Introduction: Few biological and morphological parameters have been found to date that can aid in patient selection and surgical strategy for eloquent area tumors.
Methods: Retrospective, consecutive group of 70 patients harboring supratentorial gliomas in eloquent areas undergoing awake surgery. Parameters: neuroradiologica, functional, neurological, hystological. End-points: extent of resection (EOR) and functional short- and long-term outcome. ?2 analyses were used to evaluate parameters that could be predictive. Multivariate logistic regression analyses were used to evaluate the best combination to predict binary positive outcomes.
Results: The EOR: total in 27 (38.5%), subtotal in 38 (54.2%),partial in 6 (8.5%). In 90%, subcortical stimulation was positive in the margins of the surgical cavity. Postoperatively, 51% of the patients worsened; 90% of the patients regained their preoperative neurological score. Factors affecting negatively EOR: volume, degree of subcortical infiltration, presence of paresis (P < 0.01). Sharp margins and cystic components favoured gross total resection (P < 0.01). Contrast enhancement (P < 0.02), higher grade (P <0.01), paresis (P < 0.01), and residual tumor in the cortex (p < 0.02) negatively affected long-term functional outcomes, whereas postoperative worsening could not be predict for any factor other than paresis. Subcortical responsiveness does not correlate to deterioration of functional status, both postoperatively (P < 0.08) and at follow-up (P < 0.042).
Conclusions: We obtained 88% correct predictions for EOR using the type of margins, volume, symptoms, cystic components, type of infiltration into the white matter. For follow-up Rankin, 95% correct predictions using histology, infiltration of functional cortex, preoperative paresis. Indication for this aggressive surgery must be carefully balanced with the risk of definitive functional impairment especially in those patients with high-grade gliomas who present with deficits.
Patient Care: Our work should help in cosidering different and multiple factors before choosing an awake surgery and direct mapping in patients with eloquent areas gliomas.
Learning Objectives: By the conclusion of this section, partecipants should be able to: 1) to consider direct mapping and awake surgery as a fundamental technique to tret eloquent areas tumors; 2) to pay more attention to the subcortical infiltration of gliomas; 2) to consider tumor morphology as a factor influencing the EOR and functional outcome; 3) to carefully consider awake surgery and direct mapping in patients with highgrade gliomas in eloquent areas who are already symptomatic.
References: Talos IF, Zou KH, Ohno-Machado L, Bhagwat JG, Kikinis R, et al. (2006) Supratentorial low-gradeglioma resectability: Statistical predictive analysis based on anatomic MR features and tumor characteristics. Radiology 239: 506–513.
Castellano A, Bello L, Michelozzi C, Gallucci M, Fava E, et al. (2012) Role of diffusion tensor magnetic resonance tractography in predicting the extent of resection in glioma surgery. Neuro Oncol 14(2): 192–202.
Majchrzak K, Kaspera W, Bobek-Billewicz B, Hebda A, Stasik-Pres G, et al. (2012) The assessment of prognostic factors in surgical treatment of low-grade gliomas: a prospective study. Clin Neurol Neurosurg 114(8): 1135–1344.
De Witt Hamer PC, Robles SG, Zwinderman AH, Duffau H, Berger MS (2012) Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis. J Clin Oncol 10 30(20): 2559–2565.
McGirt MJ, Mukherjee D, Chaichana KL, Than KD, Weingart JD, et al. (2009) Association of surgically acquired motor and language deficits on overall survival after resection of glioblastoma multiforme. Neurosurgery 65(3): 463–469.
Jakola AS, Unsgård G, Myrmel KS, Kloster R, Torp SH, et al. (2012) Low grade gliomas in eloquent locations - implications for surgical strategy, survival and long term quality of life. PLoS One 7(12): e51450.
Gulati S, Jakola AS, Nerland US, Weber C, Solheim O (2011) The risk of getting worse: surgically acquired deficits, perioperative complications, and functional outcomes after primary resection of glioblastoma. World Neurosurg 76(6): 572–579.
McGirt MJ, Chaichana KL, Attenello FJ, Weingart JD, Than K, et al. (2008) Extent of surgical resection is independently associated with survival in patients with hemispheric infiltrating low-grade gliomas. Neurosurgery 63 (4): 700–707.
McGirt MJ, Chaichana KL, Gathinji M, Attenello FJ, Than K, et al. (2009) Independent association of extent of resection with survival in patients with malignant brain astrocytoma. J Neurosurg 110(1): 156–162.
Lacroix M, Abi-Said D, Fourney DR, Gokaslan ZL, Shi W, et al. (2001) A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 95(2): 190–198.