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  • Surgical Thresholds for Patients with Newly Diagnosed Glioblastoma

    Final Number:
    1202

    Authors:
    Kaisorn Chaichana MD; Ignacio Jusue-Torres MD; Alessandro Olivi MD; Gary L. Gallia MD; Michael Lim MD; Henry Brem MD; Alfredo Quinones-Hinojosa MD

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: Surgery is first line therapy for glioblastoma (GB) and there is evidence that gross total resection (GTR) is associated with improved survival. GTR, however, is not always possible and the relationship between percent resection (EOR) and survival is unclear. The goals of this study were to evaluate if there is an association between EOR and survival for all GB, eloquent GB, and GB capable of GTR. A better understanding of these associations may help to optimize surgical care for patients with GB.

    Methods: Adult patients who underwent surgery of a newly diagnosed intracranial GB at an academic tertiary-care institution from 2007-2011 were retrospectively reviewed. Pre and postoperative volumes were measured in a semi-automated fashion using MRI with gadolinium obtained prior to and within 48 hours after surgery. Cox regression analysis was used to identify if an association existed between volumetric EOR and survival. Tumor location was assessed by three neurosurgeons blinded to patient outcomes.

    Results: 292 patients met the inclusion criteria, where 128 involved eloquent (motor and/or language) cortex and 87 were capable of GTR. The median survival of all patients was 12.7 months, and the median[IQR] pre and postoperative tumor volumes were 29.5[13.1-54.3]cm3 and 2.8[0.1-10.5]cm3, respectively. For all GB, increasing EOR was independently associated with survival [HR(95%CI); 0.994(0.990-0.997), p=0.0008], and the minimum EOR survival threshold was >70%. For eloquent tumors, EOR was also independently associated with prolonged survival [HR(95%CI);0.406(0.240-0.700),p=0.001], and the minimum EOR was >65%. For patients where GTR could be achieved, EOR was independently associated with prolonged survival [HR(95%CI);0.972(0.958-0.986),p=0.006], and the minimum EOR was >95% (p=0.01).

    Conclusions: Surgery for GB requires a fine balance between EOR and avoiding iatrogenic deficits. This study establishes thresholds necessary for prolonging survival for patients with GB, which differs between patients with and without eloquent tumors.

    Patient Care: Surgery is first line therapy for glioblastoma (GB) and there is evidence that gross total resection (GTR) is associated with improved survival. GTR, however, is not always possible and the relationship between percent resection (EOR) and survival is unclear. The goals of this study were to evaluate if there is an association between EOR and survival for all GB, eloquent GB, and GB capable of GTR. A better understanding of these associations may help to optimize surgical care for patients with GB.

    Learning Objectives: To identify if extent of resection is associated with prolonged survival for patients with glioblastoma, and if there is a resection threshold that is associated with improved outcomes

    References: 1. Chaichana K, Parker S, Olivi A, Quinones-Hinojosa A: A proposed classification system that projects outcomes based on preoperative variables for adult patients with glioblastoma multiforme. Journal of neurosurgery 112:997-1004, 2010 2. Chaichana KL, Garzon-Muvdi T, Parker S, Weingart JD, Olivi A, Bennett R, et al: Supratentorial glioblastoma multiforme: the role of surgical resection versus biopsy among older patients. Annals of surgical oncology 18:239-245, 2011 3. Chaichana KL, McGirt MJ, Frazier J, Attenello F, Guerrero-Cazares H, Quinones-Hinojosa A: Relationship of glioblastoma multiforme to the lateral ventricles predicts survival following tumor resection. Journal of neuro-oncology 89:219-224, 2008 4. Chaichana KL, Zaidi H, Pendleton C, McGirt MJ, Grossman R, Weingart JD, et al: The efficacy of carmustine wafers for older patients with glioblastoma multiforme: prolonging survival. Neurological research 33:759-764, 2011 5. Genc M, Zorlu AF, Atahan IL: Accelerated hyperfractionated radiotherapy in supratentorial malignant astrocytomas. Radiother Oncol 56:233-238, 2000 6. Lacroix M, Abi-Said D, Fourney DR, Gokaslan ZL, Shi W, DeMonte F, et al: A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. Journal of neurosurgery 95:190-198, 2001 7. McGirt MJ, Chaichana KL, Gathinji M, Attenello FJ, Than K, Olivi A, et al: Independent association of extent of resection with survival in patients with malignant brain astrocytoma. Journal of neurosurgery 110:156-162, 2009 8. McGirt MJ, Mukherjee D, Chaichana KL, Than KD, Weingart JD, Quinones-Hinojosa A: Association of surgically acquired motor and language deficits on overall survival after resection of glioblastoma multiforme. Neurosurgery 65:463-469; discussion 469-470, 2009 9. Orringer D, Lau D, Khatri S, Zamora-Berridi GJ, Zhang K, Wu C, et al: Extent of resection in patients with glioblastoma: limiting factors, perception of resectability, and effect on survival. Journal of neurosurgery 117:851-859, 2012 10. Sanai N, Polley MY, McDermott MW, Parsa AT, Berger MS: An extent of resection threshold for newly diagnosed glioblastomas. Journal of neurosurgery 115:3-8, 2011 11. Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, et al: Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987-996, 2005

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