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  • An Extent of Resection Threshold for Recurrent Glioblastoma

    Final Number:

    Debraj Mukherjee MD MPH; Alicia Ortega BS; Keith L. Black MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: In recent years, several studies have shown extent of resection (EOR) at initial surgery to be an important prognostic factor for overall survival for patients with glioblastoma However, the impact of EOR at subsequent surgeries for glioblastoma recurrence is less well studied. Our study aimed to determine the impact of EOR at the first glioblastoma recurrence on overall survival. Furthermore, we aimed to delineate an extent of resection threshold above which there is a significant overall survival benefit.

    Methods: Patients greater than 18 years of age who underwent surgery for first recurrence between July 2001 and August 2011 were retrospectively reviewed. Demographic, clinical, and outcome parameters including EOR at recurrent surgery based on volumetric analysis were obtained. Kaplan-Meier survival estimates and Cox proportional hazards models were used to evaluate the impact of EOR at recurrent surgery on overall survival (OS). We established a minimum EOR threshold that was associated with a significant survival benefit.

    Results: A total of 93 eligible recurrent glioblastoma patients with a median age of 54.5 years were included in this study. The majority (90.3%) of patients had perioperative KPS of 80 or higher. The mean EOR at first recurrent surgery was 92.7% and the median OS was 22.3 months. Longer survival times were correlated with higher levels of resection. After adjusting for age at diagnosis, perioperative KPS, and initial EOR, EOR at repeat surgery was found to be an independent predictor of survival. Patients who underwent EOR of 99% or greater at first recurrence had a 45% reduction in the hazards of mortality (HR = 0.55, p=0.02).

    Conclusions: Surgical resection for recurrent glioblastoma patients can provide a significant survival benefit as long as an EOR of 99% or greater is achieved. This survival benefit is independent of the EOR at initial surgery.

    Patient Care: By defining a new extent of resection threshold for recurrent glioblastoma, we offer patients and providers a practical guideline that will help them collectively determine when and how best to offer aggressive surgical resection to patients with recurrent disease.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1. Describe the newly defined extent of resection threshold for recurrent glioblastoma in achieving greater overall survival. 2. Identify the importance of pre-operative surgical planning and intraoperative adjuvant techniques to safely maximize extent of resection in recurrent glioblastoma.

    References: 1. Deorah S, Lynch CF, Sibenaller ZA, Ryken TC. Trends in brain cancer incidence and survival in the United States: Surveillance, Epidemiology, and End Results Program, 1973 to 2001. Neurosurgery Focus. April 2006:1-7. 2. Laws ER, Parney IF, Huang W, Anderson F. Survival following surgery and prognostic factors for recently diagnosed malignant glioma: data from the Glioma Outcomes Project. Journal of Neurosurgery. 2003;99:467-473. 3. Stupp R, Mason WP, van den Bent MJ, Weller M. Radiotherapy plus Concomitant and Adjuvant Temozolomide for Glioblastoma. New England Journal of Medicine. 2005;352(10):987-996. 4. Sia Y, Field K, Rosenthal M, Drummond K. Socio-demographic factors and their impact on the number of resections for patients with recurrent glioblastoma. Journal of Clinical Neuroscience. 2013;20(10):1362-1365. doi:10.1016/j.jocn.2013.02.010. 5. Helseth R, Helseth E, Johannesen TB, et al. Overall survival, prognostic factors, and repeated surgery in a consecutive series of 516 patients with glioblastoma multiforme. Acta Neurologica Scandinavica. 2010;122(3):159-167. doi:10.1111/j.1600-0404.2010.01350.x. 6. Brandes AA, Bartolotti M, Franceschi E. Second surgery for recurrent glioblastoma: advantages and pitfalls. Expert Rev Anticancer Ther. 2013;13(5):583-587. doi:10.1586/era.13.32. 7. Young B, Oldfield EH, Markesbery WR, et al. Reoperation for glioblastoma. Journal of Neurosurgery. 1981;55(6):917-921. doi:10.3171/jns.1981.55.6.0917. 8. Lacroix M, Abi-Said D, Fourney DR, et al. A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. Journal of Neurosurgery. 2001;95(2):190-198. doi:10.3171/jns.2001.95.2.0190. 9. McGirt MJ, Chaichana KL, Gathinji M, et al. Independent association of extent of resection with survival in patients with malignant brain astrocytoma. Journal of Neurosurgery. December 2008:156-162. doi:10.3171/2008.4.17536). 10. Sanai N, Polley M-Y, McDermott MW, Parsa AT, Berger MS. An extent of resection threshold for newly diagnosed glioblastomas. Journal of Neurosurgery. 2011;115(1):3-8. doi:10.3171/2011.7.JNS10238. 11. Bloch O, Han SJ, Cha S, et al. Impact of extent of resection for recurrent glioblastoma on overall survival. Journal of Neurosurgery. October 2012:1-7. doi:10.3171/2012.9.JNS12504). 12. Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. Journal of Neurosurgery. January 1986:476-483. 13. Sanai N, Berger MS. Glioma Extent of Resection and Its Impact on Patient Outcome. Neurosurgery. 2008;62(4):753-766. doi:10.1227/01.NEU.0000310769.20996.BD. 14. Ammirati M, Vick N, Liao YL, Ciric I, Mikhael M. Effect of the extent of surgical resection on survival and quality of life in patients with supratentorial glioblastomas and anaplastic astrocytomas. Neurosurgery. 1987;21(2):201-206. 15. Brem H, Piantadosi S, Burger PC, et al. Placebo-controlled trial of safety and efficacy of intraoperative controlled delivery by biodegradable polymers of chemotherapy for recurrent gliomas. The Polymer-brain Tumor Treatment Group. Lancet. 1995;345(8956):1008-1012. 16. Dirks P, Bernstein M, Muller PJ, Tucker WS. The value of reoperation for recurrent glioblastoma. Can J Surg. 1993;36(3):271-275. 17. Keles GE, Anderson B, Berger MS. The effect of extent of resection on time to tumor progression and survival in patients with glioblastoma multiforme of the cerebral hemisphere. Surg Neurol. 1999;52(4):371-379. 18. Landy HJ, Feun L, Schwade JG, Snodgrass S, Lu Y, Gutman F. Retreatment of intracranial gliomas. South Med J. 1994;87(2):211-214. 19. Pinsker M, Lumenta C. Experiences with reoperation on recurrent glioblastoma multiforme. Zentralbl Neurochir. 2001;62(2):43-47. doi:10.1055/s-2002-19477. 20. Carson KA, Grossman SA, Fisher JD, Shaw EG. Prognostic Factors for Survival in Adult Patients With Recurrent Glioma Enrolled Onto the New Approaches to Brain Tumor Therapy CNS Consortium Phase I and II Clinical Trials. JCO. 2007;25(18):2601-2606. doi:10.1200/JCO.2006.08.1661. 21. Clarke JL, Ennis MM, Yung WKA, et al. Is surgery at progression a prognostic marker for improved 6-month progression-free survival or overall survival for patients with recurrent glioblastoma? Neuro-Oncology. 2011;13(10):1118-1124. doi:10.1093/neuonc/nor110. 22. De Bonis P, Fiorentino A, Anile C, et al. The impact of repeated surgery and adjuvant therapy on survival for patients with recurrent glioblastoma. Clin Neurol Neurosurg. 2013;115(7):883-886. doi:10.1016/j.clineuro.2012.08.030. 23. Gorlia T, Stupp R, Brandes AA, et al. New prognostic factors and calculators for outcome prediction in patients with recurrent glioblastoma: A pooled analysis of EORTC Brain Tumour Group phase I and II clinical trials. European Journal of Cancer. 2012;48(8):1176-1184. doi:10.1016/j.ejca.2012.02.004. 24. Mandl ES, Dirven CMF, Buis DR, Postma TJ, Vandertop WP. Repeated surgery for glioblastoma multiforme: only in combination with other salvage therapy. Surg Neurol. 2008;69(5):506–9–discussion509. doi:10.1016/j.surneu.2007.03.043. 25. Harsh GR, Levin VA, Gutin PH, Seager M, Silver P, Wilson CB. Reoperation for recurrent glioblastoma and anaplastic astrocytoma. Neurosurgery. 1987;21(5):615-621. 26. Park C-K, Kim JH, Nam D-H, et al. A practical scoring system to determine whether to proceed with surgical resection in recurrent glioblastoma. Neuro-Oncology. 2013;15(8):1096-1101. doi:10.1093/neuonc/not069. 27. Ellenberg JH. Selection bias in observational and experimental studies. Stat Med. 1994;13(5-7):557-567.

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