Long-Term Cognitive Functioning and Psychological Well-Being in Surgically Treated Patients with Low-Grade Glioma

Health-related quality of life in 62 patients with diffuse low-grade glioma during a non-therapeutic and progression-free phase: a cross-sectional study

PURPOSE

Few studies have evaluated the health-related quality of life (HRQoL) of patients with diffuse low-grade glioma (LGG) during a clinical and radiological monitoring period. We report a cross sectional cohort study of HRQoL in patients with LGG and compare the results with normative population data. We then explore factors associated with HRQoL.

METHODS

We used the European Organisation for Research and Treatment of Cancer QLQ-C30, BN-20 and the Hospital Anxiety and Depression Scale (HADS) to evaluate HRQoL. Averaged QLQC30 and HADS scores were compared with scores of a normative population. A general linear model multivariate analysis of variance was used to investigate the association between HRQoL and independent factors.

RESULTS

A total of 62 patients with LGG completed HRQoL questionnaires. Compared with a normative population, LGG patients reported statistical and clinically significant lower cognitive, emotional, role and social functioning. Fatigue, anxiety, depression and sleep disturbances were frequently reported. Awake surgery and preserved high Karnofsky Performance Status were found to be independent prognostic factors for better global HRQoL, while radiotherapy was associated with worsened HRQoL.

CONCLUSION

Despite a non-therapeutic and progression free phase, LGG patients report noticeable limitations in several HRQoL subscales. Our study highlights the importance of HRQoL assessment not only at diagnosis or during active therapeutic stage. Further studies are needed to develop better adapted tools of HRQoL assessment.

Brain tumor-related epilepsy: an overview on neuropsychological, behavioral, and quality of life issues and assessment methodology

Brain tumor-related epilepsy (BTRE) is a rare disease in which brain tumor (BT) and epilepsy overlap simultaneously and can have a negative impact on a patient's neuropsychological, behavioral, and quality of life (QoL) spheres. In this review we (a) addressed the main neuropsychological, behavioral, and QoL issues that may occur in BTRE patients, (b) described how BT, BTRE, and their respective treatments can impact these domains, and (c) identified tools and standardized evaluation methodologies specific for BTRE patients. Neuropsychological disorders and behavioral issues can be direct consequences of BTRE and all related treatments, such as surgery, anti-cancer and anti-seizure medication, corticosteroids, etc., which can alter the structure of specific brain areas and networks, and by emotional aspects reactive to BTRE diagnosis, including the possible loss of autonomy, poor prognosis, and fear of death. Unfortunately, it seems there is a lack of uniformity in assessment methodologies, such as the administration of different batteries of neuropsychological tests, different times, frames, and purposes. Further research is needed to establish causality and deepen our understanding of the interplay between all these variables and our intervention in terms of diagnosis, treatment, psychosocial assessment, and their timing. We propose that the care of these patients to rely on the concepts of "BTRE-induced disability" and "biopsychosocial model" of BTRE, to prompt healthcare providers to handle and monitor BTRE-related psychological and social aspects, as to maintain the patient's best possible QoL.

Preoperative subjective impairments in language and memory in brain tumor patients

Background

Subjective reports can reveal relevant information regarding the nature of the impairment of brain tumor patients, unveiling potential gaps in current assessment practices. The co-occurrence of language and memory impairments has been previously reported, albeit scarcely. The aim of this study is therefore to understand the co-occurrence of subjective language and memory complaints in the preoperative state of brain tumor patients and its impact on Quality of Life (QoL).

Methods

31 brain tumor patients (12 LGG, 19 HGG) underwent a semi-structured interview to assess subjective complaints of language deficits, co-occurrences between language and memory dysfunction, and changes in QoL. Group and subgroup analyses were conducted to provide general and tumor grade specific data.

Results

48.4% of patients mentioned co-occurrence of language and memory impairments in reading, writing, and conversation. The HGG group reported co-occurrences in all three of these (reading: 31.6%; writing: 21.1%; conversation: 26.3%), while the LGG only described co-occurrences in reading (25%) and conversation (8.3%), although these were not statistically significant. All patients with co-occurring language and memory deficits reported these to be linked to reduced QoL (48.4%). In patients with an HGG, this number was slightly higher (52.6%) than in patients with an LGG (41.7%).

Conclusion

Language impairments co-occur with memory dysfunction as perceived in patients' daily life. Patients see these impairments as affecting their quality of life. Further attention to dedicated language and memory tasks seems necessary.

Primary brain tumor representation in the post-traumatic growth literature: A scoping review

Background

Post-traumatic growth (PTG) has been extensively explored within general oncology, yet little is known about the experience of PTG in neuro-oncology. This study aimed to determine the representation of patients with primary brain tumors (PBT) in the PTG literature.

Methods

PsycINFO, PubMed, and CINAHL were systematically searched from inception to December 2022. Search terms were related to personal growth and positive reactions to cancer. Articles were first screened by titles and abstracts, then full texts were reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method.

Results

A total of 382 articles met the inclusion criteria. Of those, 13 included patients with PBT. Over 100 000 cancer patients were represented, with 0.79% having a PBT. Most research focused on low-grade gliomas. PTG negatively correlated with post-traumatic stress symptoms and avoidant coping. In the sole longitudinal study, patients with PBT demonstrated improved PTG after 1 year. Three quasi-experimental studies investigated the effect of mindfulness-based interventions with mixed-cancer samples and demonstrated improvement in PTG.

Conclusions

The inclusion rate of patients with PBT in the PTG literature was significantly lower than the population prevalence rate (1.3% of cancer diagnoses). Relatively few studies focused exclusively on how patients with PBT experience PTG (k = 5), and those that did only included low-grade glioma. The experience of PTG in those with high-grade glioma remains unknown. Patients with PBT are scarcely included in research on PTG interventions. Few studies examined the relationship between PTG and medical, cognitive, or psychological characteristics. Our understanding of the PTG experience in neuro-oncology remains extremely limited.

Health-related quality of life in adults with low-grade gliomas: a systematic review

PURPOSE

Low-grade glioma (LGG) patients may face health-related quality-of-life (HRQoL) impairments, due to the tumour, treatment and associated side-effects and prospects of progression. We systematically identified quantitative studies assessing HRQoL in adult LGG patients, for: aspects of HRQoL impacted; comparisons with non-cancer controls (NCC) and other groups; temporal trends; and factors associated with HRQoL.

METHODS

MEDLINE, CINAHL, Embase, PubMed, and PsycINFO were systematically searched from inception to 14th September 2021. Following independent screening of titles and abstracts and full-texts, population and study characteristics, and HRQoL findings were abstracted from eligible papers, and quality appraised. Narrative synthesis was conducted.

RESULTS

Twenty-nine papers reporting 22 studies (cross-sectional, n = 13; longitudinal, n = 9) were identified. Papers were largely good quality, though many excluded patients with cognitive and communication impairments. Comparators included high-grade gliomas (HGG) (n = 7); NCCs (n = 6) and other patient groups (n = 3). Nineteen factors, primarily treatment (n = 8), were examined for association with HRQoL. There was substantial heterogeneity in HRQoL instruments used, factors and aspects of HRQoL assessed and measurement timepoints. HRQoL, primarily cognitive functioning and fatigue, in adult LGG patients is poor, and worse than in NCCs, though better than in HGG patients. Over time, HRQoL remained low, but stable. Epilepsy/seizure burden was most consistently associated with worse HRQoL.

CONCLUSION

LGG patients experience wide-ranging HRQoL impairments. HRQoL in those with cognitive and communication impairments requires further investigation. These findings may help clinicians recognise current supportive care needs and inform types and timings of support needed, as well as inform future interventions.

Dynamics in cognition and health-related quality of life in grade 2 and 3 gliomas after surgery

BACKGROUND

The focus of clinical management and research in gliomas has been on survival, but the interest in the treatment effects on cognition and health-related quality of life (HRQoL) is emerging. The primary aim of this study was to investigate the dynamics in cognition after brain tumor surgery for astrocytomas and oligodendrogliomas grade 2 and 3. The secondary aim was to investigate the association of postoperative changes in cognition with changes HRQoL.

METHODS

In this observational study, 48 patients operated for an astrocytoma or oligodendrogliomas, grade 2 or 3, at the Department of Neurosurgery, Uppsala, Sweden, 2016-2021, were included. Cognitive and language skills were assessed with a selected test battery and HRQoL was patient-reported as assessed with RAND-36 pre- and approximately 3 months postoperatively.

RESULTS

There was a significant postoperative decrease in attention span and verbal learning, but the patients improved in the test for visual memory. There was no change in visual attention, executive function, verbal memory, visual organization and construction, verbal fluency, and confrontation naming. The RAND-36 variables physical function, role physical, general health, vitality, and social functioning decreased significantly after surgery. Patients operated for tumor recurrence exhibited greater deterioration in attention and a greater extent of resection correlated with a less pronounced decrease in verbal memory, but there were otherwise weak associations between the dynamics in cognition and patient-, tumor-, and treatment-variables. A decline in cognitive variables was not associated with worse HRQoL.

CONCLUSIONS

Although both several cognitive and HRQoL domains deteriorated postoperatively, these changes did not correlate with each other. This highlights the complexity of cognitive and HRQoL dynamics in the early postoperative phase.

Effects of comprehensive nursing on postoperative complications, mental status and quality of life in patients with glioma

BACKGROUND

The complexity and refractory of brain glioma requires treatment that should involve a multidisciplinary approach to improve quality of care and fulfill patients’ needs.

AIM

To explore the effects of comprehensive nursing on postoperative complications, psychological state and quality of life in patients with brain glioma.

METHODS

A total of 106 patients with confirmed brain gliomas admitted to Nanchong Central Hospital between January 2019 and May 2021 were selected by random sampling. They were categorized into an observation group and a control group using a random number table with 53 patients in each group. Patients in the observation group were given comprehensive nursing in addition to conventional nursing and patients in the control group were given conventional nursing. The overall incidence of postoperative complications including limb dysfunction, high fever and epilepsy was compared between the two groups. The mental status was evaluated in the two groups before and after intervention using self-rating anxiety scale (SAS) and self-rating depression scale (SDS). Quality of life was assessed and compared using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire between the two groups before and after the intervention.

RESULTS

After intervention, the overall incidence of postoperative complications was significantly lower in the observation group (7.55%) than that in the control group (20.75%) (P < 0.05). Before intervention, there was no significant difference in SAS and SDS scores between the two groups (P > 0.05). However, after intervention, scores of SAS and SDS decreased in the two groups compared with those before intervention, and the scores of SAS and SDS were lower in the observation group than in the control group (all P < 0.05). There was no significant difference in quality of life between the two groups before the intervention (P > 0.05). In contrast, quality of life increased in the two groups compared with those before intervention, and it was higher in the observation group than in the control group (P < 0.05).

CONCLUSION

Comprehensive nursing can reduce the incidence of postoperative complications, improve the psychological state of anxiety and depression and improve quality of life in patients with brain glioma.

Influences on cognitive outcomes in adult patients with gliomas: A systematic review

People with brain tumors, including those previously treated, are commonly affected by a range of neurocognitive impairments involving executive function, memory, attention, and social/emotional functioning. Several factors are postulated to underlie this relationship, but evidence relating to many of these factors is conflicting and does not fully explain the variation in cognitive outcomes seen in the literature and in clinical practice. To address this, we performed a systematic literature review to identify and describe the range of factors that can influence cognitive outcomes in adult patients with gliomas. A literature search was performed of Ovid MEDLINE, PsychINFO, and PsycTESTS from commencement until September 2021. Of 9,998 articles identified through the search strategy, and an additional 39 articles identified through other sources, 142 were included in our review. The results confirmed that multiple factors influence cognitive outcomes in patients with gliomas. The effects of tumor characteristics (including location) and treatments administered are some of the most studied variables but the evidence for these is conflicting, which may be the result of methodological and study population differences. Tumor location and laterality overall appear to influence cognitive outcomes, and detection of such an effect is contingent upon administration of appropriate cognitive tests. Surgery appears to have an overall initial deleterious effect on cognition with a recovery in most cases over several months. A large body of evidence supports the adverse effects of radiotherapy on cognition, but the role of chemotherapy is less clear. To contrast, baseline cognitive status appears to be a consistent factor that influences cognitive outcomes, with worse baseline cognition at diagnosis/pre-treatment correlated with worse long-term outcomes. Similarly, much evidence indicates that anti-epileptic drugs have a negative effect on cognition and genetics also appear to have a role. Evidence regarding the effect of age on cognitive outcomes in glioma patients is conflicting, and there is insufficient evidence for gender and fatigue. Cognitive reserve, brain reserve, socioeconomic status, and several other variables discussed in this review, and their influence on cognition and recovery, have not been well-studied in the context of gliomas and are areas for focus in future research.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42017072976.

The Aftercare Survey: Assessment and intervention practices after brain tumor surgery in Europe

Background

People with gliomas need specialized neurosurgical, neuro-oncological, psycho-oncological, and neuropsychological care. The role of language and cognitive recovery and rehabilitation in patients' well-being and resumption of work is crucial, but there are no clear guidelines for the ideal timing and character of assessments and interventions. The goal of the present work was to describe representative (neuro)psychological practices implemented after brain surgery in Europe.

Methods

An online survey was addressed to professionals working with individuals after brain surgery. We inquired about the assessments and interventions and the involvement of caregivers. Additionally, we asked about recommendations for an ideal assessment and intervention plan.

Results

Thirty-eight European centers completed the survey. Thirty of them offered at least one postsurgical (neuro)psychological assessment, mainly for language and cognition, especially during the early recovery stage and at long term. Twenty-eight of the participating centers offered postsurgical therapies. Patients who stand the highest chances of being included in evaluation and therapy postsurgically are those who underwent awake brain surgery, harbored a low-grade glioma, or showed poor recovery. Nearly half of the respondents offer support programs to caregivers, and all teams recommend them. Treatments differed between those offered to individuals with low-grade glioma vs those with high-grade glioma. The figure of caregiver is not yet fully recognized in the recovery phase.

Conclusion

We stress the need for more complete rehabilitation plans, including the emotional and health-related aspects of recovery. In respondents' opinions, assessment and rehabilitation plans should also be individually tailored and goal-directed (eg, professional reinsertion).

Repeated Awake Surgical Resection(s) for Recurrent Diffuse Low-Grade Gliomas: Why, When, and How to Reoperate?

Early maximal surgical resection is the first treatment in diffuse low-grade glioma (DLGG), because the reduction of tumor volume delays malignant transformation and extends survival. Awake surgery with intraoperative mapping and behavioral monitoring enables to preserve quality of life (QoL). However, because of the infiltrative nature of DLGG, relapse is unavoidable, even after (supra)total resection. Therefore, besides chemotherapy and radiotherapy, the question of reoperation(s) is increasingly raised, especially because patients with DLGG usually enjoy a normal life with long-lasting projects. Here, the purpose is to review the literature in the emerging field of iterative surgeries in DLGG. First, long-term follow-up results showed that patients with DLGG who underwent multiple surgeries had an increased survival (above 17 years) with preservation of QoL. Second, the criteria guiding the decision to reoperate and defining the optimal timing are discussed, mainly based on the dynamic intercommunication between the glioma relapse (including its kinetics and pattern of regrowth) and the reactional cerebral reorganization—i.e., mechanisms underpinning reconfiguration within and across neural networks to enable functional compensation. Third, how to adapt medico-surgical strategy to this individual spatiotemporal brain tumor interplay is detailed, by considering the perpetual changes in connectome. These data support early reoperation in recurrent DLGG, before the onset of symptoms and before malignant transformation. Repeat awake resection(s) should be integrated in a global management including (neo)adjuvant medical treatments, to enhance long-lasting functional and oncological outcomes. The prediction of potential and limitation of neuroplasticity at each step of the disease must be improved to anticipate personalized multistage therapeutic attitudes.

Changes in Cognitive Functioning After Surgical Resection of Language-related, Eloquent-area, High-grade Gliomas Under Awake Craniotomy

BACKGROUND

Dominant-hemisphere tumors, especially gliomas, as infiltrative tumors, frequently affect cognitive functioning. Establishing a balance between extensive resection, which is proven to result in longer survival, and less extensive resection, in order to maintain more cognitive abilities, is challenging.

OBJECTIVE

To evaluate changes in cognitive functioning before and after surgical resection of language-related, eloquent-area, high-grade gliomas under awake craniotomy.

METHOD

We provided individuals with newly diagnosed high-grade gliomas of the language-related eloquent areas with the same standard of care, including surgical resection of the glioma using intraoperative sensory-motor and cognitive mapping under awake craniotomy, and the same protocol for chemoradiotherapy. Cognitive functioning was assessed using Addenbrooke's Cognitive Examination-Revised (ACE-R) at four time points (preoperatively, early after surgery, and 3 and 6 months postoperatively).

RESULTS

The preoperative evaluation revealed a range of cognitive impairments in 70.7% of the individuals, affecting all of the cognitive subdomains (mostly attention and visuospatial abilities). Overall cognitive functioning (ie, ACE-R score) dropped by 13.5% (P= 0.169) early postoperatively. At the 3-month evaluation, an average of 15.3% (P= 0.182) recovery in cognitive functioning was observed (mostly in verbal fluency: 39.1%). This recovery improved further, reaching 29% (P< 0.001) at the 6-month evaluation. The greatest improvement occurred in verbal fluency: 68.8%,P= 0.001.

CONCLUSION

Extensive resection of eloquent-area gliomas with the aid of modern neuroimaging and neuromonitoring techniques under awake craniotomy is possible without significant long-term cognitive sequela.

Long-term impact of adult WHO grade II or III gliomas on health-related quality of life: A systematic review

Background

Glioma diagnosis can be devastating and result in a range of symptoms. Relatively little is known about the long-term health-related quality of life (HRQOL) challenges faced by these patients. Establishing the impact of diagnosis on HRQOL could help positively tailor clinical decision making regarding patient support and treatment. The aim of this review is to identify the long-term HRQOL issues reported at least 2 years following diagnosis of WHO grade II/III glioma.

Method

Systematic literature searches were carried out using Medline, EMBASE, CINAHL, PsycINFO, and Web of Science Core Collection. Searches were designed to identify patient self-reports on HRQOL aspects defined as physical, mental, or social issues. Quality assessment was conducted using the Mixed Methods Appraisal Tool (MMAT). Narrative synthesis was used to collate findings.

Results

The search returned 8923 articles. Two hundred seventy-eight titles remained after title and abstract screening, with 21 full-text articles included in the final analysis. The majority of studies used quantitative methods, with 3 articles reporting mixed methodology. Negative emotional/psychological/cognitive changes were the most commonly reported. Physical complaints included fatigue, seizures, and restricted daily activity. Social challenges included strained social relationships and financial problems. Patient coping strategies were suggested to influence patient’s survival quality.

Conclusion

The consequences of a glioma diagnosis and treatment can have substantial implications for patients’ long-term HRQOL and daily functioning. Findings from this review lay the groundwork for efforts to improve patient HRQOL in long-term survivorship.

Rule Perseveration during Task-Switching in Brain Tumor: A Severe Form of Task-Setting Impairment

It has been proposed that at least two distinct processes are engaged during task-switching: reconfiguration of the currently relevant task-set and interference resolution arising from the competing task-set. Whereas in healthy individuals the two are difficult to disentangle, their disruption is thought to cause different impairments in brain-damaged patients. Yet, the observed deficits are inconsistent across studies and do not allow drawing conclusions regarding their independence. Forty-one brain tumor patients were tested on a task-switching paradigm. We compared their performance between switch and repeat trials (switch cost) to assess rule reconfiguration, and between trials requiring the same response (congruent) and a different response for the two tasks (incongruent) to assess interference control. In line with previous studies, we found the greatest proportion of errors on incongruent trials, suggesting an interference control impairment. However, a closer look at the distribution of errors between two task rules revealed a rule perseveration impairment: Patients with high error rate on incongruent trials often applied only one task rule throughout the task and less frequently switched to the alternative one. Multivariate lesion-symptom mapping analysis unveiled the relationship between lesions localized in left orbitofrontal and posterior subcortical regions and perseveration scores, measured as absolute difference in accuracy between two task rules. This finding points to a more severe task-setting impairment, not reflected as a mere switching deficit, but instead as a difficulty in creating multiple stable task representations, in line with recent accounts of OFC functions suggesting its critical role in representing task states.

Functional Outcomes and Health-Related Quality of Life Following Glioma Surgery

Functional outcome following glioma surgery is defined as how the patient functions or feels. Functional outcome is a coprimary end point of surgery in patients with diffuse glioma, together with oncological outcome. In this review, we structure the functional outcome measurements following glioma surgery as reported in the last 5 yr. We review various perspectives on functional outcome of glioma surgery with available measures, and offer suggestions for their use. From the recent neurosurgical literature, 160 publications were retrieved fulfilling the selection criteria. In these publications, neurological outcomes were reported most often, followed by activities of daily living, seizure outcomes, neurocognitive outcomes, and health-related quality of life or well-being. In more than a quarter of these publications functional outcome was not reported. A minimum essential consensus set of functional outcome measurements would benefit comparison across neurosurgical reports. The consensus set should be based on a combination of clinician- and patient-reported outcomes, assessed at a predefined time before and after surgery. The selected measurements should have psychometric properties supporting the intended use including validity-related evidence, reliability, and sensitivity to detect meaningful change with minimal burden to ensure compliance. We circulate a short survey as a start towards reporting guidelines. Many questions remain to better understand, report, and improve functional outcome following glioma surgery.

Mental time travel in patients "cured" from primary central nervous system lymphoma

Introduction: Significant advances in neuro-oncological treatment led to considering neurocognitive functioning and everyday functional needs in patients with long-term survival. Since a potentially lethal disease interrupts normal life and represents a threat to physical and psychological integrity, patients have to cope with the new challenges. Long-term survival and even "cure" is possible in primary central nervous system lymphoma (PCNSL), however, suffering from a life-threatening disease may affect patients´ cognitive processing of past and future (i.e., the generation of personal past memories and generation of personal future events). Therefore, the present study aimed to assess how PCNSL long-term survivors remember their past and anticipate their future.Methods: Recall of past and anticipation of future events (i.e., mental time travel), both positive and negative, was assessed in 39 PCNSL patients with ongoing complete remission to therapy for at least 1 year in an adapted verbal fluency paradigm. A group of 39 healthy controls matched for age, gender and education was assessed with the same paradigm evaluating retrospective and prospective cognitions.Results: Concerning the generation of personal future events PCNSL patients anticipated significantly fewer negative events for the distant future as compared to healthy controls. At trend level, patients also reported fewer negative events regarding their recent past.Conclusions: The results provide support for an altered generation of personal future events (i.e., future-directed assumptions) in PCNSL patients with ongoing complete remission. Being "cured" after experiencing a threat to life might induce cognitive reappraisal processes and lead people to reexamine their priorities and principles in life, resulting in a less negative evaluation of (future) life (i.e., "optimism bias") after facing death. Clinicians should be aware of these possible cognitive and affective processes and of chronic psychological disturbances in cancer survivors. Possible adaptive strategies ought to be promoted in supportive (neuro)psychological therapy.

Updated perspectives on awake neurosurgery with cognitive and emotional assessment for patients with low-grade gliomas

Introduction: Thanks to early extensive surgical resection combined with medical oncological therapies, life expectancy dramatically increased in low-grade glioma (LGG), with an overall survival currently over 15 years. Therefore, patients should be able to maintain valuable family and socio-professional activities.Areas covered: For many decades, cognitive and emotional aspects were neglected by surgical and medical neurooncologists. The goal of surgery was to avoid hemiplegia and/or aphasia, with no considerations regarding behavior. However, because LGG patients live longer, they must be cognitively and affectively able to make long-term projects. Preservation of higher-order functions should be considered systematically in LGG surgery by means of awake cognitive/emotional mapping and monitoring.Expert opinion: The aim is to incorporate recent advances in neurosciences, which proposed revisited models of cerebral processing relying on a meta-network perspective, into the pre-, intra- and postoperative procedure. In this connectomal approach, brain functions result from complex interactions within and between neural networks. This improved understanding of a constant instability of the neural system allows a better cognitive/emotional assessment before and after each treatment over years, in order to preserve personality and adaptive behavior for each LGG patient, based on his/her own definition of quality of life. It is time to create oncological neurosciences.

Proton therapy for selected low grade glioma patients in the Netherlands

Proton therapy offers an attractive alternative to conventional photon-based radiotherapy in low grade glioma patients, delivering radiotherapy with equivalent efficacy to the tumour with less radiation exposure to the brain. In the Netherlands, patients with favourable prognosis based on tumour and patient characteristics can be offered proton therapy. Radiation-induced neurocognitive function decline is a major concern in these long surviving patients. Although level 1 evidence of superior clinical outcome with proton therapy is lacking, the Dutch National Health Care Institute concluded that there is scientific evidence to assume that proton therapy can have clinical benefit by reducing radiation-induced brain damage. Based on this decision, proton therapy is standard insured care for selected low grade glioma patients. Patients with other intracranial tumours can also qualify for proton therapy, based on the same criteria. In this paper, the evidence and considerations that led to this decision are summarised. Additionally, the eligibility criteria for proton therapy and the steps taken to obtain high-quality data on treatment outcome are discussed.

Cognitive Functions in Repeated Glioma Surgery

Low-grade gliomas (LGG) are slow-growing brain tumors infiltrating the central nervous system which tend to recur, often with malignant degeneration after primary treatment. Re-operations are not always recommended due to an assumed higher risk of neurological and cognitive deficits. However, this assumption is relatively ungrounded due to a lack of extensive neuropsychological testing. We retrospectively examined a series of 40 patients with recurrent glioma in eloquent areas of the left hemisphere, who all completed comprehensive pre- (T3) and post-surgical (T4) neuropsychological assessments after a second surgery (4-month follow up). The lesions were most frequent in the left insular cortex and the inferior frontal gyrus. Among this series, in 17 patients the cognitive outcomes were compared before the first surgery (T1), 4 months after the first surgery (T2), and at T3 and T4. There was no significant difference either in the number of patients scoring within the normal range between T3 and T4, or in their level of performance. Further addressing the T1-T4 evolution, there was no significant difference in the number of patients scoring within the normal range. As to their level of performance, the only significant change was in phonological fluency. This longitudinal follow-up study showed that repeated glioma surgery is possible without major damage to cognitive functions in the short-term period (4 months) after surgery.

Intraoperative Identification and Preservation of Verbal Memory in Diffuse Gliomas: A Matched-Pair Cohort Study

BACKGROUND

Recent glioma surgery series with intraoperative electrical stimulation (IES) language mapping have demonstrated high rates of postoperative memory impairment, raising a question regarding the efficacy of this approach to preserve memory.

OBJECTIVE

To evaluate if intraoperative identification and preservation of verbal memory sites with IES mapping in diffuse gliomas in eloquent areas consistently protect patients from long-term postoperative decline in short-term memory.

METHODS

A cohort of 16 subjects with diffuse low-grade or anaplastic gliomas that were operated with IES and intraoperative evaluation of language and verbal memory (cohort A) was matched by tumor side, pathology, and radiotherapy with a cohort of 16 subjects that were operated with IES and evaluation of language (cohort B). Detailed neuropsychological assessment was performed before and 6 mo after surgery.

RESULTS

Intraoperative memory mapping was a strong predictor of verbal memory prognosis. In cohort A, 4 patients (26.7%) had a decline of at least one of the 4 short-term memory tests evaluated. In cohort B, 11 patients (73.3%) had a decline of at least one of the 4 tests. This difference was statistically significant in multivariate analysis (P = .022; odds ratio = 9.88; 95% confidence interval = 1.39-70.42).

CONCLUSION

Verbal memory areas identified intraoperatively with the current paradigm are critically involved in verbal memory, as memory impairment can be significantly reduced by adapting the resection to avoid those memory areas. Incorporation of verbal memory evaluation in stimulation mapping protocols might assist in reducing postoperative sequelae and preserving the patient's quality of life.

Conscious Experience and Psychological Consequences of Awake Craniotomy

BACKGROUND

Experiencing cranial surgery under awake conditions may expose patients to considerable psychological strain.

METHODS

This study aimed to investigate the occurrence and course of psychological sequelae following awake craniotomy (AC) for brain tumors in a series of 20 patients using a broad, validated psychological assessment preoperatively, intraoperatively, postoperatively and a standardized follow-up of 3 months. In addition, the association of the preoperative psychological condition (including, but not limited to, anxiety and fear) with perioperative pain perception and interference was assessed.

RESULTS

AC did not induce any shift in the median levels of anxiety, depression, and stress symptoms already present prior to the procedure. Furthermore, anxiety and depression were all moderately to strongly associated over time (all P < 0.05). Stress symptoms also correlated positively over all times of measurement. Stress 3 days after surgery was strongly associated with stress 3 months after surgery (P < 0.001), whereas the correlation between preoperative and immediate postoperative stress showed a statistical trend (P = 0.07). Preoperative fear was not related to intraoperative pain, but to pain and its interference with daily activity on the third postoperative day (P < 0.001 and P < 0.01, respectively).

CONCLUSIONS

Postoperative psychological symptoms clearly correlated with their corresponding preoperative symptoms. Thus, mental health was not negatively affected by the AC experience in our series. Intraoperative fear and pain were not related to the preoperative psychological condition. However, preoperative fear and anxiety were positively related with pain and its interference with daily activity in the immediate postoperative period.

Are Posttraumatic Stress Symptoms and Avoidant Coping Inhibitory Factors? The Association Between Posttraumatic Growth and Quality of Life Among Low-Grade Gliomas Patients in China

Background: Diagnosing with low-grade gliomas (LGGs) can be a very shocking and stressful experience, a traumatic event potentially leading to the development of posttraumatic stress symptoms (PTSS), and posttraumatic growth (PTG). Understanding how patients cognitively and behaviorally response to their diagnosing is also important to postoperative treatment. Thus, the current study explored the association between PTG and quality of life (QoL) of Chinese patients with LGGs. The moderation effects of coping strategies and PTSS on the relationship between PTG and QoL have been examined as well. Methods: Posttraumatic stress symptoms, Posttraumatic growth, coping strategies, and QoL were measured by using self-report surveys. Three hundred and thirty patients completed surveys approximately 1 month after surgery. We used three multiple regression models and added interaction terms in these models to test the moderation effects of PTSS and coping strategies on the relationship between PTG and QoL. Results: The results of hierarchical multiple regression suggested that PTG significantly predicted QoL, both PTSS and coping strategies moderated the association between PTG and QoL. Specifically, the association between PTG and QoL for patients who have non-significant PTSS is stronger than those who have significant PTSS. Furthermore, as the score of Avoidant Coping increases, the association between PTG and QoL becomes weaker. Conclusion: Posttraumatic growth may help to improve the QoL of LGGs patients, but PTSS and Avoidant Coping impeded the positive effect of PTG on QoL.

The Surgeon in Action: Representations of Neurosurgery in Movies from the Frères Lumière to Today

In this review, we examine the portrayal of neurosurgery and neurosurgeons in 61 movies produced from the beginnings of cinema from the Lumière brothers (1895) to 2017, across 4 continents and covering 10 cinematic genres. We find that these movies tend to shape most beliefs and stereotypes about neurosurgery. However, we notice that there is a trend to describe neurosurgery and neurosurgical disorders with more accuracy as we progress in time. Although it is not for the medical profession to dictate or censor fictional content, a keen eye on these depictions will help us to understand, and perhaps combat, some of the stereotypes and myths that continue to surround neurosurgery in the twenty-first century.

Improving surgical outcome for gliomas with intraoperative mapping

INTRODUCTION

Radical glioma resection improves overall survival, both in low-grade and high-grade glial tumors. However, preservation of the quality of life is also crucial. Areas covered: Due to the diffuse feature of gliomas, which invade the central nervous system, and due to considerable variations of brain organization among patients, an individual cerebral mapping is mandatory to solve the classical dilemma between the oncological and functional issues. Because functional neuroimaging is not reliable enough, intraoperative electrical stimulation, especially in awake patients benefiting from a real-time cognitive monitoring, is the best way to increase the extent of resection while sparing eloquent neural networks. Expert commentary: Here, we propose a paradigmatic shift from image-guided resection to functional mapping-guided resection, based on the study of the dynamic distribution of delocalized cortico-subcortical circuits at the individual level, i.e., the investigation of brain connectomics and neuroplastic potential. This surgical philosophy results in an improvement of both oncological outcomes and quality of life. This highlights the need to reinforce the link between glioma surgery and cognitive neurosciences.

An attempt to conceptualize the individual onco-functional balance: Why a standardized treatment is an illusion for diffuse low-grade glioma patients

In the era of evidence-based medicine, clinicians aim to establish standards of care from randomized studies. Following, personalized medicine has emerged, as new individualized biomarkers could help to predict sensitivity to specific treatment. In this paper, we show that, for diffuse low-grade glioma, some specificities - dual goal of both survival and functional gain, long duration of the disease with multistep treatments, multiparametric evaluation of the onco-functional balance of each treatment modality - call for a change of paradigm. After summarizing how to weight the benefits and risks of surgery, chemotherapy and radiotherapy, we show that the overall efficacy of a treatment modality cannot be assessed per se, as it depends on its integration in the whole sequence. Then, we revisit the notion of personalized medicine: instead of decision-making based solely on molecular profile, we plead for a recursive algorithm, allowing a dynamic evaluation of the onco-functional balance, integrating many individual characteristics of the patient's tumor and brain function.