Low-grade hemispheric gliomas in adults: a critical review of extent of resection as a factor influencing outcome

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Object. The goal of this study was to perform a critical review of literature pertinent to low-grade gliomas of the cerebral hemisphere in adults and, on the basis of this review, to evaluate systematically the prognostic effect of extent of resection on survival and to determine if treatment-related guidelines could be established for patients in whom these tumors have been newly diagnosed. Quality of evidence for current treatment options, guidelines, and standards as well as methodological limitations were evaluated.

Methods. Several prognostic factors thought to affect outcome in patients with low-grade gliomas include the patient's age and neurological status, tumor volume and histological characteristics, and treatment-related variables such as timing of surgical intervention, extent of resection, postoperative tumor volume, and radiation therapy. Patient age and the histological characteristics of the lesion are generally accepted prognostic factors. Among treatment-related factors, timing and extent of resection are controversial because of the lack of randomized controlled trials addressing these issues and the difficulty in obtaining information from available studies that have methodological limitations.

All English-language studies on low-grade gliomas published between January 1970 and April 2000 were reviewed. Thirty studies that included statistical analyses were further evaluated with regard to the prognostic effect of extent of resection. Of these 30 studies, those that included pediatric patients, unless adults were analyzed separately, were excluded from further study because of the favorable outcome associated with the pediatric age group. Also excluded were studies including pilocytic and gemistocytic astrocytomas, because the natural histories of these histological subtypes are significantly different from that of low-grade gliomas. Series in which there were small numbers of patients (< 75) were also excluded. Results for oligodendrogliomas are reported separately.

Currently, for patients with low-grade glial tumors located in the cerebral hemisphere, the only management standard based on high-quality evidence is tissue diagnosis. All other treatment methods are practice options supported by evidence that is inconclusive or conflicting. The majority of published series that the authors identified had design-related limitations including a small study size, a small number of events (that is, deaths for survival studies), inclusion of pediatric patients, and/or inclusion of various histological types of tumors with different natural histories. Of the 30 series addressing the issue of timing and extent of surgery, almost all had additional design limitations. Methods used to determine the extent of resection were subjective and qualitative in almost all studies. Only five of the 30 series met the authors' criteria, and these studies are discussed in detail.

Conclusions. Management of low-grade gliomas is controversial and practice parameters are ill defined. This is caused by limited knowledge regarding the natural history of these tumors and the lack of high-quality evidence supporting various treatment options. Although a prospective randomized study seems unlikely, both retrospective matched studies and prospective observational trials will improve the clinician's ability to understand the importance of various prognostic factors.

Article Information

Address reprint requests to: Mitchel S. Berger, M.D., Brain Tumor Research Center, Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, Room M-786, San Francisco, California 94143–0112. email: bergerm@neurosurg.ucsf.edu.

© AANS, except where prohibited by US copyright law.

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References

1.

Bahary JPVillemure JGChoi Set al: Low-grade pure and mixed cerebral astrocytomas treated in the CT scan era. J Neurooncol 27:1731771996Bahary JP Villemure JG Choi S et al: Low-grade pure and mixed cerebral astrocytomas treated in the CT scan era. J Neurooncol 27:173–177 1996

2.

Bampoe JBernstein M: The role of surgery in low grade gliomas. J Neurooncol 42:2592691999Bampoe J Bernstein M: The role of surgery in low grade gliomas. J Neurooncol 42:259–269 1999

3.

Bauman GLote KLarson Det al: Pretreatment factors predict overall survival for patients with low-grade glioma: a recursive partitioning analysis. Int J Radiat Oncol Biol Phys 45:9239291999Bauman G Lote K Larson D et al: Pretreatment factors predict overall survival for patients with low-grade glioma: a recursive partitioning analysis. Int J Radiat Oncol Biol Phys 45:923–929 1999

4.

Bauman GPahapill PMacdonald Det al: Low grade glioma: a measuring radiographic response to radiotherapy. Can J Neurol Sci 26:18221999Bauman G Pahapill P Macdonald D et al: Low grade glioma: a measuring radiographic response to radiotherapy. Can J Neurol Sci 26:18–22 1999

5.

Berger MSDeliganis AVDobbins Jet al: The effect of extent of resection on recurrence in patients with low grade cerebral hemisphere gliomas. Cancer 74:178417911994Berger MS Deliganis AV Dobbins J et al: The effect of extent of resection on recurrence in patients with low grade cerebral hemisphere gliomas. Cancer 74:1784–1791 1994

6.

Bloom HJC: Intracranial tumors: response and resistance to therapeutic endeavors, 1970–1980. Int J Radiat Oncol Biol Phys 8:108311131982Bloom HJC: Intracranial tumors: response and resistance to therapeutic endeavors 1970–1980. Int J Radiat Oncol Biol Phys 8:1083–1113 1982

7.

Cairncross JGLaperriere NJ: Low-grade glioma. To treat or not to treat? Arch Neurol 46:123812391989Cairncross JG Laperriere NJ: Low-grade glioma. To treat or not to treat? Arch Neurol 46:1238–1239 1989

8.

Celli PNofrone IPalma Let al: Cerebral oligodendroglioma: prognostic factors and life history. Neurosurgery 35:101810351994Celli P Nofrone I Palma L et al: Cerebral oligodendroglioma: prognostic factors and life history. Neurosurgery 35:1018–1035 1994

9.

Daumas-Duport CTucker MLKolles Het al: Oligodendrogliomas. Part II: A new grading system based on morphological and imaging criteria. J Neurooncol 34:61781997Daumas-Duport C Tucker ML Kolles H et al: Oligodendrogliomas. Part II: A new grading system based on morphological and imaging criteria. J Neurooncol 34:61–78 1997

10.

Daumas-Duport CVarlet PTucker MLet al: Oligodendrogliomas. Part I: Patterns of growth, histological diagnosis, clinical and imaging correlations: a study of 153 cases. J Neurooncol 34:37591997Daumas-Duport C Varlet P Tucker ML et al: Oligodendrogliomas. Part I: Patterns of growth histological diagnosis clinical and imaging correlations: a study of 153 cases. J Neurooncol 34:37–59 1997

11.

Earnest F IIIKernohan JWCraig WM: Oligodendrogliomas. A review of two hundred cases. Arch Neurol Psychiatry 63:9649761950Earnest F III Kernohan JW Craig WM: Oligodendrogliomas. A review of two hundred cases. Arch Neurol Psychiatry 63:964–976 1950

12.

Eddy DM: Clinical decision making: from therapy to practice. Designing a practice policy. Standards, guidelines, and options. JAMA 263:307730841990Eddy DM: Clinical decision making: from therapy to practice. Designing a practice policy. Standards guidelines and options. JAMA 263:3077–3084 1990

13.

Eyre HJCrowley JJTownsend JJet al: A randomized trial of radiotherapy versus radiotherapy plus CCNU for incompletely resected low-grade gliomas: a Southwest Oncology Group study. J Neurosurg 78:9099141993Eyre HJ Crowley JJ Townsend JJ et al: A randomized trial of radiotherapy versus radiotherapy plus CCNU for incompletely resected low-grade gliomas: a Southwest Oncology Group study. J Neurosurg 78:909–914 1993

14.

Fazekas JT: Treatment of grades I and II brain astrocytomas. The role of radiotherapy. Int J Radiat Oncol Biol Phys 2:6616661977Fazekas JT: Treatment of grades I and II brain astrocytomas. The role of radiotherapy. Int J Radiat Oncol Biol Phys 2:661–666 1977

15.

Fortin DCairncross GJHammond RR: Oligodendroglioma: an appraisal of recent data pertaining to diagnosis and treatment. Neurosurgery 45:127912911999Fortin D Cairncross GJ Hammond RR: Oligodendroglioma: an appraisal of recent data pertaining to diagnosis and treatment. Neurosurgery 45:1279–1291 1999

16.

Gannett DEWisbeck WMSilbergeld DLet al: The role of postoperative irradiation in the treatment of oligodendroglioma. Int J Radiat Oncol Biol Phys 30:5675731994Gannett DE Wisbeck WM Silbergeld DL et al: The role of postoperative irradiation in the treatment of oligodendroglioma. Int J Radiat Oncol Biol Phys 30:567–573 1994

17.

Garcia DMFulling KHMarks JE: The value of radiation therapy in addition to surgery for astrocytomas of the adult cerebellum. Cancer 55:9199271985Garcia DM Fulling KH Marks JE: The value of radiation therapy in addition to surgery for astrocytomas of the adult cerebellum. Cancer 55:919–927 1985

18.

Guidelines and Outcomes Committee of the AANS: Practice parameters in adults with suspected or known supratentorial nonoptic pathway low-grade glioma. Neurosurg Focus 4 (6):Article 101998Guidelines and Outcomes Committee of the AANS: Practice parameters in adults with suspected or known supratentorial nonoptic pathway low-grade glioma. Neurosurg Focus 4 (6):Article 10 1998

19.

Hess KR: Extent of resection as a prognostic variable in the treatment of gliomas. J Neurooncol 42:2272311999Hess KR: Extent of resection as a prognostic variable in the treatment of gliomas. J Neurooncol 42:227–231 1999

20.

Ito SChandler KLPrados MDet al: Proliferative potential and prognostic evaluation of low—grade astrocytomas. J Neurooncol 19:191994Ito S Chandler KL Prados MD et al: Proliferative potential and prognostic evaluation of low—grade astrocytomas. J Neurooncol 19:1–9 1994

21.

Janny PCure HMohr Met al: Low grade supratentorial astrocytomas. Management and prognostic factors. Cancer 73:193719451994Janny P Cure H Mohr M et al: Low grade supratentorial astrocytomas. Management and prognostic factors. Cancer 73:1937–1945 1994

22.

Jeremic BShibamoto YGrujicic Det al: Hyperfractionated radiation therapy for incompletely resected supratentorial low-grade glioma. A phase II study. Radiother Oncol 49:49541998Jeremic B Shibamoto Y Grujicic D et al: Hyperfractionated radiation therapy for incompletely resected supratentorial low-grade glioma. A phase II study. Radiother Oncol 49:49–54 1998

23.

Karim ABMFCornu PBleehen Net al: Immediate postoperative radiotherapy in low grade glioma improves progression free survival, but not overall survival: preliminary results of an EORTC/MRC randomized phase III study. Proc Am Soc Clin Oncol 17:400a1998 (Abstract)Karim ABMF Cornu P Bleehen N et al: Immediate postoperative radiotherapy in low grade glioma improves progression free survival but not overall survival: preliminary results of an EORTC/MRC randomized phase III study. Proc Am Soc Clin Oncol 17:400a 1998 (Abstract)

24.

Karim ABMFMaat BHatlevoll Ret al: A randomized trial on dose-response in radiation therapy of low-grade cerebral glioma: European Organization for Research and Treatment of Cancer (EORTC) Study 22844. Int J Radiat Oncol Biol Phys 36:5495561996Karim ABMF Maat B Hatlevoll R et al: A randomized trial on dose-response in radiation therapy of low-grade cerebral glioma: European Organization for Research and Treatment of Cancer (EORTC) Study 22844. Int J Radiat Oncol Biol Phys 36:549–556 1996

25.

Kernohan JWMaybon RFSvien HJet al: A simplified classification of the gliomas. Proc Staff Meet Mayo Clin 24:71751949Kernohan JW Maybon RF Svien HJ et al: A simplified classification of the gliomas. Proc Staff Meet Mayo Clin 24:71–75 1949

26.

Kreth FWFaist MRossner Ret al: Supratentorial World Health Organization Grade 2 astrocytomas and oligoastrocytomas. A new pattern of prognostic factors. Cancer 79:3703791997Kreth FW Faist M Rossner R et al: Supratentorial World Health Organization Grade 2 astrocytomas and oligoastrocytomas. A new pattern of prognostic factors. Cancer 79:370–379 1997

27.

Kros JMPieterman Hvan Eden CGet al: Oligodendroglioma: the Rotterdam-Dijkzigt experience. Neurosurgery 34:9599661994Kros JM Pieterman H van Eden CG et al: Oligodendroglioma: the Rotterdam-Dijkzigt experience. Neurosurgery 34:959–966 1994

28.

Laws ER JrTaylor WFClifton MBet al: Neurosurgical management of low-grade astrocytoma of the cerebral hemispheres. J Neurosurg 61:6656731984Laws ER Jr Taylor WF Clifton MB et al: Neurosurgical management of low-grade astrocytoma of the cerebral hemispheres. J Neurosurg 61:665–673 1984

29.

Leibel SASheline GEWara WMet al: The role of radiation therapy in the treatment of astrocytomas. Cancer 35:155115571975Leibel SA Sheline GE Wara WM et al: The role of radiation therapy in the treatment of astrocytomas. Cancer 35:1551–1557 1975

30.

Leighton CFisher BBauman Get al: Supratentorial low-grade glioma in adults: an analysis of prognostic factors and timing of radiation. J Clin Oncol 15:129413011997Leighton C Fisher B Bauman G et al: Supratentorial low-grade glioma in adults: an analysis of prognostic factors and timing of radiation. J Clin Oncol 15:1294–1301 1997

31.

Lindegaard KFMork SJEide GEet al: Statistical analysis of clinicopathological features, radiotherapy, and survival in 170 cases of oligodendroglioma. J Neurosurg 67:2242301987Lindegaard KF Mork SJ Eide GE et al: Statistical analysis of clinicopathological features radiotherapy and survival in 170 cases of oligodendroglioma. J Neurosurg 67:224–230 1987

32.

Lote KEgeland THager Bet al: Survival, prognostic factors, and therapeutic efficacy in low-grade glioma: a retrospective study in 379 patients. J Clin Oncol 15:312931401997Lote K Egeland T Hager B et al: Survival prognostic factors and therapeutic efficacy in low-grade glioma: a retrospective study in 379 patients. J Clin Oncol 15:3129–3140 1997

33.

Lunsford LDSomaza SKondziolka Det al: Survival after stereotactic biopsy and irradiation of cerebral nonanaplastic, nonpilocytic astrocytoma. J Neurosurg 82:5235291995Lunsford LD Somaza S Kondziolka D et al: Survival after stereotactic biopsy and irradiation of cerebral nonanaplastic nonpilocytic astrocytoma. J Neurosurg 82:523–529 1995

34.

McCormack BMMiller DCBudzilovich GNet al: Treatment and survival of low-grade astrocytoma in adults—1977–1988. Neurosurgery 31:6366421992McCormack BM Miller DC Budzilovich GN et al: Treatment and survival of low-grade astrocytoma in adults—1977–1988. Neurosurgery 31:636–642 1992

35.

Medberry CA IIIStraus KLSteinberg SMet al: Low-grade astrocytomas: treatment results and prognostic variables. Int J Radiat Oncol Biol Phys 15:8378411988Medberry CA III Straus KL Steinberg SM et al: Low-grade astrocytomas: treatment results and prognostic variables. Int J Radiat Oncol Biol Phys 15:837–841 1988

36.

Miralbell RBalart JMatias-Guiu Xet al: Radiotherapy for supratentorial low-grade gliomas: results and prognostic factors with special focus on tumour volume parameters. Radiother Oncol 27:1121161993Miralbell R Balart J Matias-Guiu X et al: Radiotherapy for supratentorial low-grade gliomas: results and prognostic factors with special focus on tumour volume parameters. Radiother Oncol 27:112–116 1993

37.

Mork SJLindegaard KFHalvorsen TBet al: Oligodendroglioma: incidence and biological behavior in a defined population. J Neurosurg 63:8818891985Mork SJ Lindegaard KF Halvorsen TB et al: Oligodendroglioma: incidence and biological behavior in a defined population. J Neurosurg 63:881–889 1985

38.

Muller WAfra DSchroder R: Supratentorial recurrences of gliomas. Morphological studies in relation to time intervals with astrocytomas. Acta Neurochir 37:75911977Muller W Afra D Schroder R: Supratentorial recurrences of gliomas. Morphological studies in relation to time intervals with astrocytomas. Acta Neurochir 37:75–91 1977

39.

Muller WAfra DSchroder R: Supratentorial recurrences of gliomas. Morphological studies in relation to time intervals with oligodendrogliomas. Acta Neurochir 39:15251977Muller W Afra D Schroder R: Supratentorial recurrences of gliomas. Morphological studies in relation to time intervals with oligodendrogliomas. Acta Neurochir 39:15–25 1977

40.

Nicolato AGerosa MAFina Pet al: Prognostic factors in low-grade supratentorial astrocytomas: a uni-multivariate statistical analysis in 76 surgically treated adult patients. Surg Neurol 44:2082231995Nicolato A Gerosa MA Fina P et al: Prognostic factors in low-grade supratentorial astrocytomas: a uni-multivariate statistical analysis in 76 surgically treated adult patients. Surg Neurol 44:208–223 1995

41.

North CANorth RBEpstein JAet al: Low-grade cerebral astrocytomas. Survival and quality of life after radiation therapy. Cancer 66:6141990North CA North RB Epstein JA et al: Low-grade cerebral astrocytomas. Survival and quality of life after radiation therapy. Cancer 66:6–14 1990

42.

Peraud AAnsari HBise Ket al: Clinical outcome of supratentorial astrocytoma WHO Grade II. Acta Neurochir 140:121312221998Peraud A Ansari H Bise K et al: Clinical outcome of supratentorial astrocytoma WHO Grade II. Acta Neurochir 140:1213–1222 1998

43.

Philippon JHClemenceau SHFauchon FHet al: Supratentorial low-grade astrocytomas in adults. Neurosurgery 32:5545591993Philippon JH Clemenceau SH Fauchon FH et al: Supratentorial low-grade astrocytomas in adults. Neurosurgery 32:554–559 1993

44.

Piepmeier JChristopher SSpencer Det al: Variations in the natural history and survival of patients with supratentorial low-grade astrocytomas. Neurosurgery 38:8728791996Piepmeier J Christopher S Spencer D et al: Variations in the natural history and survival of patients with supratentorial low-grade astrocytomas. Neurosurgery 38:872–879 1996

45.

Piepmeier JM: Observations on the current treatment of low-grade astrocytic tumors of the cerebral hemispheres. J Neurosurg 67:1771811987Piepmeier JM: Observations on the current treatment of low-grade astrocytic tumors of the cerebral hemispheres. J Neurosurg 67:177–181 1987

46.

Rajan BPickuth DAshley Set al: The management of histologically unverified presumed cerebral gliomas with radiotherapy. Int J Radiat Oncol Biol Phys 28:4054131994Rajan B Pickuth D Ashley S et al: The management of histologically unverified presumed cerebral gliomas with radiotherapy. Int J Radiat Oncol Biol Phys 28:405–413 1994

47.

Recht LDLew RSmith TW: Suspected low-grade glioma: is deferring treatment safe? Ann Neurol 31:4314361992Recht LD Lew R Smith TW: Suspected low-grade glioma: is deferring treatment safe? Ann Neurol 31:431–436 1992

48.

Rudoler SCorn BWWerner-Wasik Met al: Patterns of tumor progression after radiotherapy for low-grade gliomas: analysis from the computed tomography/magnetic resonance imaging era. Am J Clin Oncol 21:23271998Rudoler S Corn BW Werner-Wasik M et al: Patterns of tumor progression after radiotherapy for low-grade gliomas: analysis from the computed tomography/magnetic resonance imaging era. Am J Clin Oncol 21:23–27 1998

49.

Scanlon PWTaylor WF: Radiotherapy of intracranial astrocytomas: analysis of 417 cases treated from 1960 through 1969. Neurosurgery 5:3013081979Scanlon PW Taylor WF: Radiotherapy of intracranial astrocytomas: analysis of 417 cases treated from 1960 through 1969. Neurosurgery 5:301–308 1979

50.

Scerrati MRoselli RIacoangeli Met al: Prognostic factors in low grade (WHO grade II) gliomas of the cerebral hemispheres: the role of surgery. J Neurol Neurosurg Psychiatry 61:2912961996Scerrati M Roselli R Iacoangeli M et al: Prognostic factors in low grade (WHO grade II) gliomas of the cerebral hemispheres: the role of surgery. J Neurol Neurosurg Psychiatry 61:291–296 1996

51.

Schiffer DDutto ACavalla Pet al: Prognostic factors in oligodendroglioma. Can J Neurol Sci 24:3133191997Schiffer D Dutto A Cavalla P et al: Prognostic factors in oligodendroglioma. Can J Neurol Sci 24:313–319 1997

52.

Shafqat SHedley-White ETHenson JW: Age-dependent rate of anaplastic transformation in low-grade astrocytoma. Neurology 52:8678691999Shafqat S Hedley-White ET Henson JW: Age-dependent rate of anaplastic transformation in low-grade astrocytoma. Neurology 52:867–869 1999

53.

Shaw EGDaumas-Duport CScheithauer BWet al: Radiation therapy in the management of low-grade supratentorial astrocytomas. J Neurosurg 70:8538611989Shaw EG Daumas-Duport C Scheithauer BW et al: Radiation therapy in the management of low-grade supratentorial astrocytomas. J Neurosurg 70:853–861 1989

54.

Shaw EGScheithauer BWGilbertson DTet al: Postoperative radiotherapy of supratentorial low-grade gliomas. Int J Radiat Oncol Biol Phys 16:6636681989Shaw EG Scheithauer BW Gilbertson DT et al: Postoperative radiotherapy of supratentorial low-grade gliomas. Int J Radiat Oncol Biol Phys 16:663–668 1989

55.

Shaw EGScheithauer BWO'Fallon JR: Supratentorial gliomas: a comparative study by grade and histologic type. J Neurooncol 31:2732781997Shaw EG Scheithauer BW O'Fallon JR: Supratentorial gliomas: a comparative study by grade and histologic type. J Neurooncol 31:273–278 1997

56.

Shaw EGScheithauer BWO'Fallon JRet al: Mixed oligoastrocytomas: a survival and prognostic factor analysis. Neurosurgery 34:5775821994Shaw EG Scheithauer BW O'Fallon JR et al: Mixed oligoastrocytomas: a survival and prognostic factor analysis. Neurosurgery 34:577–582 1994

57.

Shaw EGScheithauer BWO'Fallon JRet al: Oligodendrogliomas: the Mayo Clinic experience. J Neurosurg 76:4284341992Shaw EG Scheithauer BW O'Fallon JR et al: Oligodendrogliomas: the Mayo Clinic experience. J Neurosurg 76:428–434 1992

58.

Shibamoto YKitakabu YTakahashi Met al: Supratentorial low-grade astrocytoma. Correlation of computed tomography findings with effect of radiation therapy and prognostic variables. Cancer 72:1901951993Shibamoto Y Kitakabu Y Takahashi M et al: Supratentorial low-grade astrocytoma. Correlation of computed tomography findings with effect of radiation therapy and prognostic variables. Cancer 72:190–195 1993

59.

Simon RAltman DG: Statistical aspects of prognostic factor studies in oncology. Br J Cancer 69:9799851994Simon R Altman DG: Statistical aspects of prognostic factor studies in oncology. Br J Cancer 69:979–985 1994

60.

Singer JM: Supratentorial low grade gliomas in adults. A retrospective analysis of 43 cases treated with surgery and radiotherapy. Eur J Surg Oncol 21:1982001995Singer JM: Supratentorial low grade gliomas in adults. A retrospective analysis of 43 cases treated with surgery and radiotherapy. Eur J Surg Oncol 21:198–200 1995

61.

Smith MTLudwig CLGodfrey ADet al: Grading of oligodendrogliomas. Cancer 52:210721141983Smith MT Ludwig CL Godfrey AD et al: Grading of oligodendrogliomas. Cancer 52:2107–2114 1983

62.

Soffietti RChio AGiordana MTet al: Prognostic factors in well-differentiated cerebral astrocytomas in the adult. Neurosurgery 24:6866921989Soffietti R Chio A Giordana MT et al: Prognostic factors in well-differentiated cerebral astrocytomas in the adult. Neurosurgery 24:686–692 1989

63.

Steiger HJMarkwalder RVSeiler RWet al: Early prognosis of supratentorial grade 2 astrocytomas in adult patients after resection or stereotactic biopsy. An analysis of 50 cases operated on between 1984 and 1988. Acta Neurochir 106:991051990Steiger HJ Markwalder RV Seiler RW et al: Early prognosis of supratentorial grade 2 astrocytomas in adult patients after resection or stereotactic biopsy. An analysis of 50 cases operated on between 1984 and 1988. Acta Neurochir 106:99–105 1990

64.

Sun ZMGenka SShitara Net al: Factors possibly influencing the prognosis of oligodendroglioma. Neurosurgery 22:8868911988Sun ZM Genka S Shitara N et al: Factors possibly influencing the prognosis of oligodendroglioma. Neurosurgery 22:886–891 1988

65.

van Veelen MLCAvezaat CJJKros JMet al: Supratentorial low grade astrocytoma: prognostic factors, dedifferentiation, and the issue of early versus late surgery. J Neurol Neurosurg Psychiatry 64:5815871998van Veelen MLC Avezaat CJJ Kros JM et al: Supratentorial low grade astrocytoma: prognostic factors dedifferentiation and the issue of early versus late surgery. J Neurol Neurosurg Psychiatry 64:581–587 1998

66.

Vertosick FT JrSelker RGArena VC: Survival of patients with well-differentiated astrocytomas diagnosed in the era of computed tomography. Neurosurgery 28:4965011991Vertosick FT Jr Selker RG Arena VC: Survival of patients with well-differentiated astrocytomas diagnosed in the era of computed tomography. Neurosurgery 28:496–501 1991

67.

Weingart JOlivi ABrem H: Supratentorial low-grade astrocytomas in adults. Neurosurg Q 1:1411591991Weingart J Olivi A Brem H: Supratentorial low-grade astrocytomas in adults. Neurosurg Q 1:141–159 1991

68.

Weir BGrace M: The relative significance of factors affecting postoperative survival in astrocytomas, grades one and two. Can J Neurol Sci 3:47501976Weir B Grace M: The relative significance of factors affecting postoperative survival in astrocytomas grades one and two. Can J Neurol Sci 3:47–50 1976

69.

Whitton ACBloom HJG: Low grade glioma of the cerebral hemispheres in adults: a retrospective analysis of 88 cases. Int J Radiat Oncol Biol Phys 18:7837861990Whitton AC Bloom HJG: Low grade glioma of the cerebral hemispheres in adults: a retrospective analysis of 88 cases. Int J Radiat Oncol Biol Phys 18:783–786 1990

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