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Chow KE, Tyrrell D, Long SN. EARLY POSTOPERATIVE MAGNETIC RESONANCE IMAGING FINDINGS IN FIVE DOGS WITH CONFIRMED AND SUSPECTED BRAIN TUMORS. Vet Radiol Ultrasound 2015; 56:531-9. [PMID: 26372362 DOI: 10.1111/vru.12248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 01/25/2015] [Indexed: 11/29/2022] Open
Abstract
Early postoperative neuroimaging has been performed in people for over 20 years to detect residual brain tumor tissue and surgical complications. The purpose of this retrospective study was to describe characteristics observed using early postoperative magnetic resonance imaging in a group of dogs undergoing craniotomy for brain tumor removal. Two independent observers came to a consensus opinion for presence/absence of the following MRI characteristics: residual tumor tissue; hemorrhage and ischemic lesions; abnormal enhancement (including the margins of the resection cavity, choroid plexus, meninges) and signal intensity changes on diffusion-weighted imaging. Five dogs were included in the study, having had preoperative and early postoperative MRI acquired within four days after surgery. The most commonly observed characteristics were abnormal meningeal enhancement, linear enhancement at margins of the resection cavity, hemorrhage, and a thin rim of hyperintensity surrounding the resection cavity on diffusion-weighted imaging. Residual tumor tissue was detected in one case of an enhancing tumor and in one case of a tumor containing areas of hemorrhage preoperatively. Residual tumor tissue was suspected but could not be confirmed when tumors were nonenhancing. Findings supported the use of early postoperative MRI as a method for detecting residual brain tumor tissue in dogs.
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Affiliation(s)
- Kathleen Ella Chow
- University of Melbourne Veterinary Hospital, Radiology Department, Melbourne, Victoria, Australia
| | - Dayle Tyrrell
- University of Melbourne Veterinary Hospital, Radiology Department, Melbourne, Victoria, Australia
| | - Sam Nicholas Long
- University of Melbourne Veterinary Hospital, Radiology Department, Melbourne, Victoria, Australia
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Neagu MR, Huang RY, Reardon DA, Wen PY. How treatment monitoring is influencing treatment decisions in glioblastomas. Curr Treat Options Neurol 2015; 17:343. [PMID: 25749847 DOI: 10.1007/s11940-015-0343-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OPINION STATEMENT Glioblastoma (GBM), the most common malignant primary tumor in adults, carries a dismal prognosis with an average median survival of 14-16 months. The current standard of care for newly diagnosed GBM consists of maximal safe resection followed by fractionated radiotherapy combined with concurrent temozolomide and 6 to 12 cycles of adjuvant temozolomide. The determination of treatment response and clinical decision-making in the treatment of GBM depends on accurate radiographic assessment. Differentiating treatment response from tumor progression is challenging and combines long-term follow-up using standard MRI, with assessing clinical status and corticosteroid dependency. At progression, bevacizumab is the mainstay of treatment. Incorporation of antiangiogenic therapies leads to rapid blood-brain barrier normalization with remarkable radiographic response often not accompanied by the expected survival benefit, further complicating imaging assessment. Improved radiographic interpretation criteria, such as the Response Assessment in Neuro-Oncology (RANO) criteria, incorporate non-enhancing disease but still fall short of definitely distinguishing tumor progression, pseudoresponse, and pseudoprogression. With new evolving treatment modalities for this devastating disease, advanced imaging modalities are increasingly becoming part of routine clinical care in a field where neuroimaging has such essential role in guiding treatment decisions and defining clinical trial eligibility and efficacy.
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Affiliation(s)
- Martha R Neagu
- Dana Farber Cancer Institute, G4200, 44 Binney St, Boston, MA, 02115, USA
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53
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Chang WS, Jung HH, Kweon EJ, Zadicario E, Rachmilevitch I, Chang JW. Unilateral magnetic resonance guided focused ultrasound thalamotomy for essential tremor: practices and clinicoradiological outcomes. J Neurol Neurosurg Psychiatry 2015; 86:257-64. [PMID: 24876191 DOI: 10.1136/jnnp-2014-307642] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Several options exist for surgical management of essential tremor (ET), including radiofrequency lesioning, deep brain stimulation and γ knife radiosurgery of the ventralis intermedius nucleus of the thalamus. Recently, magnetic resonance-guided focused ultrasound (MRgFUS) has been developed as a less-invasive surgical tool aimed to precisely generate focal thermal lesions in the brain. METHODS Patients underwent tremor evaluation and neuroimaging study at baseline and up to 6 months after MRgFUS. Tremor severity and functional impairment were assessed at baseline and then at 1 week, 1 month, 3 months and 6 months after treatment. Adverse effects were also sought and ascertained by directed questions, neuroimaging results and neurological examination. RESULTS The current feasibility study attempted MRgFUS thalamotomy in 11 patients with medication-resistant ET. Among them, eight patients completed treatment with MRgFUS, whereas three patients could not complete the treatment because of insufficient temperature. All patients who completed treatment with MRgFUS showed immediate and sustained improvements in tremors lasting for the 6-month follow-up period. Skull volume and maximum temperature rise were linearly correlated (linear regression, p=0.003). Other than one patient who had mild and delayed postoperative balance, no patient developed significant postsurgical complications; about half of the patients had bouts of dizziness during the MRgFUS. CONCLUSIONS Our results demonstrate that MRgFUS thalamotomy is a safe, effective and less-invasive surgical method for treating medication-refractory ET. However, several issues must be resolved before clinical application of MRgFUS, including optimal patient selection and management of patients during treatment.
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Affiliation(s)
- Won Seok Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Jung Kweon
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | | | | | - Jin Woo Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Abd-El-Barr MM, Santos SM, Aglio LS, Young GS, Mukundan S, Golby AJ, Gormley WB, Dunn IF. "Extraoperative" MRI (eoMRI) for Brain Tumor Surgery: Initial Results at a Single Institution. World Neurosurg 2015; 83:921-8. [PMID: 25700968 DOI: 10.1016/j.wneu.2015.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Revised: 10/18/2014] [Accepted: 02/02/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is accumulating evidence that extent of resection (EOR) in intrinsic brain tumor surgery prolongs overall survival (OS) and progression-free survival (PFS). One of the strategies to increase EOR is the use of intraoperative MRI (ioMRI); however, considerable infrastructure investment is needed to establish and maintain a sophisticated ioMRI. We report the preliminary results of an extraoperative (eoMRI) protocol, with a focus on safety, feasibility, and EOR in intrinsic brain tumor surgery. METHODS Ten patients underwent an eoMRI protocol consisting of surgical resection in a conventional operating room followed by an immediate MRI in a clinical MRI scanner while the patient was still under anesthesia. If findings of the MRI suggested residual safely resectable tumor, the patient was returned to the operating room. A retrospective volumetric analysis was undertaken to investigate the percentage of tumor resected after first resection and if applicable, after further resection. RESULTS Six of 10 (60%) patients were thought to require no further resection after eoMRI. The EOR in these patients was 97.8% ± 1.8%. In the 4 patients who underwent further resection, the EOR during the original surgery was 88.5% ± 9.5% (P = 0.04). There was an average of 10.1% more tumor removed between the first and second surgery. In 3 of 4 (75%) of patients who returned for further resection, gross total resection of tumor was achieved. CONCLUSION An eoMRI protocol appears to be a safe and practical method to ensure maximum safe resections in patients with brain tumors and can be performed readily in all centers with MRI capabilities.
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Affiliation(s)
- Muhammad M Abd-El-Barr
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Seth M Santos
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Linda S Aglio
- Department of Anesthesiology, Perioperative and Pain Management, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Geoffrey S Young
- Section of Neuroradiology, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Srinivasan Mukundan
- Section of Neuroradiology, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Section of Neuroradiology, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William B Gormley
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian F Dunn
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Hollon T, Hervey-Jumper SL, Sagher O, Orringer DA. Advances in the Surgical Management of Low-Grade Glioma. Semin Radiat Oncol 2015; 25:181-8. [PMID: 26050588 DOI: 10.1016/j.semradonc.2015.02.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Over the past 2 decades, extent of resection has emerged as a significant prognostic factor in patients with low-grade gliomas (LGGs). Greater extent of resection has been shown to improve overall survival, progression-free survival, and time to malignant transformation. The operative goal in most LGG cases is to maximize extent of resection, while avoiding postoperative neurologic deficits. Several advanced surgical techniques have been developed in an attempt to better achieve maximal safe resection. Intraoperative magnetic resonance imaging, fluorescence-guided surgery, intraoperative functional pathway mapping, and neuronavigation are some of the most commonly used techniques with multiple studies to support their efficacy in glioma surgery. By using these techniques either alone or in combination, patients harboring LGGs have a better prognosis with less surgical morbidity following tumor resection.
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Affiliation(s)
- Todd Hollon
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | | | - Oren Sagher
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
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The Value of Extent of Resection of Glioblastomas: Clinical Evidence and Current Approach. Curr Neurol Neurosci Rep 2014; 15:517. [DOI: 10.1007/s11910-014-0517-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Murphy M, Parney IF. Clinical trials in neurosurgical oncology. J Neurooncol 2014; 119:569-76. [PMID: 25106866 DOI: 10.1007/s11060-014-1569-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 07/23/2014] [Indexed: 10/24/2022]
Abstract
Brain tumors such as diffuse infiltrating gliomas continue to represent a major clinical challenge. Overall survival for patients diagnosed with glioblastoma, the most common primary brain tumor, remains less than 2 years despite intensive multimodal therapy with surgery, radiation, and chemotherapy. However, advances have been made in standard therapies and novel treatments that are showing great potential. These advances reflect careful study performed in the context of clinical trials. Neurosurgeons have played and will continue to play key parts in these studies. In this manuscript, we review clinical trials in neuro-oncology from a neurosurgical point of view and discuss potential roles for neurosurgeons in advancing glioma therapy in the future.
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Affiliation(s)
- Meghan Murphy
- Department of Neurological Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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58
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Kast RE, Auner GW, Rosenblum ML, Mikkelsen T, Yurgelevic SM, Raghunathan A, Poisson LM, Kalkanis SN. Raman molecular imaging of brain frozen tissue sections. J Neurooncol 2014; 120:55-62. [PMID: 25038847 DOI: 10.1007/s11060-014-1536-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 07/06/2014] [Indexed: 02/03/2023]
Abstract
Raman spectroscopy provides a molecular signature of the region being studied. It is ideal for neurosurgical applications because it is non-destructive, label-free, not impacted by water concentration, and can map an entire region of tissue. The objective of this paper is to demonstrate the meaningful spatial molecular information provided by Raman spectroscopy for identification of regions of normal brain, necrosis, diffusely infiltrating glioma and solid glioblastoma (GBM). Five frozen section tissues (1 normal, 1 necrotic, 1 GBM, and 2 infiltrating glioma) were mapped in their entirety using a 300-µm-square step size. Smaller regions of interest were also mapped using a 25-µm step size. The relative concentrations of relevant biomolecules were mapped across all tissues and compared with adjacent hematoxylin and eosin-stained sections, allowing identification of normal, GBM, and necrotic regions. Raman peaks and peak ratios mapped included 1003, 1313, 1431, 1585, and 1659 cm(-1). Tissue maps identified boundaries of grey and white matter, necrosis, GBM, and infiltrating tumor. Complementary information, including relative concentration of lipids, protein, nucleic acid, and hemoglobin, was presented in a manner which can be easily adapted for in vivo tissue mapping. Raman spectroscopy can successfully provide label-free imaging of tissue characteristics with high accuracy. It can be translated to a surgical or laboratory tool for rapid, non-destructive imaging of tumor margins.
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Affiliation(s)
- Rachel E Kast
- Electrical and Computer Engineering, Wayne State University, Detroit, MI, 48202, USA
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Watts C, Price SJ, Santarius T. Current concepts in the surgical management of glioma patients. Clin Oncol (R Coll Radiol) 2014; 26:385-94. [PMID: 24882149 DOI: 10.1016/j.clon.2014.04.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 04/01/2014] [Indexed: 12/16/2022]
Abstract
The scientific basis for the surgical management of patients with glioma is rapidly evolving. The infiltrative nature of these cancers precludes a surgical cure, but despite this, cytoreductive surgery remains central to high-quality patient care. In addition to tissue sampling for accurate histopathological diagnosis and molecular genetic characterisation, clinical benefit from decompression of space-occupying lesions and microsurgical cytoreduction has been reported in patients with different grades of glioma. By integrating advanced surgical techniques with molecular genetic characterisation of the disease and targeted radiotherapy and chemotherapy, it is possible to construct a programme of personalised surgical therapy throughout the patient journey. The goal of therapeutic packages tailored to each patient is to optimise patient safety and clinical outcome and must be delivered in a multidisciplinary setting. Here we review the current concepts that underlie surgical subspecialisation in the management of patients with glioma.
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Affiliation(s)
- C Watts
- University of Cambridge, Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK; Department of Clinical Neurosciences, Cambridge Centre for Brain Repair, University of Cambridge, Cambridge, UK.
| | - S J Price
- University of Cambridge, Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - T Santarius
- University of Cambridge, Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
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D'Amico RS, Kennedy BC, Bruce JN. Neurosurgical oncology: advances in operative technologies and adjuncts. J Neurooncol 2014; 119:451-63. [PMID: 24969924 DOI: 10.1007/s11060-014-1493-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 05/22/2014] [Indexed: 12/31/2022]
Abstract
Modern glioma surgery has evolved around the central tenet of safely maximizing resection. Recent surgical adjuncts have focused on increasing the maximum extent of resection while minimizing risk to functional brain. Technologies such as cortical and subcortical stimulation mapping, intraoperative magnetic resonance imaging, functional neuronavigation, navigable intraoperative ultrasound, neuroendoscopy, and fluorescence-guided resection have been developed to augment the identification of tumor while preserving brain anatomy and function. However, whether these technologies offer additional long-term benefits to glioma patients remains to be determined. Here we review advances over the past decade in operative technologies that have offered the most promising benefits for glioblastoma patients.
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Affiliation(s)
- Randy S D'Amico
- Department of Neurological Surgery, Neurological Institute, Columbia University Medical Center, 4th Floor, 710 West 168th Street, New York, NY, 10032, USA,
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Ito-Yamashita T, Nakasu Y, Mitsuya K, Mizokami Y, Namba H. Detection of tumor progression by signal intensity increase on fluid-attenuated inversion recovery magnetic resonance images in the resection cavity of high-grade gliomas. Neurol Med Chir (Tokyo) 2014; 53:496-500. [PMID: 23883561 DOI: 10.2176/nmc.53.496] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Increased signal intensity (SI) on fluid-attenuated inversion recovery (FLAIR) magnetic resonance (MR) images in the resection cavity is sometimes observed after partial resection of gliomas. SI in the resection cavity of 44 high-grade gliomas was retrospectively investigated. Twelve of 35 patients with progressive disease (PD) showed SI increase in the resection cavity, and SI increase preceded PD in 6 of these 12 patients. None of nine patients without PD showed SI increase during the follow-up period. The analysis of SI on FLAIR images in the resection cavity had a specificity of 100% and a sensitivity of 34%. Higher sensitivity was found in grade IV tumors than in grade III tumors. SI increase is thus considered as a potent highly specific hallmark for subsequent or coincident tumor progression, which is clinically useful since MR imaging is easily performed during routine clinical examinations.
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Affiliation(s)
- Tae Ito-Yamashita
- Division of Neurosurgery, Shizuoka Cancer Center, Sunto-gun, Shizuoka, Japan
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Díez Valle R, Slof J, Galván J, Arza C, Romariz C, Vidal C. Observational, retrospective study of the effectiveness of 5-aminolevulinic acid in malignant glioma surgery in Spain (The VISIONA study). NEUROLOGÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.nrleng.2013.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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63
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Díez Valle R, Slof J, Galván J, Arza C, Romariz C, Vidal C. Estudio observacional retrospectivo sobre la efectividad del ácido 5-aminolevulínico en la cirugía de los gliomas malignos en España (Estudio VISIONA). Neurologia 2014; 29:131-8. [DOI: 10.1016/j.nrl.2013.05.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 05/10/2013] [Accepted: 05/15/2013] [Indexed: 10/26/2022] Open
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Hervey-Jumper SL, Berger MS. Role of surgical resection in low- and high-grade gliomas. Curr Treat Options Neurol 2014; 16:284. [PMID: 24595756 DOI: 10.1007/s11940-014-0284-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OPINION STATEMENT Central nervous system tumors are a major cause of morbidity and mortality in the United States. Outside of brain metastasis, low- and high-grade gliomas are the most common intrinsic brain tumors. Low-grade gliomas have a 5- and 10-year survival rate of 97 % and 91 %, respectively, when extent of resection is greater than 90 %. High-grade gliomas are extremely aggressive with the vast majority of patients experiencing recurrence and a median survival of 1 to 3 years. Survival of patients with both low- and high-grade gliomas is enhanced with maximal tumor resection. The pursuit of more aggressive extent of resection must be balanced with preservation of functional pathways. Several innovations in neurosurgical oncology have expanded our understanding of individualized patient neuroanatomy, physiology, and function. Emerging imaging technologies as well as intraoperative techniques have expanded our ability to resect maximal amounts of tumor while preserving essential function. Stimulation mapping of language and motor pathways is well-established for the safe resection of intrinsic brain lesions. Additional techniques including neuro-navigation, fluorescence-guided microsurgery using 5-aminolevulinic acid, intraoperative magnetic resonance imaging, and high-frequency ultrasonography can all be used to improve extent of resection in glioma patients.
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Affiliation(s)
- Shawn L Hervey-Jumper
- Department of Neurological Surgery, University of California, 505 Parnassus Avenue, M779, San Francisco, CA, 94143, USA
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Maximizing the extent of resection and survival benefit of patients in glioblastoma surgery: High-field iMRI versus conventional and 5-ALA-assisted surgery. Eur J Surg Oncol 2014; 40:297-304. [DOI: 10.1016/j.ejso.2013.11.022] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/16/2013] [Accepted: 11/23/2013] [Indexed: 11/19/2022] Open
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Quick J, Gessler F, Dützmann S, Hattingen E, Harter PN, Weise LM, Franz K, Seifert V, Senft C. Benefit of tumor resection for recurrent glioblastoma. J Neurooncol 2014; 117:365-72. [PMID: 24535317 DOI: 10.1007/s11060-014-1397-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 01/29/2014] [Indexed: 11/28/2022]
Abstract
In the treatment of glioblastoma (GBM) the impact of radical tumor resection as first line therapy is beyond controversy. The significance of a second resection in case of tumor-recurrence remains unclear and is an issue of debate. Since GBMs always recur, it is important to determine whether or not patients will benefit from repeat surgery. We performed a retrospective analysis of our prospectively collected database and evaluated all re-resected patients with primary GBM who underwent second surgery during a 3 years period. All patients underwent early postoperative magnetic resonance imaging. We determined survival after re-resection with regard to possible prognostic factors using Kaplan-Meier estimates and Cox regression analyses. Forty patients were included in this study. Median age was 58 years and median KPS score was 80. Average tumor volume was 5.5 cm(3). A radiologically confirmed complete resection was achieved in 29 patients (72.5 %). Median follow-up was 18.8 months, and median survival after re-resection was 13.5 months. Only complete removal of contrast enhancing tumor was significantly correlated with survival after re-resection according to multivariate analysis. There was a statistical trend for KPS score influencing survival. In contrast, time between first diagnosis and tumor-recurrence, tumor volume at recurrence, MGMT status and MSM score were not significantly correlated with survival after second surgery. In the event of tumor recurrence, patients in good clinical condition with recurrent GBM amenable to complete resection should thus not be withheld second surgery as a treatment option.
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Affiliation(s)
- Johanna Quick
- Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany,
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67
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Mut M, Schiff D. Unmet needs in the treatment of glioblastoma. Expert Rev Anticancer Ther 2014; 9:545-51. [DOI: 10.1586/era.09.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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The value of immediate postoperative MR imaging following endoscopic endonasal pituitary surgery. Acta Neurochir (Wien) 2014; 156:133-40; discussion 140. [PMID: 23982229 DOI: 10.1007/s00701-013-1834-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 07/23/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although the value of early MR imaging has been justified for microscopic transphenoidal surgery, there is no literature evaluating immediate postoperative MR imaging following endoscopic endonasal resection of pituitary adenomas. We hypothesized that MRI of the pituitary gland performed on the first postoperative day is just as effective at detecting residual disease and/or reconstruction materials as the MRI at 3 months following surgery. METHODS We retrospectively evaluated 102 consecutive patients who underwent endoscopic endonasal surgery for presumed pituitary adenomas. Sixty-four patients met the inclusion criteria with immediate and 3 months MR imaging. Imaging was evaluated by two sets of observers. The following parameters were assessed: enhancement pattern of the pituitary gland, pituitary stalk, nodular enhancement (residual tumor) or linear enhancement (non-tumoral) and residual reconstruction/packing materials. RESULTS Gross total resection of the tumors with no cavernous sinus involvement was achieved in 49 out of 52 (94%) patients. Eleven out of 12 remaining patients with cavernous sinus invasion had residual cavernous sinus component visible on both immediate and 3 month MR imaging. The pituitary gland, position of stalk, and nasoseptal flap could be identified on both post-operative MRIs in all patients. The sensitivity and specificity for residual tumor detection on immediate MRI was 100% and 97.9%, respectively. The kappa index evaluating interobserver agreement for identification of residual tumor and packing/reconstruction material on immediate MR was 0.83 and 0.72 indicating near perfect and substantial agreement, respectively. CONCLUSION Immediate MR imaging performed following endoscopic endonasal resection of pituitary lesions provides accurate and reliable information regarding the presence of residual tumor compared to reconstruction and packing materials.
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Eljamel S, Petersen M, Valentine R, Buist R, Goodman C, Moseley H, Eljamel S. Comparison of intraoperative fluorescence and MRI image guided neuronavigation in malignant brain tumours, a prospective controlled study. Photodiagnosis Photodyn Ther 2013; 10:356-61. [DOI: 10.1016/j.pdpdt.2013.03.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Revised: 03/16/2013] [Accepted: 03/19/2013] [Indexed: 10/27/2022]
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Schucht P, Murek M, Jilch A, Seidel K, Hewer E, Wiest R, Raabe A, Beck J. Early re-do surgery for glioblastoma is a feasible and safe strategy to achieve complete resection of enhancing tumor. PLoS One 2013; 8:e79846. [PMID: 24348904 PMCID: PMC3865346 DOI: 10.1371/journal.pone.0079846] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 09/25/2013] [Indexed: 11/18/2022] Open
Abstract
Background Complete resection of enhancing tumor as assessed by early (<72 hours) postoperative MRI is regarded as the optimal result in glioblastoma surgery. As yet, there is no consensus on standard procedure if post-operative imaging reveals unintended tumor remnants. Objective The current study evaluated the feasibility and safety of an early re-do surgery aimed at completing resections with the aid of 5-ALA fluorescence and neuronavigation after detection of enhancing tumor remnants on post-operative MRI. Methods From October 2008 to October 2012 a single center institutional protocol offered a second surgery within one week to patients with unintentional incomplete glioblastoma resection. We report on the feasibility of the use 5-ALA fluorescence guidance, the extent of resection (EOR) rates and complications of early re-do surgery. Results Nine of 151 patients (6%) with glioblastoma resections had an unintentional tumor remnant with a volume >0.175 cm3. 5-ALA guided re-do surgery completed the resection (CRET) in all patients without causing neurological deficits, infections or other complications. Patients who underwent a re-do surgery remained hospitalized between surgeries, resulting in a mean length of hospital stay of 11 days (range 7-15), compared to 9 days for single surgery (range 3-23; p=0.147). Conclusion Our early re-do protocol led to complete resection of all enhancing tumor in all cases without any new neurological deficits and thus provides a similar oncological result as intraoperative MRI (iMRI). The repeated use of 5-ALA induced fluorescence, used for identification of small remnants, remains highly sensitive and specific in the setting of re-do surgery. Early re-do surgery is a feasible and safe strategy to complete unintended subtotal resections.
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Affiliation(s)
- Philippe Schucht
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Michael Murek
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Astrid Jilch
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Kathleen Seidel
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Ekkehard Hewer
- Department of Neuropathology, University Hospital Bern, Bern, Switzerland
| | - Roland Wiest
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
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71
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Ginat DT, Swearingen B, Curry W, Cahill D, Madsen J, Schaefer PW. 3 Tesla intraoperative MRI for brain tumor surgery. J Magn Reson Imaging 2013; 39:1357-65. [DOI: 10.1002/jmri.24380] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Daniel Thomas Ginat
- Department of Radiology, Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts USA
| | - Brooke Swearingen
- Department of Neurosurgery, Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts USA
| | - William Curry
- Department of Neurosurgery, Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts USA
| | - Daniel Cahill
- Department of Neurosurgery, Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts USA
| | - Joseph Madsen
- Department of Neurosurgery, Boston Children's Hospital; Harvard Medical School; Boston Massachusetts USA
| | - Pamela W. Schaefer
- Department of Neurosurgery, Boston Children's Hospital; Harvard Medical School; Boston Massachusetts USA
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72
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Sanz-Requena R, Revert-Ventura A, Martí-Bonmatí L, Alberich-Bayarri A, García-Martí G. Quantitative MR perfusion parameters related to survival time in high-grade gliomas. Eur Radiol 2013; 23:3456-65. [PMID: 23839170 DOI: 10.1007/s00330-013-2967-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 06/12/2013] [Accepted: 06/18/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the quantitative parameters obtained from dynamic MR T2*-weighted images as predictors of survival taking into consideration the biasing effects of other survival-related covariates. METHODS Thirty-nine patients (60 ± 14 years; survival 267 ± 191 days) with high-grade gliomas (8 grade III, 31 grade IV) were retrospectively included in the study. Additional data incorporated Karnofsky performance scale, tumour resection extension after surgery and type of treatment. Dynamic T2*-weighted MRI was acquired before treatment. Tumour curves were extracted for each voxel, and several quantitative parameters were obtained from the whole tumour volume and the 10 % maximum values. Additional image covariates included the presence of necrosis, single or multiple lesions, and tumour and oedema volumes. The relationship between quantitative parameters and survival was assessed using clusterisation techniques and the log-rank method. Cox regression analysis was used to evaluate each parameter's predictive value. RESULTS Only the mean of the 10 % maximum values of the transfer coefficient showed an independent relationship with patient survival (log-rank chi-squared test <0.001, Cox regression P = 0.015), with higher values corresponding to lower survival rates. CONCLUSIONS High maximum transfer coefficient values show an independent statistical relationship with low survival in high-grade glioma patients. This imaging biomarker can be used as a predictor of prognosis.
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Affiliation(s)
- Roberto Sanz-Requena
- Radiology Department, Hospital Quirón Valencia, Av Blasco Ibañez 14, 46010, Valencia, Spain,
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73
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Park CK, Kim JH, Nam DH, Kim CY, Chung SB, Kim YH, Seol HJ, Kim TM, Choi SH, Lee SH, Heo DS, Kim IH, Kim DG, Jung HW. A practical scoring system to determine whether to proceed with surgical resection in recurrent glioblastoma. Neuro Oncol 2013; 15:1096-101. [PMID: 23800677 DOI: 10.1093/neuonc/not069] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND To determine the benefit of surgical management in recurrent glioblastoma, we analyzed a series of patients with recurrent glioblastoma who had undergone surgery, and we devised a new scale to predict their survival. METHODS Clinical data from 55 consecutive patients with recurrent glioblastoma were evaluated after surgical management. Kaplan-Meier survival analysis and Cox proportional hazards regression modeling were used to identify prognostic variables for the development of a predictive scale. After the multivariate analysis, performance status (P = .078) and ependymal involvement (P = .025) were selected for inclusion in the new prognostic scale. The devised scale was validated with a separate set of 96 patients from 3 different institutes. RESULTS A 3-tier scale (scoring range, 0-2 points) composed of additive scores for the Karnofsky performance status (KPS) (0 for KPS ≥ 70 and 1 for KPS < 70) and ependymal involvement (0 for no enhancement and 1 for enhancement of the ventricle wall in the magnetic resonance imaging) significantly distinguished groups with good (0 points; median survival, 18.0 months), intermediate (1 point; median survival, 10.0 months), and poor prognoses (2 points; median survival, 4.0 months). The new scale was successfully applied to the validation cohort of patients showing distinct prognosis among the groups (median survivals of 11.0, 9.0, and 4.0 months for the 0-, 1-, and 2-point groups, respectively). CONCLUSIONS We developed a practical scale to facilitate deciding whether to proceed with surgical management in patients with recurrent glioblastoma. This scale was useful for the diagnosis of prognostic groups and can be used to develop guidelines for patient treatment.
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Affiliation(s)
- Chul-Kee Park
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea.
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Zhao S, Wu J, Wang C, Liu H, Dong X, Shi C, Shi C, Liu Y, Teng L, Han D, Chen X, Yang G, Wang L, Shen C, Li H. Intraoperative fluorescence-guided resection of high-grade malignant gliomas using 5-aminolevulinic acid-induced porphyrins: a systematic review and meta-analysis of prospective studies. PLoS One 2013; 8:e63682. [PMID: 23723993 PMCID: PMC3665818 DOI: 10.1371/journal.pone.0063682] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 04/06/2013] [Indexed: 12/18/2022] Open
Abstract
Background We performed a systematic review and meta-analysis to address the (added) value of intraoperative 5-aminolevulinic acid (5-ALA)-guided resection of high-grade malignant gliomas compared with conventional neuronavigation-guided resection, with respect to diagnostic accuracy, extent of tumor resection, safety, and survival. Methods and Findings An electronic database search of Medline, Embase, and the Cochrane Library was undertaken. The review process followed the guidelines of the Cochrane Collaboration. 10 studies matched all selection criteria, and were thus used for qualitative synthesis. 5-ALA-guided resection demonstrated an overall sensitivity of 0.87 (95% confidence interval [CI], 0.81–0.92), specificity of 0.89 (95% CI, 0.79–0.94), positive likelihood ratio (LR) of 7.62 (95% CI, 3.87–15.01), negative LR of 0.14 (95% CI, 0.09–0.23), and diagnostic odds ratio (OR) of 53.06 (95% CI, 18.70–150.51). Summary receiver operating characteristic curves (SROC) showed an area under curve (AUC) of 94%. Contrast-enhancing tumor was completely resected in patients assigned 5-ALA as compared with patients assigned white light. Patients in the 5-ALA group had higher 6-month progression free survival and overall survival than those in the white light group. Conclusion Based on available literature, there is level 2 evidence that 5-ALA-guided surgery is more effective than conventional neuronavigation-guided surgery in increasing diagnostic accuracy and extent of tumor resection, enhancing quality of life, or prolonging survival in patients with high-grade malignant gliomas.
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Affiliation(s)
- Shiguang Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.
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Exérèse neurochirurgicale optimale des gliomes de haut grade guidée par fluorescence : mise au point à partir d’une série rétrospective de 22 patients. Neurochirurgie 2013; 59:9-16. [DOI: 10.1016/j.neuchi.2012.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Revised: 07/09/2012] [Accepted: 07/27/2012] [Indexed: 11/21/2022]
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76
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Immediate post-operative MRI suggestive of the site and timing of glioblastoma recurrence after gross total resection: a retrospective longitudinal preliminary study. Eur Radiol 2013; 23:1467-77. [PMID: 23314599 DOI: 10.1007/s00330-012-2762-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 12/11/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To retrospectively identify morphological and physiological post-operative magnetic resonance imaging (MRI) characteristics predictive of glioblastoma recurrences after gross total resection (gross-TR). METHODS Resection margins of 24 glioblastoma were analysed immediately post-operatively (MRI ≤ 2 h) and early post-operatively (24 h ≤ MRI ≤ 48 h), and subdivided into areas with and without subtle contrast enhancement previously considered non-specific. On follow-up MRI, tumour regrowth areas were subdivided according to recurrence extent (focally/extended) and delay (≤6 and ≥12 months). Co-registration of pre-operative, immediately post-operative and early post-operative MRI with the first follow-up MRI demonstrating recurrence authorised their morphological (contrast enhancements) and physiological (rCBV) characterisation. RESULTS Morphologically, on immediately post-operative MRI, micro-nodular and frayed enhancements correlate significantly with early recurrences (≤6 months). After gross-TR the absence of these enhancements is associated with a significant increase in progression-free survival (61 vs 15 weeks respectively) and overall survival (125 vs 51 weeks respectively). Physiologically, areas with a future focal recurrence have a trend toward higher rCBV than other areas. CONCLUSION Immediately post-operative topography of micro-nodular and frayed enhancements is suggestive of recurrence location and delay. Absence of such enhancements is associated with a fourfold increase in progression-free survival and a 2.5-fold increase in overall survival. KEY POINTS • Immediately post-operative MRI reveals contrast enhancement after glioblastoma gross total resection. • Immediately post-operative micro-nodular and frayed enhancement correlate with early recurrence. • Absence of micro-nodular/frayed enhancement is associated with 61 weeks' progression-free survival. • Absence of micro-nodular/frayed enhancement is associated with 125 weeks' overall survival.
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Farace P, Amelio D, Ricciardi GK, Zoccatelli G, Magon S, Pizzini F, Alessandrini F, Sbarbati A, Amichetti M, Beltramello A. Early MRI changes in glioblastoma in the period between surgery and adjuvant therapy. J Neurooncol 2012; 111:177-85. [PMID: 23264191 DOI: 10.1007/s11060-012-0997-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 10/31/2012] [Indexed: 11/26/2022]
Abstract
To investigate the increase in MRI contrast enhancement (CE) occurring in glioblastoma during the period between surgery and initiation of chemo-radiotherapy, thirty-seven patients with newly diagnosed glioblastoma were analyzed by early post-operative magnetic resonance (EPMR) imaging within three days of surgery and by pre-adjuvant magnetic resonance (PAMR) examination before adjuvant therapy. Areas of new CE were investigated by use of EPMR diffusion-weighted imaging and PAMR perfusion imaging (by arterial spin-labeling). PAMR was acquired, on average, 29.9 days later than EPMR (range 20-37 days). During this period an increased area of CE was observed for 17/37 patients. For 3/17 patients these regions were confined to areas of reduced EPMR diffusion, suggesting postsurgical infarct. For the other 14/17 patients, these areas suggested progression. For 11/17 patients the co-occurrence of hyperperfusion in PAMR perfusion suggested progression. PAMR perfusion and EPMR diffusion did not give consistent results for 3/17 patients for whom small new areas of CE were observed, presumably because of the poor spatial resolution of perfusion imaging. Before initiation of adjuvant therapy, areas of new CE of resected glioblastomas are frequently observed. Most of these suggest tumor progression, according to EPMR diffusion and PAMR perfusion criteria.
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Affiliation(s)
- Paolo Farace
- Anatomy and Histology Section, Department of Morphological and Biomedical Sciences, University of Verona, Via Le Grazie 8, 37134 Verona, VR, Italy.
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78
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Garrett MC, Pouratian N, Liau LM. Use of language mapping to aid in resection of gliomas in eloquent brain regions. Neurosurg Clin N Am 2012; 23:497-506. [PMID: 22748661 DOI: 10.1016/j.nec.2012.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Studies looking at resection in high-grade gliomas have had mixed results. The authors briefly review the literature regarding the value of the extent of resection. They proceed to the preoperative and intraoperative tools available to the neurosurgeon to distinguish eloquent from noneloquent language cortex and fibers, including the emerging roles of functional magnetic resonance imaging diffusion tensor imaging tractography and direct cortical/subcortical stimulation in the surgical management of tumors in eloquent areas. Finally, the authors evaluate the postoperative course of these patients and the effect of language deficits on their quality of life.
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Affiliation(s)
- Matthew C Garrett
- UCLA Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90096-6901, USA
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79
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Gadolinium- and 5-aminolevulinic acid-induced protoporphyrin IX levels in human gliomas: an ex vivo quantitative study to correlate protoporphyrin IX levels and blood-brain barrier breakdown. J Neuropathol Exp Neurol 2012; 71:806-13. [PMID: 22878664 DOI: 10.1097/nen.0b013e31826775a1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
In recent years, 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) fluorescence guidance has been used as a surgical adjunct to improve the extent of resection of gliomas. Exogenous administration of ALA before surgery leads to the accumulation of red fluorescent PpIX in tumor tissue that the surgeon can visualize and thereby discriminate between normal and tumor tissue. Selective accumulation of PpIX has been linked to numerous factors, of which blood-brain barrier breakdown has been suggested to be a key factor. To test the hypothesis that PpIX concentration positively correlates with gadolinium (Gd) concentrations, we performed ex vivo measurements of PpIX and of Gd using inductively coupled plasma mass spectrometry, the latter as a quantitative biomarker of blood-brain barrier breakdown; this was corroborated with immunohistochemistry of microvascular density in surgical biopsies of patients undergoing fluorescence-guided surgery for glioma. We found positive correlations between PpIX concentration and Gd concentration (r = 0.58, p < 0.0001) and between PpIX concentration and microvascular density (r = 0.55, p < 0.0001), suggesting a significant, yet limited, association between blood-brain barrier breakdown and ALA-induced PpIX fluorescence. To our knowledge, this is the first time that Gd measurements by inductively coupled plasma mass spectrometry have been used in human gliomas.
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Price SJ, Whittle IR, Ashkan K, Grundy P, Cruickshank G. NICE guidance on the use of carmustine wafers in high grade gliomas: a national study on variation in practice. Br J Neurosurg 2012; 26:331-5. [PMID: 22482926 PMCID: PMC3432583 DOI: 10.3109/02688697.2012.673651] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background. Multidisciplinary team (MDT) working in oncology aims to improve outcomes for patients with cancer. One role is to ensure the implementation of best practice and National Institute for Health and Clinical Excellence (NICE) guidance. In this study, we have assessed the role of MDT in implementing the TA121 appraisal of the use of carmustine wafers in high grade gliomas. Methods. 296 patients with high-grade glioma suitable for maximal resection were recruited from 17 Neurosurgical Centres. The number of patients treated with carmustine wafers and reasons for not using this were recorded. Complications at 48 hours post-operatively and at 6 weeks post-radiotherapy were recorded. Results. 94/296 (32%) of suitable patients received carmustine wafers. In 55% of cases carmustine was not used due to either surgeon preference or a lack of an MDT decision. There was no increased complication rate with carmustine use at either 48 hours post-surgery or at 6 weeks post radiotherapy. Use of carmustine wafers did not decrease access to and use of chemoradiotherapy. Conclusions. One third of patients suitable for carmustine wafers received them. Their use was neither associated with more frequent complications, nor decreased use of chemoradiotherapy. Implementation of NICE TA121 Guidance is extremely variable in different MDTs across the United Kingdom.
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Affiliation(s)
- Stephen J Price
- Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
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81
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Hlavac M, König R, Halatsch M, Wirtz C. Intraoperative Magnetresonanztomographie. Unfallchirurg 2012; 115:121-4. [DOI: 10.1007/s00113-011-2122-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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82
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Stummer W, Meinel T, Ewelt C, Martus P, Jakobs O, Felsberg J, Reifenberger G. Prospective cohort study of radiotherapy with concomitant and adjuvant temozolomide chemotherapy for glioblastoma patients with no or minimal residual enhancing tumor load after surgery. J Neurooncol 2012; 108:89-97. [PMID: 22307805 PMCID: PMC3337400 DOI: 10.1007/s11060-012-0798-3] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 01/07/2012] [Indexed: 11/24/2022]
Abstract
Survival of glioblastoma patients has been linked to the completeness of surgical resection. Available data, however, were generated with adjuvant radiotherapy. Data confirming that extensive cytoreduction remains beneficial to patients treated with the current standard, concomitant temozolomide radiochemotherapy, are limited. We therefore analyzed the efficacy of radiochemotherapy for patients with little or no residual tumor after surgery. In this prospective, non-interventional multicenter cohort study, entry criteria were histological diagnosis of glioblastoma, small enhancing or no residual tumor on post-operative MRI, and intended temozolomide radiochemotherapy. The primary study objective was progression-free survival; secondary study objectives were survival and toxicity. Furthermore, the prognostic value of O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation was investigated in a subgroup of patients. One-hundred and eighty patients were enrolled. Fourteen were excluded by patient request or failure to initiate radiochemotherapy. Twenty-three patients had non-evaluable post-operative imaging. Thus, 143 patients qualified for analysis, with 107 patients having residual tumor diameters ≤1.5 cm. Median follow-up was 24.0 months. Median survival or patients without residual enhancing tumor exceeded the follow-up period. Median survival was 16.9 months for 32 patients with residual tumor diameters >0 to ≤1.5 cm (95% CI: 13.3-20.5, p = 0.039), and 13.9 months (10.3-17.5, overall p < 0.001) for 36 patients with residual tumor diameters >1.5 cm. Patient age at diagnosis and extent of resection were independently associated with survival. Patients with MGMT promoter methylated tumors and complete resection made the best prognosis. Completeness of resection acts synergistically with concomitant and adjuvant radiochemotherapy, especially in patients with MGMT promoter methylation.
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Affiliation(s)
- Walter Stummer
- Department of Neurosurgery, University of Münster, Albert-Schweitzer Campus 1, Geb. 1 A, 48149, Münster, Germany,
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Prognostic factors and survival in a prospective cohort of patients with high-grade glioma treated with carmustine wafers or temozolomide on an intention-to-treat basis. Acta Neurochir (Wien) 2012; 154:211-22; discussion 222. [PMID: 22002506 DOI: 10.1007/s00701-011-1199-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 09/29/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Patients with high-grade glioma can be treated with carmustine wafers or following the Stupp protocol. As far as we are aware, no scientific evidence has been published comparing the two treatments. The primary objective of this study was to analyse the survival of groups of patients with each of these treatment modalities. The secondary objective was to assess the influence of the usual prognostic factors on the patients in our hospital. METHODS A prospective cohort of 110 patients with single, supratentorial high-grade glioma treated by craniotomy and tumour resection was retrospectively studied. Half of the patients had carmustine wafers placed during this operation while the others (55) did not, the latter group receiving first-line systemic chemotherapy on an intention-to-treat basis. FINDINGS Patients treated with carmustine wafers had a median survival of 13.414 months compared with 11.047 in the group without implants (p = 0.856). For the overall cohort of patients, the following factors were found to influence survival: age (p < 0.0001), postoperative KPS score (p = 0.001), histological grade (p = 0.004), RPA class (p = 0.001), extent of resection (p = 0.002) and salvage surgery (p = 0.028). CONCLUSIONS In this prospective cohort of patients, analysed on the basis of intention-to-treat at the time of the first surgery, no statistically significant differences in survival were found between the two treatment modalities (carmustine wafers vs. first-line systemic chemotherapy). On the other hand, age, preoperative KPS, histological grade, and RPA class were confirmed to be prognostic factors in this cohort. Finally, the extent of resection was also found to influence survival.
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Noël G, Schott R, Froelich S, Gaub MP, Boyer P, Fischer-Lokou D, Dufour P, Kehrli P, Maitrot D. Retrospective Comparison of Chemoradiotherapy Followed by Adjuvant Chemotherapy, With or Without Prior Gliadel Implantation (Carmustine) After Initial Surgery in Patients With Newly Diagnosed High-Grade Gliomas. Int J Radiat Oncol Biol Phys 2012; 82:749-55. [DOI: 10.1016/j.ijrobp.2010.11.073] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Revised: 11/18/2010] [Accepted: 11/30/2010] [Indexed: 11/26/2022]
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Chawla S, Korones DN, Milano MT, Hussain A, Hussien AR, Muhs AG, Mangla M, Silberstein H, Ekholm S, Constine LS. Spurious progression in pediatric brain tumors. J Neurooncol 2012; 107:651-7. [PMID: 22237949 DOI: 10.1007/s11060-011-0794-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 12/27/2011] [Indexed: 01/04/2023]
Abstract
In this study, we sought to characterize post-therapy MRI changes mimicking progression, which we refer to as "spurious progression" (SP) in children with brain tumors. We analyzed whether SP is associated with particular tumor types or therapeutic modalities. Between 2000 and 2009, we identified 181 consecutive children <21 years of age at our center who were treated for brain tumors and had at least three MRI scans within a year after completing therapy. SP was defined as MRI abnormalities characterized by increase in size, enhancement, edema, or cystic changes within 12 months following therapy, and stabilization or improvement on subsequent imaging. One-hundred forty-one patients with brain tumors were evaluable. Fifty-six (40%) had imaging abnormalities initially suggestive of disease progression; of these, 34 (24%) had true disease progression (TP). The remaining 22 (16%) had SP based on either stability, decrease in enhancement, edema, size, or disappearance of these cystic or non-cystic abnormalities. SP occurred in patients with low grade (n = 20) and high grade lesions (n = 2). Median time to SP was 2.4 months (range, 0.7-8.3 months), with time to stability, decrease, or disappearance at a median of 4 months (range 1.4-7.7 months). Five patients were clinically symptomatic from SP and were treated with steroids, cyst drainage, and/or surgery. Therefore, SP occurs more commonly in children with low grade tumors, but can also occur with high grade brain tumors, regardless of therapeutic approach.
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Affiliation(s)
- Sheema Chawla
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Ave Box 647, Rochester, NY 14642, USA
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KONISHI Y, MURAGAKI Y, ISEKI H, MITSUHASHI N, OKADA Y. Patterns of Intracranial Glioblastoma Recurrence After Aggressive Surgical Resection and Adjuvant Management: Retrospective Analysis of 43 Cases. Neurol Med Chir (Tokyo) 2012; 52:577-86. [DOI: 10.2176/nmc.52.577] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Yoshiyuki KONISHI
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University
| | - Yoshihiro MURAGAKI
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University
- Department of Neurosurgery, Tokyo Women's Medical University
| | - Hiroshi ISEKI
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University
- Department of Neurosurgery, Tokyo Women's Medical University
| | - Norio MITSUHASHI
- Department of Radiation Oncology, Tokyo Women's Medical University
| | - Yoshikazu OKADA
- Department of Neurosurgery, Tokyo Women's Medical University
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Affiliation(s)
- Ian F Parney
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA.
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Recurrence patterns of glioblastoma treated with postoperative radiation therapy: relationship between extent of resection and progression-free interval. Jpn J Radiol 2011; 30:193-7. [DOI: 10.1007/s11604-011-0031-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 11/09/2011] [Indexed: 10/14/2022]
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Tsai HC, Wei KC, Tsai CN, Huang YC, Chen PY, Chen SM, Lu YJ, Lee ST. Effect of valproic acid on the outcome of glioblastoma multiforme. Br J Neurosurg 2011; 26:347-54. [PMID: 22168970 DOI: 10.3109/02688697.2011.638996] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Glioblastoma multiforme (GBM) is the most aggressive type of primary brain tumor. It is a rapidly progressive, highly recurrent, fatal intracranial neoplasm, and the demand for novel treatment is urgent. Valproic acid (VPA) is a potential anticancer agent that belongs to a class of histone deacetylase (HDAC) inhibitors, targeting the epigenetic control of gene functions in cancer cells. This drug has been administered for the prevention or treatment of seizure disorder in GBM patients; therefore, a retrospective analysis may further our understanding of the effect of VPA on GBM patients. MATERIALS AND METHODS A retrospective analysis of 102 patients with GBM was conducted to study the effects of VPA on disease outcome. Tumor samples from seven patients receiving VPA treatment between the first and second operations were obtained in order to verify the HDAC inhibitory activity of VPA in these patients. RESULTS In univariate analysis, administration of VPA within 2 weeks of initial diagnosis seemed to confer a survival benefit. However, stratified analysis according to chemotherapy showed that VPA did not have significant impact on the GBM patients' overall survival. Analysis of tissue samples from these patients revealed that a small subset of patients had increased histone acetylation after VPA treatment. CONCLUSION VPA treatment, when administered according to a protocol targeting seizure control, may result in HDAC inhibition in a small subset of patients, but does not significantly affect overall patient survival. Early administration of VPA as an adjunct to temozolomide chemotherapy may have its merits, but the optimal dosing schedule and target serum level require further investigation.
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Affiliation(s)
- Hong-Chieh Tsai
- Department of Neurosurgery, Chang-Gung Memorial Hospital and University, Tao-Yuan, Taiwan
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Valdés PA, Kim A, Leblond F, Conde OM, Harris BT, Paulsen KD, Wilson BC, Roberts DW. Combined fluorescence and reflectance spectroscopy for in vivo quantification of cancer biomarkers in low- and high-grade glioma surgery. JOURNAL OF BIOMEDICAL OPTICS 2011; 16:116007. [PMID: 22112112 PMCID: PMC3221714 DOI: 10.1117/1.3646916] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 09/12/2011] [Accepted: 09/16/2011] [Indexed: 05/19/2023]
Abstract
Biomarkers are indicators of biological processes and hold promise for the diagnosis and treatment of disease. Gliomas represent a heterogeneous group of brain tumors with marked intra- and inter-tumor variability. The extent of surgical resection is a significant factor influencing post-surgical recurrence and prognosis. Here, we used fluorescence and reflectance spectral signatures for in vivo quantification of multiple biomarkers during glioma surgery, with fluorescence contrast provided by exogenously-induced protoporphyrin IX (PpIX) following administration of 5-aminolevulinic acid. We performed light-transport modeling to quantify multiple biomarkers indicative of tumor biological processes, including the local concentration of PpIX and associated photoproducts, total hemoglobin concentration, oxygen saturation, and optical scattering parameters. We developed a diagnostic algorithm for intra-operative tissue delineation that accounts for the combined tumor-specific predictive capabilities of these quantitative biomarkers. Tumor tissue delineation achieved accuracies of up to 94% (specificity = 94%, sensitivity = 94%) across a range of glioma histologies beyond current state-of-the-art optical approaches, including state-of-the-art fluorescence image guidance. This multiple biomarker strategy opens the door to optical methods for surgical guidance that use quantification of well-established neoplastic processes. Future work would seek to validate the predictive power of this proof-of-concept study in a separate larger cohort of patients.
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Affiliation(s)
- Pablo A Valdés
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire 03755, USA.
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91
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Koshy M, Villano JL, Dolecek TA, Howard A, Mahmood U, Chmura SJ, Weichselbaum RR, McCarthy BJ. Improved survival time trends for glioblastoma using the SEER 17 population-based registries. J Neurooncol 2011; 107:207-12. [PMID: 21984115 DOI: 10.1007/s11060-011-0738-7] [Citation(s) in RCA: 304] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 09/26/2011] [Indexed: 12/31/2022]
Abstract
The EORTC/NCIC 22981/26981 study demonstrated an improvement in median overall survival (OS) from 12.1 to 14.6 months in patients with glioblastoma (GBM) who received temozolomide with post-operative radiotherapy (RT). The current study was performed to determine if those results translated into a survival benefit in a population-based cohort. Patients diagnosed between 2000 and 2006 with a GBM who underwent surgery and post-operative RT were selected from the Surveillance, Epidemiology and End Results database. Patients were grouped into time periods: 2000-2001, 2002-2003, 2004 and 2005-2006 (which represented those treated after the EORTC/NCIC trial presentation in 2004). Relative survival (RS) was estimated by the Kaplan-Meier method, and Cox multivariable regression modeling was used to estimate proportional hazard ratios (HR). Over time, there was improvement in the median and 2-year RS of 12 months and 15% for 2000-2001, 13 months and 19% for 2002-2003, 14 months and 24% for 2004, and 15 months and 26% for 2005-2006 (P < 0.0001 compared to 2000-2001 and 2002-2003; P = 0.07 compared to 2004). The estimated adjusted HR showed that patients diagnosed in 2005-2006 had significantly improved survival when compared to patients diagnosed in 2000-2001 (HR = 0.648, 95% CI 0.604-0.696). The median and 2 year RS of 15 months and 26% in 2005-2006 was similar to the median and 2 year OS of 14.6 months and 26% seen in the EORTC/NCIC phase III study. These results are encouraging and suggest that the current treatment of glioblastoma nationwide is now associated with an improved survival compared to previous time cohorts.
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Affiliation(s)
- Matthew Koshy
- Department of Radiation Oncology, University of Illinois at Chicago, Chicago, IL, USA.
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92
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Senft C, Bink A, Franz K, Vatter H, Gasser T, Seifert V. Intraoperative MRI guidance and extent of resection in glioma surgery: a randomised, controlled trial. Lancet Oncol 2011; 12:997-1003. [PMID: 21868284 DOI: 10.1016/s1470-2045(11)70196-6] [Citation(s) in RCA: 536] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intraoperative MRI is increasingly used in neurosurgery, although there is little evidence for its use. We aimed to assess efficacy of intraoperative MRI guidance on extent of resection in patients with glioma. METHODS In our prospective, randomised, parallel-group trial, we enrolled adults (≥18 years) with contrast enhancing gliomas amenable to radiologically complete resection who presented to Goethe University (Frankfurt, Germany). We randomly assigned patients (1:1) with computer-generated blocks of four and a sealed-envelope design to undergo intraoperative MRI-guided surgery or conventional microsurgery (control group). Surgeons and patients were unmasked to treatment group allocation, but an independent neuroradiologist was masked during analysis of all preoperative and postoperative imaging data. The primary endpoint was rate of complete resections as established by early postoperative high-field MRI (1·5 T or 3·0 T). Analysis was done per protocol. This study is registered with ClinicalTrials.gov, number NCT01394692. FINDINGS We enrolled 58 patients between Oct 1, 2007, and July 1, 2010. 24 (83%) of 29 patients randomly allocated to the intraoperative MRI group and 25 (86%) of 29 controls were eligible for analysis (four patients in each group had metastasis and one patient in the intraoperative MRI group withdrew consent after randomisation). More patients in the intraoperative MRI group had complete tumour resection (23 [96%] of 24 patients) than did in the control group (17 [68%] of 25, p=0·023). Postoperative rates of new neurological deficits did not differ between patients in the intraoperative MRI group (three [13%] of 24) and controls (two [8%] of 25, p=1·0). No patient for whom use of intraoperative MRI led to continued resection of residual tumour had neurological deterioration. One patient in the control group died before 6 months. INTERPRETATION Our study provides evidence for the use of intraoperative MRI guidance in glioma surgery: such imaging helps surgeons provide the optimum extent of resection. FUNDING None.
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Affiliation(s)
- Christian Senft
- Department of Neurosurgery, Goethe University, Frankfurt, Germany.
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93
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Sanghera P, Rampling R, Haylock B, Jefferies S, McBain C, Rees JH, Soh C, Whittle IR. The concepts, diagnosis and management of early imaging changes after therapy for glioblastomas. Clin Oncol (R Coll Radiol) 2011; 24:216-27. [PMID: 21783349 DOI: 10.1016/j.clon.2011.06.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 03/31/2011] [Accepted: 04/24/2011] [Indexed: 10/18/2022]
Abstract
Since postoperative radiotherapy plus concomitant temozolomide followed by adjuvant temozolomide has become standard treatment for glioblastoma, the phenomenon of early post-treatment enlargement of the imaged tumour volume, usually without clinical deterioration, has become widely recognised. The term pseudoprogression has been used to describe a poorly understood pathophysiological process. In this review, the pathophysiological concepts, relevance, diagnosis and management of patients with 'pseudoprogression' and 'pseudoresponse' are discussed. Guidelines are given with respect to radiological imaging modality, mode and frequency. Further biological and clinical insights into these phenomena require carefully designed prospective studies.
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Affiliation(s)
- P Sanghera
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, UK
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94
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Belhawi SMK, Hoefnagels FWA, Baaijen JC, Sanchez Aliaga E, Reijneveld JC, Heimans JJ, Barkhof F, Vandertop WP, De Witt Hamer PC. Early postoperative MRI overestimates residual tumour after resection of gliomas with no or minimal enhancement. Eur Radiol 2011; 21:1526-34. [PMID: 21331595 PMCID: PMC3101346 DOI: 10.1007/s00330-011-2081-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 12/16/2010] [Accepted: 01/10/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Standards for residual tumour measurement after resection of gliomas with no or minimal enhancement have not yet been established. In this study residual volumes on early and late postoperative T2-/FLAIR-weighted MRI are compared. METHODS A retrospective cohort included 58 consecutive glioma patients with no or minimal preoperative gadolinium enhancement. Inclusion criteria were first-time resection between 2007 and 2009 with a T2-/FLAIR-based target volume and availability of preoperative, early (<48 h) and late (1-7 months) postoperative MRI. The volumes of non-enhancing T2/FLAIR tissue and diffusion restriction areas were measured. RESULTS Residual tumour volumes were 22% smaller on late postoperative compared with early postoperative T2-weighted MRI and 49% smaller for FLAIR-weighted imaging. Postoperative restricted diffusion volume correlated with the difference between early and late postoperative FLAIR volumes and with the difference between T2 and FLAIR volumes on early postoperative MRI. CONCLUSION We observed a systematic and substantial overestimation of residual non-enhancing volume on MRI within 48 h of resection compared with months postoperatively, in particular for FLAIR imaging. Resection-induced ischaemia contributes to this overestimation, as may other operative effects. This indicates that early postoperative MRI is less reliable to determine the extent of non-enhancing residual glioma and restricted diffusion volumes are imperative.
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Affiliation(s)
- Sinan M. K. Belhawi
- Neurosurgical Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Friso W. A. Hoefnagels
- Neurosurgical Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Johannes C. Baaijen
- Neurosurgical Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Jaap C. Reijneveld
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - Jan J. Heimans
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology, VU University Medical Center, Amsterdam, The Netherlands
| | - W. Peter Vandertop
- Neurosurgical Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Philip C. De Witt Hamer
- Neurosurgical Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
- Department of Neurosurgery, Room 2F010, VU Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
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95
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Stummer W, van den Bent MJ, Westphal M. Cytoreductive surgery of glioblastoma as the key to successful adjuvant therapies: new arguments in an old discussion. Acta Neurochir (Wien) 2011; 153:1211-8. [PMID: 21479583 DOI: 10.1007/s00701-011-1001-x] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 03/16/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND This article discusses data from 3 randomized phase 3 trials, supporting a role for surgery in glioblastoma. METHODS Data were reviewed by extent of resection during primary surgery from the ALA-Glioma Study (fluorescence-guided versus conventional resection), the BCNU wafer study (BCNU wafer versus placebo), and the EORTC Study 26981-22981 (radiotherapy versus chemoradiotherapy with temozolomide). RESULTS For glioblastoma patients in the ALA study, median survival was 16.7 and 11.8 months for complete versus partial resection, respectively (P < 0.0001). Survival effects were maintained after correction for differences in age and tumor location. For glioblastoma patients who received ≥90% resection in the BCNU wafer study, median survival increased for BCNU wafer versus placebo (14.5 versus 12.4 months, respectively; P = 0.02), but no survival increase was found for <90% resection (11.7 versus 10.6 months, respectively; P = 0.98). In the EORTC study, absolute median gain in survival with chemoradiotherapy versus radiotherapy was greatest for complete resections (+4.1 months; P = 0.0001), compared with partial resections (+1.8 months; P = 0.0001), or biopsies (+1.5 months; P = 0.088), suggesting surgery enhanced adjuvant treatment. CONCLUSION Complete resection appears to improve survival and may increase the efficacy of adjunct/adjuvant therapies. If safely achievable, complete resection should be the surgical goal for glioblastoma.
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Affiliation(s)
- Walter Stummer
- Department of Neurosurgery, University of Münster, Albert-Schweitzer-Str. 33, 48149, Münster, Germany.
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96
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Intraoperative MRI detects a pattern of remnants? Acta Neurochir (Wien) 2011; 153:489. [PMID: 21234618 DOI: 10.1007/s00701-010-0912-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 12/01/2010] [Indexed: 10/18/2022]
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97
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Rohde V, Coenen VA. Intraoperative 3-dimensional ultrasound for resection control during brain tumour removal: preliminary results of a prospective randomized study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 109:187-90. [PMID: 20960341 DOI: 10.1007/978-3-211-99651-5_29] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
INTRODUCTION The amount of resection is closely related to survival in brain tumours. To enhance resection, especially intraoperative magnetic resonance imaging (MRI) has been applied. The aim of this prospective, randomized study was to test if intraoperative 3-D ultrasound likewise can be used for resection control. METHODS 16 patients, who underwent surgery for intraaxial tumours in non-eloquent brain areas, were initially included into this prospective study. In two patients, the small size of the craniotomy hindered intraoperative ultrasound imaging. In 14 patients, 3-D ultrasound images were obtained before and after opening of the dura, during tumour removal, prior to evaluation by a blinded investigator for identification of tumour remnants, and after dura closure. Seven patients were randomized to complete tumour removal according to the impression of the surgeon (group 1). Seven patients were randomized to incomplete tumour removal (tumour remnant <1cm) (group 2); in these patients, the neurosurgeon intentionally left a tumour remnant prior to evaluation by the blinded investigator. The tumour remnant was then removed. It was tested if 3-D ultrasound can correctly identify complete and incomplete tumour resection. All patients underwent early postoperative MRI. RESULTS In two patients (one each of the two groups) the image quality was too poor for a meaningful intraoperative evaluation. In the six patients randomized for incomplete tumour removal, 3-D ultrasound correctly identified tumour remnants in four patients (67%). In six patients randomized for complete tumour removal, 3-D ultrasound confirmed complete tumour resection in three patients. In addition, 3-D ultrasound identified correctly one tumour remnant in a patient randomized for complete tumour removal. Thus, the sensitivity for tumour remnant detection increased to 71% (five of seven patients) and that of confirmation of complete tumour removal was 60 % (three of five patients). CONCLUSION The number of investigated patients is still to low to allow definite conclusions. However, the study results suggest, that 3-D ultrasound is especially helpful for detection of overseen brain tumour tissue.
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Affiliation(s)
- Veit Rohde
- Department of Neurosurgery, Georg-August-University Goettingen, Robert-Koch-Strasse 40, 37075 Goettingen, Germany.
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98
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Schmidt T, König R, Hlavac M, Antoniadis G, Wirtz CR. Lows and highs: 15 years of development in intraoperative magnetic resonance imaging. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 109:17-20. [PMID: 20960315 DOI: 10.1007/978-3-211-99651-5_3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Intraoperative magnetic resonance imaging (ioMRI) during neurosurgical procedures was first implemented in 1995. In the following decade ioMRI and image guided surgery has evolved from an experimental stage into a safe and routinely clinically applied technique. The development of ioMRI has led to a variety of differently designed systems which can be basically classified in one- or two-room concepts and low- and high-field installations. Nowadays ioMRI allows neurosurgeons not only to increase the extent of tumor resection and to preserve eloquent areas or white matter tracts but it also provides physiological and biological data of the brain and tumor tissue. This article tries to give a comprehensive review of the milestones in the development of ioMRI and neuronavigation over the last 15 years and describes the personal experience in intraoperative low and high-field MRI.
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Affiliation(s)
- T Schmidt
- Department of Neurosurgery, District Hospital Günzburg, University of Ulm, Ludwig Heilmeyer Straße 2, 89312 Günzburg, Germany.
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99
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Seifert V, Gasser T, Senft C. Low Field Intraoperative MRI in Glioma Surgery. INTRAOPERATIVE IMAGING 2011; 109:35-41. [DOI: 10.1007/978-3-211-99651-5_6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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100
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Traitement chirurgical des glioblastomes. Neurochirurgie 2010; 56:477-82. [DOI: 10.1016/j.neuchi.2010.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 07/01/2010] [Indexed: 11/24/2022]
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