimulation is conducted alongside intermittently to ensure no injury is caused to the ventral language pathway (tag “L”). Copyright Jinsong Wu. Published with permission.

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    A: MRI sequence showing the preoperative, postoperative, and follow-up images of a typical insular tumor. AF = arcuate fasciculus; ILF = inferior longitudinal fasciculus. B: MR image showing a cortical window created to access the insula tumor.

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    A: EOR is an independent predictor of OS in both LGG and HGG patients. Patients with EOR ≥ 90% had longer survival among LGGs. B: Patients with GTR had better prognosis than those with STR among HGG. C: LGG patients who experienced no postoperative neurological deficit had better survival than those who did experience postoperative neurological deficits. D: In HGG, development of neurological deficit did not affect survival outcomes in our cohort. E and F: Patients who experienced transient neurological deficits had better OS than those who experienced permanent deficits in LGG (E) and HGG (F) patients. G and H: Insular tumor location was an independent predictor of OS. Longer OS (G) and PFS (H) were observed in the ASPI zone tumors (I+IV [anterior], I+II [superior], II+III [posterior], or III+IV [inferior]) as compared with the giant tumors (involving all insular zones).

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