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Ille S, Zhang H, Stassen N, Schwendner M, Schröder A, Wiestler B, Meyer B, Krieg SM. Noninvasive- and invasive mapping reveals similar language network centralities - A function-based connectome analysis. Cortex 2024; 174:189-200. [PMID: 38569257 DOI: 10.1016/j.cortex.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/11/2023] [Accepted: 01/23/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Former comparisons between direct cortical stimulation (DCS) and navigated transcranial magnetic stimulation (nTMS) only focused on cortical mapping. While both can be combined with diffusion tensor imaging, their differences in the visualization of subcortical and even network levels remain unclear. Network centrality is an essential parameter in network analysis to measure the importance of nodes identified by mapping. Those include Degree centrality, Eigenvector centrality, Closeness centrality, Betweenness centrality, and PageRank centrality. While DCS and nTMS have repeatedly been compared on the cortical level, the underlying network identified by both has not been investigated yet. METHOD 27 patients with brain lesions necessitating preoperative nTMS and intraoperative DCS language mapping during awake craniotomy were enrolled. Function-based connectome analysis was performed based on the cortical nodes obtained through the two mapping methods, and language-related network centralities were compared. RESULTS Compared with DCS language mapping, the positive predictive value of cortical nTMS language mapping is 74.1%, with good consistency of tractography for the arcuate fascicle and superior longitudinal fascicle. Moreover, network centralities did not differ between the two mapping methods. However, ventral stream tracts can be better traced based on nTMS mappings, demonstrating its strengths in acquiring language-related networks. In addition, it showed lower centralities than other brain areas, with decentralization as an indicator of language function loss. CONCLUSION This study deepens the understanding of language-related functional anatomy and proves that non-invasive mapping-based network analysis is comparable to the language network identified via invasive cortical mapping.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany; TUM-Neuroimaging Center, Technical University of Munich, Munich, Germany; Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Haosu Zhang
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany; Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Nina Stassen
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
| | - Maximilian Schwendner
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany; Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Axel Schröder
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany; TranslaTUM (Zentralinstitut für translationale Krebsforschung der Technischen Universität München), Munich, Germany.
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany; TUM-Neuroimaging Center, Technical University of Munich, Munich, Germany; Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
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Yang J, Shen L, Long Q, Li W, Zhang W, Chen Q, Han B. Electrical stimulation induced self-related auditory hallucinations correlate with oscillatory power change in the default mode network. Cereb Cortex 2024; 34:bhad473. [PMID: 38061695 DOI: 10.1093/cercor/bhad473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/17/2023] [Accepted: 11/18/2023] [Indexed: 01/19/2024] Open
Abstract
Self-related information is crucial in our daily lives, which has led to the proposal that there is a specific brain mechanism for processing it. Neuroimaging studies have consistently demonstrated that the default mode network (DMN) is strongly associated with the representation and processing of self-related information. However, the precise relationship between DMN activity and self-related information, particularly in terms of neural oscillations, remains largely unknown. We electrically stimulated the superior temporal and fusiform areas, using stereo-electroencephalography to investigate neural oscillations associated with elicited self-related auditory hallucinations. Twenty-two instances of auditory hallucinations were recorded and categorized into self-related and other-related conditions. Comparing oscillatory power changes within the DMN between self-related and other-related auditory hallucinations, we discovered that self-related hallucinations are associated with significantly stronger positive power changes in both alpha and gamma bands compared to other-related hallucinations. To ensure the validity of our findings, we conducted controlled analyses for factors of familiarity and clarity, which revealed that the observed effects within the DMN remain independent of these factors. These results underscore the significance of the functional role of the DMN during the processing of self-related auditory hallucinations and shed light on the relationship between self-related perception and neural oscillatory activity.
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Affiliation(s)
- Jing Yang
- Center for Studies of Psychological Application, South China Normal University, No.55, West of Zhongshan Avenue, Tianhe District, 510631, Guangzhou, China
- School of Psychology, South China Normal University, No. 55, West of Zhongshan Avenue, Tianhe District, 510631, Guangzhou, China
| | - Lu Shen
- Center for Studies of Psychological Application, South China Normal University, No.55, West of Zhongshan Avenue, Tianhe District, 510631, Guangzhou, China
- School of Psychology, South China Normal University, No. 55, West of Zhongshan Avenue, Tianhe District, 510631, Guangzhou, China
| | - Qiting Long
- School of Psychology, South China Normal University, No. 55, West of Zhongshan Avenue, Tianhe District, 510631, Guangzhou, China
| | - Wenjie Li
- School of Psychology, South China Normal University, No. 55, West of Zhongshan Avenue, Tianhe District, 510631, Guangzhou, China
| | - Wei Zhang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, Litang Road No. 168, Changping District, 102218, Beijing, China
- Epilepsy Center, Shanghai Neuromedical Center, Gulang Road No. 378, Putuo District, 200331, Shanghai, China
| | - Qi Chen
- Center for Studies of Psychological Application, South China Normal University, No.55, West of Zhongshan Avenue, Tianhe District, 510631, Guangzhou, China
- School of Psychology, South China Normal University, No. 55, West of Zhongshan Avenue, Tianhe District, 510631, Guangzhou, China
| | - Biao Han
- Center for Studies of Psychological Application, South China Normal University, No.55, West of Zhongshan Avenue, Tianhe District, 510631, Guangzhou, China
- School of Psychology, South China Normal University, No. 55, West of Zhongshan Avenue, Tianhe District, 510631, Guangzhou, China
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Zhu E, Shi W, Chen Z, Wang J, Ai P, Wang X, Zhu M, Xu Z, Xu L, Sun X, Liu J, Xu X, Shan D. Reasoning and causal inference regarding surgical options for patients with low-grade gliomas using machine learning: A SEER-based study. Cancer Med 2023; 12:20878-20891. [PMID: 37929878 PMCID: PMC10709720 DOI: 10.1002/cam4.6666] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/17/2023] [Accepted: 10/07/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Due to the heterogeneity of low-grade gliomas (LGGs), the lack of randomized control trials, and strong clinical evidence, the effect of the extent of resection (EOR) is currently controversial. AIM To determine the best choice between subtotal resection (STR) and gross-total resection (GTR) for individual patients and to identify features that are potentially relevant to treatment heterogeneity. METHODS Patients were enrolled from the SEER database. We used a novel DL approach to make treatment recommendations for patients with LGG. We also made causal inference of the average treatment effect (ATE) of GTR compared with STR. RESULTS The patients were divided into the Consis. and In-consis. groups based on whether their actual treatment and model recommendations were consistent. Better brain cancer-specific survival (BCSS) outcomes in the Consis. group was observed. Overall, we also identified two subgroups that showed strong heterogeneity in response to GTR. By interpreting the models, we identified numerous variables that may be related to treatment heterogeneity. CONCLUSIONS This is the first study to infer the individual treatment effect, make treatment recommendation, and guide surgical options through deep learning approach in LGG research. Through causal inference, we found that heterogeneous responses to STR and GTR exist in patients with LGG. Visualization of the model yielded several factors that contribute to treatment heterogeneity, which are worthy of further discussion.
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Affiliation(s)
- Enzhao Zhu
- School of MedicineTongji UniversityShanghaiChina
| | - Weizhong Shi
- Shanghai Hospital Development CenterShanghaiChina
| | - Zhihao Chen
- School of BusinessEast China University of Science and TechnologyShanghaiChina
| | - Jiayi Wang
- School of MedicineTongji UniversityShanghaiChina
| | - Pu Ai
- School of MedicineTongji UniversityShanghaiChina
| | - Xiao Wang
- School of MedicineTongji UniversityShanghaiChina
| | - Min Zhu
- Department of Computer Science and Technology, School of Electronics and Information EngineeringTongji UniversityShanghaiChina
| | - Ziqin Xu
- Department of Industrial Engineering and Operations ResearchColumbia UniversityNew YorkNew YorkUSA
| | - Lingxiao Xu
- School of MedicineTongji UniversityShanghaiChina
| | - Xueyi Sun
- School of Ocean and Earth ScienceTongji UniversityShanghaiChina
| | - Jingyu Liu
- School of Ocean and Earth ScienceTongji UniversityShanghaiChina
| | - Xuetong Xu
- College of Civil EngineeringTongji UniversityShanghaiChina
| | - Dan Shan
- Regenerative Medicine Institute, School of MedicineNational University of IrelandGalwayIreland
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Singh A, Jain G, Sharma V, Singh S. Preoperative Diffusion Tensor Imaging in Supratentorial Intra-Axial Brain Tumors: Its Role in Predicting Tumor Histology and Prognosis as well in Surgical Planning and Resection. Asian J Neurosurg 2023; 18:476-483. [PMID: 38152530 PMCID: PMC10749847 DOI: 10.1055/s-0043-1772758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Objective There are a large number of prospective studies that use diffusion tensor imaging (DTI) to show the relationship between intracranial tumors and white matter (WM) fibers. We studied the role of DTI in supratentorial intra-axial (ST-IA) tumors of the brain in deciding the surgical approach with maximal resection and minimal or no deficit and in predicting the histological characterization of the tumor and the neurological outcome. Methods A total of 91 cases of ST-IA tumors were included in our study. The neurological status of the patients was assessed preoperatively, and the tumor volume and DTI pattern were noted radiologically. Surgical plan was decided by the senior consultants of the neurosurgery department taking into consideration the findings of tractography and magnetic resonance imaging. The neurological status and the extent of resection were evaluated postoperatively, and the correlation between histopathology with DTI was studied. Results Of the 91 patients, 25 had high-grade glioma (HGG), 60 had low-grade glioma (LGG), and 6 were metastatic lesions. Gross total excisions were done mostly in patients with DTI showing displaced fibers and subtotal/partial resections were done mostly in disrupted/infiltrated tracts, which was statistically significant. The correlation between histopathology and tractography revealed that intact/displaced tracts were seen mostly in LGG (79%), whereas 86% of HGG showed disrupted/infiltrated fibers; both were statistically significant. Conclusion Preoperative DTI in ST-IA brain tumors is an important tool for deciding the appropriate surgical approach for maximal safe resection, thus improving the post-op neurological outcome in patients. It also helps in predicting the tumor histology while also serving as an important prognostication indicator.
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Affiliation(s)
- Ajay Singh
- Department of Neurosurgery, SMS Medical College and Hospital, Jaipur, Rajasthan, India
| | - Gaurav Jain
- Department of Neurosurgery, SMS Medical College and Hospital, Jaipur, Rajasthan, India
| | - Vinod Sharma
- Department of Neurosurgery, SMS Medical College and Hospital, Jaipur, Rajasthan, India
| | - Shaveta Singh
- Department of Neurosurgery, SMS Medical College and Hospital, Jaipur, Rajasthan, India
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Wu S, Wang C, Li N, Ballah AK, Lyu J, Liu S, Wang X. Analysis of Prognostic Factors and Surgical Management of Elderly Patients with Low-Grade Gliomas. World Neurosurg 2023; 176:e20-e31. [PMID: 36858293 DOI: 10.1016/j.wneu.2023.02.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 02/20/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The number of elderly patients with low-grade glioma (LGG) is increasing, but their prognostic factors and surgical treatment are still controversial. This paper aims to investigate the prognostic factors of overall survival and cancer-specific survival in elderly patients with LGG and analyze the optimal surgical treatment strategy. METHODS Patients in the study were obtained from the Surveillance, Epidemiology, and End Results database and patients were randomized into a training and a test set (7:3). Clinical variables were analyzed by univariate and multivariate Cox regression analysis to screen for significant prognostic factors, and nomograms visualized the prognosis. In addition, survival analysis of elderly patients regarding different surgical management was also analyzed by Kaplan-Meier curves. RESULTS Six prognostic factors were screened by univariate and multivariate Cox regression analysis on the training set: tumor site, laterality, histological type, the extent of surgery, radiotherapy, and chemotherapy, and all factors were visualized by nomogram. And we evaluated the accuracy of the nomogram model using consistency index, calibration plots, receiver operator characteristic curves, and decision curve analysis, showing that the nomogram has strong accuracy and applicability. We also found that gross total resection improved overall survival and cancer-specific survival in patients with LGG aged ≥65 years relative to those who did not undergo surgery (P < 0.001). CONCLUSIONS Based on the Surveillance, Epidemiology, and End Results database, we created and validated prognostic nomograms for elderly patients with LGG, which can help clinicians to provide personalized treatment services and clinical decisions for their patients. More importantly, we found that older age alone should not preclude aggressive surgery for LGGs.
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Affiliation(s)
- Shuaishuai Wu
- Neurosurgery Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Changli Wang
- Department of Pathology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ning Li
- Neurosurgery Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Augustine K Ballah
- Neurosurgery Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Jun Lyu
- Clinical Research Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Shengming Liu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.
| | - Xiangyu Wang
- Neurosurgery Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
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Peters DR, Halimi F, Ozduman K, Levivier M, Conti A, Reyns N, Tuleasca C. Resection of the contrast-enhancing tumor in diffuse gliomas bordering eloquent areas using electrophysiology and 5-ALA fluorescence: evaluation of resection rates and neurological outcome-a systematic review and meta-analysis. Neurosurg Rev 2023; 46:185. [PMID: 37498398 PMCID: PMC10374773 DOI: 10.1007/s10143-023-02064-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023]
Abstract
Independently, both 5-aminolevulinic acid (5-ALA) and intraoperative neuromonitoring (IONM) have been shown to improve outcomes with high-grade gliomas (HGG). The interplay and overlap of both techniques are scarcely reported in the literature. We performed a systematic review and meta-analysis focusing on the concomitant use of 5-ALA and intraoperative mapping for HGG located within eloquent cortex. Using PRISMA guidelines, we reviewed articles published between May 2006 and December 2022 for patients with HGG in eloquent cortex who underwent microsurgical resection using intraoperative mapping and 5-ALA fluorescence guidance. Extent of resection was the primary outcome. The secondary outcome was new neurological deficit at day 1 after surgery and persistent at day 90 after surgery. Overall rate of complete resection of the enhancing tumor (CRET) was 73.3% (range: 61.9-84.8%, p < .001). Complete 5-ALA resection was performed in 62.4% (range: 28.1-96.7%, p < .001). Surgery was stopped due to mapping findings in 20.5% (range: 15.6-25.4%, p < .001). Neurological decline at day 1 after surgery was 29.2% (range: 9.8-48.5%, p = 0.003). Persistent neurological decline at day 90 after surgery was 4.6% (range: 0.4-8.7%, p = 0.03). Maximal safe resection guided by IONM and 5-ALA for high-grade gliomas in eloquent areas is achievable in a high percentage of cases (73.3% CRET and 62.4% complete 5-ALA resection). Persistent neurological decline at postoperative day 90 is as low as 4.6%. A balance between 5-ALA and IONM should be maintained for a better quality of life while maximizing oncological control.
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Affiliation(s)
- David R Peters
- Department of Neurosurgery, Atrium Health, Charlotte, NC, USA.
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland.
| | - Floriana Halimi
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Koray Ozduman
- Department of Neurosurgery, School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alfredo Conti
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
- Dipartimento Di Scienze Biomediche E Neuromotorie (DIBINEM), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Nicolas Reyns
- Neurosurgery and Neurooncology Service, Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Lille, France
| | - Constantin Tuleasca
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Ecole Polytechnique Fédérale de Lausanne (EPFL, LTS-5), Lausanne, Switzerland
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Tuleasca C, Leroy HA, Strachowski O, Derre B, Maurage CA, Peciu-Florianu I, Reyns N. Combined use of intraoperative MRI and awake tailored microsurgical resection to respect functional neural networks: preliminary experience. Swiss Med Wkly 2023; 153:40072. [PMID: 37192405 DOI: 10.57187/smw.2023.40072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION The combined use of intraoperative MRI and awake surgery is a tailored microsurgical resection to respect functional neural networks (mainly the language and motor ones). Intraoperative MRI has been classically considered to increase the extent of resection for gliomas, thereby reducing neurological deficits. Herein, we evaluated the combined technique of awake microsurgical resection and intraoperative MRI for primary brain tumours (gliomas, metastasis) and epilepsy (cortical dysplasia, non-lesional, cavernomas). PATIENTS AND METHODS Eighteen patients were treated with the commonly used "asleep awake asleep" (AAA) approach at Lille University Hospital, France, from November 2016 until May 2020. The exact anatomical location was insular with various extensions, frontal, temporal or fronto-temporal in 8 (44.4%), parietal in 3 (16.7%), fronto-opercular in 4 (22.2%), Rolandic in two (11.1%), and the supplementary motor area (SMA) in one (5.6%). RESULTS The patients had a mean age of 38.4 years (median 37.1, range 20.8-66.9). The mean surgical duration was 4.1 hours (median 4.2, range 2.6-6.4) with a mean duration of intraoperative MRI of 28.8 minutes (median 25, range 13-55). Overall, 61% (11/18) of patients underwent further resection, while 39% had no additional resection after intraoperative MRI. The mean preoperative and postoperative tumour volumes of the primary brain tumours were 34.7 cc (median 10.7, range 0.534-130.25) and 3.5 cc (median 0.5, range 0-17.4), respectively. Moreover, the proportion of the initially resected tumour volume at the time of intraoperative MRI (expressed as 100% from preoperative volume) and the final resected tumour volume were statistically significant (p= 0.01, Mann-Whitney test). The tumour remnants were commonly found posterior (5/9) or anterior (2/9) insular and in proximity with the motor strip (1/9) or language areas (e.g. Broca, 1/9). Further resection was not required in seven patients because there were no remnants (3/7), cortical stimulation approaching eloquent areas (3/7) and non-lesional epilepsy (1/7). The mean overall follow-up period was 15.8 months (median 12, range 3-36). CONCLUSION The intraoperative MRI and awake microsurgical resection approach is feasible with extensive planning and multidisciplinary collaboration, as these methods are complementary and synergic rather than competitive to improve patient oncological outcomes and quality of life.
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Affiliation(s)
- Constantin Tuleasca
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Henri-Arthur Leroy
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Ondine Strachowski
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Benoit Derre
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Claude-Alain Maurage
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Iulia Peciu-Florianu
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Nicolas Reyns
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
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Current Trends in Neurosurgical Management of Adult Diffuse Low-Grade Gliomas in Canada. Can J Neurol Sci 2023; 50:278-281. [PMID: 35510291 DOI: 10.1017/cjn.2022.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
There is considerable variability in the management of diffuse low-grade gliomas (LGGs). To characterize treatment paradigms, a survey of Canadian neurosurgeons was performed with forty neurosurgeons responding. Their responses show that the management of patients with LGGs has evolved in the past decade and findings from the RTOG9802 trial have been integrated into the practice of Canadian neurosurgeons. Most respondents stated that the patient selection and treatment strategy advocated by the RTOG9802 trial needs further evaluation. Overall, there is a trend toward more aggressive surgical resections, and future investigations will have to more accurately stratify patient risk profiles.
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Yamaguchi T, Kuwano A, Koyama T, Okamoto J, Suzuki S, Okuda H, Saito T, Masamune K, Muragaki Y. Construction of brain area risk map for decision making using surgical navigation and motor evoked potential monitoring information. Int J Comput Assist Radiol Surg 2023; 18:269-278. [PMID: 36151348 DOI: 10.1007/s11548-022-02752-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 09/09/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE Surgical devices or systems typically operate in a stand-alone manner, making it difficult to perform integration analysis of both intraoperative anatomical and functional information. To address this issue, the intraoperative information integration system OPeLiNK® was developed. The objective of this study is to generate information for decision making using surgical navigation and intraoperative monitoring information accumulated in the OPeLiNK® database and to analyze its utility. METHODS We accumulated intraoperative information from 27 brain tumor patients who underwent resection surgery. First, the risk rank for postoperative paralysis was set according to the attenuation rate and amplitude width of the motor evoked potential (MEP). Then, the MEP and navigation log data were combined and plotted on an intraoperative magnetic resonance image of the individual brain. Finally, statistical parametric mapping (SPM) transformation was performed to generate a standard brain risk map of postoperative paralysis. Additionally, we determined the anatomical high-risk areas using atlases and analyzed the relationship with each set risk rank. RESULTS The average distance between the navigation log corresponding to each MEP risk rank and the anatomical high-risk area differed significantly between the with postoperatively paralyzed and without postoperatively paralyzed groups, except for "safe." Furthermore, no excessive deformation was observed resulting from SPM conversion to create the standard brain risk map. There were cases in which no postoperative paralysis occurred even when MEP decreased intraoperatively, and vice versa. CONCLUSION The time synchronization reliability of the study data is very high. Therefore, our created risk map can be reported as being functional at indicating the risk areas. Our results suggest that the statistical risks of postoperative complications can be presented for each area where brain surgery is to be performed. In the future, it will be possible to provide surgical navigation with intraoperative support that reflects the risk maps created.
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Affiliation(s)
- Tomoko Yamaguchi
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan. .,Center for Advanced Medical Engineering Research & Development, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan.
| | - Atsushi Kuwano
- Department of Neurosurgery, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | | | - Jun Okamoto
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Hideki Okuda
- DENSO Corporation, Aichi, Japan.,OPExPARK Inc., Tokyo, Japan
| | - Taiichi Saito
- Department of Neurosurgery, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Ken Masamune
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshihiro Muragaki
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan
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Intraoperative Monitoring During Neurosurgical Procedures and Patient Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00542-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Rincon-Torroella J, Rakovec M, Materi J, Raj D, Vivas-Buitrago T, Ferres A, Reyes Serpa W, Redmond KJ, Holdhoff M, Bettegowda C, González Sánchez JJ. Current and Future Frontiers of Molecularly Defined Oligodendrogliomas. Front Oncol 2022; 12:934426. [PMID: 35957904 PMCID: PMC9358027 DOI: 10.3389/fonc.2022.934426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/13/2022] [Indexed: 11/17/2022] Open
Abstract
Oligodendrogliomas are a subtype of adult diffuse glioma characterized by their better responsiveness to systemic chemotherapy than other high-grade glial tumors. The World Health Organization (WHO) 2021 brain tumor classification highlighted defining molecular markers, including 1p19q codeletion and IDH mutations which have become key in diagnosing and treating oligodendrogliomas. The management for patients with oligodendrogliomas includes observation or surgical resection potentially followed by radiation and chemotherapy with PCV (Procarbazine, Lomustine, and Vincristine) or Temozolomide. However, most of the available research about oligodendrogliomas includes a mix of histologically and molecularly diagnosed tumors. Even data driving our current management guidelines are based on post-hoc subgroup analyses of the 1p19q codeleted population in landmark prospective trials. Therefore, the optimal treatment paradigm for molecularly defined oligodendrogliomas is incompletely understood. Many questions remain open, such as the optimal timing of radiation and chemotherapy, the response to different chemotherapeutic agents, or what genetic factors influence responsiveness to these agents. Ultimately, oligodendrogliomas are still incurable and new therapies, such as targeting IDH mutations, are necessary. In this opinion piece, we present relevant literature in the field, discuss current challenges, and propose some studies that we think are necessary to answer these critical questions.
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Affiliation(s)
- Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurosurgery, Hospital Clínic i Provincial, Barcelona, Spain
| | - Maureen Rakovec
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Josh Materi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Divyaansh Raj
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Abel Ferres
- Department of Neurosurgery, Hospital Clínic i Provincial, Barcelona, Spain
| | | | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Matthias Holdhoff
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Chetan Bettegowda, ; José Juan González Sánchez,
| | - José Juan González Sánchez
- Department of Neurosurgery, Hospital Clínic i Provincial, Barcelona, Spain
- *Correspondence: Chetan Bettegowda, ; José Juan González Sánchez,
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Schiavao LJV, Neville Ribeiro I, Yukie Hayashi C, Gadelha Figueiredo E, Russowsky Brunoni A, Jacobsen Teixeira M, Pokorny G, Silva Paiva W. Assessing the Capabilities of Transcranial Magnetic Stimulation (TMS) to Aid in the Removal of Brain Tumors Affecting the Motor Cortex: A Systematic Review. Neuropsychiatr Dis Treat 2022; 18:1219-1235. [PMID: 35734549 PMCID: PMC9208734 DOI: 10.2147/ndt.s359855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The brain tumor is frequently related to severe motor impairment and impacts the quality of life. The corticospinal tract can sometimes be affected depending on the type and size of the neoplasm, so different tools can evaluate motor function and connections. It is essential to organize surgical procedures and plan the approach. Functional motor status is mapped before, during, and after surgery. Studying corticospinal tract status can help map the functional areas, predict postoperative outcomes, and help the decision, reducing neurological deficits, aiming to preserve functional networks, using the concepts of white matters localization and fibbers connections. Nowadays, there are new techniques that provide functional information regarding the motor cortex, such as transcranial magnetic stimulation (TMS), direct cortical stimulation (DCS), and navigated TMS (nTMS). These tools can be used to plan a customized surgical strategy and the role of motor evoked potentials (MEPs) is well described during intra-operative, using intraoperative neuromonitoring. MEPs can help to localize primary motor areas and delineate the cut-off point of resection in real-time, using direct stimulation. In the post-operative, the MEP has increased your function as a predictive marker of permanent or transitory neurological lesion marker. METHODS Systematic review performed in MEDLINE via PUBMED, EMBASE, and SCOPUS databases regarding the post-operative assessment of MEP in patients with brain tumors. The search strategy included the following terms: (("Evoked Potentials, Motor"[Mesh]) AND "Neoplasms"[Mesh]) AND "Transcranial Magnetic Stimulation"[Mesh] AND "Brain Tumor"[Mesh]), the analysis followed the PRISMA guidelines for systematic reviews, the review spanned until 06/04/2021, inclusion criteria were studies presenting confirmed diagnosis of brain tumor (primary or metastatic), patients >18 y/o, using TMS, Navigated TMS, and/or Evoked Potentials as tools in preoperative planning or at the intra-operative helping the evaluation of the neurological status of the motor cortex, articles published in peer-reviewed journals, and written in English or Portuguese. RESULTS A total of 38 studies were selected for this review, of which 14 investigated the potential of nTMS to predict the occurrence of motor deficits, while 25 of the articles investigated the capabilities of the nTMS technique in performing pre/intraoperative neuro mapping of the motor cortex. CONCLUSION Further studies regarding motor function assessment are needed and standardized protocols for MEPs also need to be defined.
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Affiliation(s)
- Lucas Jose Vaz Schiavao
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil.,Neurology, Instituto do Câncer do Estado de São Paulo - ICESP, São Paulo, Brazil
| | - Iuri Neville Ribeiro
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil.,Neurology, Instituto do Câncer do Estado de São Paulo - ICESP, São Paulo, Brazil
| | - Cintya Yukie Hayashi
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | - Eberval Gadelha Figueiredo
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | - Andre Russowsky Brunoni
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | | | - Wellingson Silva Paiva
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
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Aaronson DM, Martinez Del Campo E, Boerger TF, Conway B, Cornell S, Tate M, Mueller WM, Chang EF, Krucoff MO. Understanding Variable Motor Responses to Direct Electrical Stimulation of the Human Motor Cortex During Brain Surgery. Front Surg 2021; 8:730367. [PMID: 34660677 PMCID: PMC8517489 DOI: 10.3389/fsurg.2021.730367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
Direct electrical stimulation of the brain is the gold standard technique used to define functional-anatomical relationships during neurosurgical procedures. Areas that respond to stimulation are considered “critical nodes” of circuits that must remain intact for the subject to maintain the ability to perform certain functions, like moving and speaking. Despite its routine use, the neurophysiology underlying downstream motor responses to electrical stimulation of the brain, such as muscle contraction or movement arrest, is poorly understood. Furthermore, varying and sometimes counterintuitive responses can be seen depending on how and where the stimulation is applied, even within the human primary motor cortex. Therefore, here we review relevant neuroanatomy of the human motor system, provide a brief historical perspective on electrical brain stimulation, explore mechanistic variations in stimulation applications, examine neurophysiological properties of different parts of the motor system, and suggest areas of future research that can promote a better understanding of the interaction between electrical stimulation of the brain and its function.
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Affiliation(s)
- Daniel M Aaronson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Timothy F Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Brian Conway
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Sarah Cornell
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Matthew Tate
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Wade M Mueller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Edward F Chang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, United States
| | - Max O Krucoff
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Biomedical Engineering, Marquette University, Milwaukee, WI, United States
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14
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You H, Qiao H. Intraoperative Neuromonitoring During Resection of Gliomas Involving Eloquent Areas. Front Neurol 2021; 12:658680. [PMID: 34248818 PMCID: PMC8260928 DOI: 10.3389/fneur.2021.658680] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/18/2021] [Indexed: 11/23/2022] Open
Abstract
In the case of resection of gliomas involving eloquent areas, equal consideration should be given to maintain maximal extent of resection (EOR) and neurological protection, for which the intraoperative neuromonitoring (IONM) proves an effective and admirable approach. IONM techniques applied in clinical practice currently consist of somatosensory evoked potential (SSEP), direct electrical stimulation (DES), motor evoked potential (MEP), electromyography (EMG), and electrocorticography (ECoG). The combined use of DES and ECoG has been adopted widely. With the development of technology, more effective IONM tactics and programs would be proposed. The ultimate goal would be strengthening the localization of eloquent areas and epilepsy foci, reducing the incidence of postoperative dysfunction and epilepsy improving the life quality of patients.
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Affiliation(s)
- Hao You
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Hui Qiao
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
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Impact of combined use of intraoperative MRI and awake microsurgical resection on patients with gliomas: a systematic review and meta-analysis. Neurosurg Rev 2021; 44:2977-2990. [PMID: 33537890 PMCID: PMC8592967 DOI: 10.1007/s10143-021-01488-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/29/2020] [Accepted: 01/25/2021] [Indexed: 10/29/2022]
Abstract
Microsurgical resection of primary brain tumors located within or near eloquent areas is challenging. Primary aim is to preserve neurological function, while maximizing the extent of resection (EOR), to optimize long-term neurooncological outcomes and quality of life. Here, we review the combined integration of awake craniotomy and intraoperative MRI (IoMRI) for primary brain tumors, due to their multiple challenges. A systematic review of the literature was performed, in accordance with the Prisma guidelines. Were included 13 series and a total number of 527 patients, who underwent 541 surgeries. We paid particular attention to operative time, rate of intraoperative seizures, rate of initial complete resection at the time of first IoMRI, the final complete gross total resection (GTR, complete radiological resection rates), and the immediate and definitive postoperative neurological complications. The mean duration of surgery was 6.3 h (median 7.05, range 3.8-7.9). The intraoperative seizure rate was 3.7% (range 1.4-6; I^2 = 0%, P heterogeneity = 0.569, standard error = 0.012, p = 0.002). The intraoperative complete resection rate at the time of first IoMRI was 35.2% (range 25.7-44.7; I^2 = 66.73%, P heterogeneity = 0.004, standard error = 0.048, p < 0.001). The rate of patients who underwent supplementary resection after one or several IoMRI was 46% (range 39.8-52.2; I^2 = 8.49%, P heterogeneity = 0.364, standard error = 0.032, p < 0.001). The GTR rate at discharge was 56.3% (range 47.5-65.1; I^2 = 60.19%, P heterogeneity = 0.01, standard error = 0.045, p < 0.001). The rate of immediate postoperative complications was 27.4% (range 15.2-39.6; I^2 = 92.62%, P heterogeneity < 0.001, standard error = 0.062, p < 0.001). The rate of permanent postoperative complications was 4.1% (range 1.3-6.9; I^2 = 38.52%, P heterogeneity = 0.123, standard error = 0.014, p = 0.004). Combined use of awake craniotomy and IoMRI can help in maximizing brain tumor resection in selected patients. The technical obstacles to doing so are not severe and can be managed by experienced neurosurgery and anesthesiology teams. The benefits of bringing these technologies to bear on patients with brain tumors in or near language areas are obvious. The lack of equipoise on this topic by experienced practitioners will make it difficult to do a prospective, randomized, clinical trial. In the opinion of the authors, such a trial would be unnecessary and would deprive some patients of the benefits of the best available methods for their tumor resections.
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16
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Surgical Paradigms in Diffuse Low-grade Glioma: Insular Glioma Case Illustration. Can J Neurol Sci 2021. [DOI: 10.1017/cjn.2021.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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17
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Obara T, Blonski M, Brzenczek C, Mézières S, Gaudeau Y, Pouget C, Gauchotte G, Verger A, Vogin G, Moureaux JM, Duffau H, Rech F, Taillandier L. Adult Diffuse Low-Grade Gliomas: 35-Year Experience at the Nancy France Neurooncology Unit. Front Oncol 2020; 10:574679. [PMID: 33194684 PMCID: PMC7656991 DOI: 10.3389/fonc.2020.574679] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/20/2020] [Indexed: 01/14/2023] Open
Abstract
Background To report survival, spontaneous prognostic factors, and treatment efficacy in a French monocentric cohort of diffuse low-grade glioma (DLGG) patients over 35 years of follow-up. Methods A monocentric retrospective study of 339 patients diagnosed with a new DLGG between 01/01/1982 and 01/01/2017 was created. Inclusion criteria were patient age ≥18 years at diagnosis and histological diagnosis of WHO grade II glioma (according to 1993, 2007, and 2016 WHO classifications). The survival parameters were estimated using the Kaplan-Meier method with a 95% confidence interval. Differences in survival were tested for statistical significance by the log-rank test. Factors were considered significant when p ≤ 0.1 and p ≤ 0.05 in the univariate and multivariate analyses, respectively. Results A total of 339 patients were included with a median follow-up of 8.7 years. The Kaplan-Meier median overall survival was 15.7 years. At the time of radiological diagnosis, Karnofsky Performance Status score and initial tumor volume were significant independent prognostic factors. Oncological prognostic factors were the extent of resection for patients who underwent surgery and the timing of radiotherapy for those concerned. In this study, patients who had delayed radiotherapy (provided remaining low grade) did not have worse survival compared with patients who had early radiotherapy. The functional capabilities of the patients were preserved enough so that they could remain independent during at least three quarters of the follow-up. Conclusion This large monocentric series spread over a long time clarifies the effects of different therapeutic strategies and their combination in the management of DLGG.
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Affiliation(s)
- Tiphaine Obara
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France.,Neurology Departement, Neurooncology Unit, CHRU, Nancy, France
| | - Marie Blonski
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France.,Neurology Departement, Neurooncology Unit, CHRU, Nancy, France
| | - Cyril Brzenczek
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Sophie Mézières
- Department of Mathematics, Elie Cartan Institute, Nancy, France.,INRIA Biology, Genetics and Statistics, Nancy, France
| | - Yann Gaudeau
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Celso Pouget
- Department of Pathology, CHRU, Nancy, France.,Centre de Ressources Biologiques, BB-0033-00035, CHRU Nancy, France
| | - Guillaume Gauchotte
- Department of Pathology, CHRU, Nancy, France.,Centre de Ressources Biologiques, BB-0033-00035, CHRU Nancy, France
| | - Antoine Verger
- Department of Nuclear Medicine and Nancyclotep Imaging Platform, CHRU Nancy, France.,IADI, INSERM U1254, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Guillaume Vogin
- UMR 7365 CNRS, IMoPA Biopole Lorraine University Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France.,Department of Radiation Therapy, Baclese Radiation Therapy Centre, Esch/Alzette, Luxembourg
| | - Jean-Marie Moureaux
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Hugues Duffau
- Department of Neurosurgery, Montpellier University Medical Center, Gui de Chauliac Hospital, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", U1051 Laboratory, National Institute for Health and Medical Research (INSERM), Institute for Neurosciences of Montpellier, Montpellier University Medical Center, Montpellier, France
| | - Fabien Rech
- Department of Neurosurgery, CHRU, Nancy, France
| | - Luc Taillandier
- Centre de Recherche en Automatique Nancy France - UMR 7039 - BioSiS Department, Faculty of Medicine, Université de Lorraine, Vandoeuvre-lès-Nancy, France.,Neurology Departement, Neurooncology Unit, CHRU, Nancy, France
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18
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Development status and application of neuronavigation system. JOURNAL OF COMPLEXITY IN HEALTH SCIENCES 2020. [DOI: 10.21595/chs.2020.21260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Garton ALA, Kinslow CJ, Rae AI, Mehta A, Pannullo SC, Magge RS, Ramakrishna R, McKhann GM, Sisti MB, Bruce JN, Canoll P, Cheng SK, Sonabend AM, Wang TJC. Extent of resection, molecular signature, and survival in 1p19q-codeleted gliomas. J Neurosurg 2020; 134:1357-1367. [PMID: 32384274 DOI: 10.3171/2020.2.jns192767] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Genomic analysis in neurooncology has underscored the importance of understanding the patterns of survival in different molecular subtypes within gliomas and their responses to treatment. In particular, diffuse gliomas are now principally characterized by their mutation status (IDH1 and 1p/19q codeletion), yet there remains a paucity of information regarding the prognostic value of molecular markers and extent of resection (EOR) on survival. Furthermore, given the modern emphasis on molecular rather than histological diagnosis, it is important to examine the effect of maximal resection on survival in all gliomas with 1p/q19 codeletions, as these will now be classified as oligodendrogliomas under the new WHO guidelines. The objectives of the present study were twofold: 1) to assess the association between EOR and survival for patients with oligodendrogliomas in the National Cancer Database (NCDB), which includes information on mutation status, and 2) to demonstrate the same effect for all patients with 1p/19q codeleted gliomas in the NCDB. METHODS The NCDB was queried for all cases of oligodendroglioma between 2004 and 2014, with follow-up dates through 2016. The authors found 2514 cases of histologically confirmed oligodendrogliomas for the final analysis of the effect of EOR on survival. Upon further query, 1067 1p/19q-codeleted tumors were identified in the NCDB. Patients who received subtotal resection (STR) or gross-total resection (GTR) were compared to those who received no tumor debulking surgery. Univariable and multivariable analyses of both overall survival and cause-specific survival were performed. RESULTS EOR was associated with increased overall survival for both histologically confirmed oligodendrogliomas and all 1p/19q-codeleted-defined tumors (p < 0.001 and p = 0.002, respectively). Tumor grade, location, and size covaried predictably with EOR. When evaluating tumors by each classification system for predictors of overall survival, facility setting, age, comorbidity index, grade, location, chemotherapy, and radiation therapy were all shown to be significantly associated with overall survival. STR and GTR were independent predictors of improved survival in historically classified oligodendrogliomas (HR 0.83, p = 0.18; HR 0.69, p = 0.01, respectively) and in 1p/19q-codeleted tumors (HR 0.49, p < 0.01; HR 0.43, p < 0.01, respectively). CONCLUSIONS By using the NCDB, the authors have demonstrated a side-by-side comparison of the survival benefits of greater EOR in 1p/19q-codeleted gliomas.
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Affiliation(s)
- Andrew L A Garton
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center
| | - Connor J Kinslow
- 2Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Ali I Rae
- 3Department of Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon
| | - Amol Mehta
- 4Department of Neurology, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center
| | - Susan C Pannullo
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center
| | - Rajiv S Magge
- 5Department of Radiation Oncology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center
| | - Rohan Ramakrishna
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center
| | - Guy M McKhann
- 6Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center
| | - Michael B Sisti
- 6Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center
| | - Jeffrey N Bruce
- 6Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center
| | - Peter Canoll
- 7Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center.,8Departments of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center
| | - Simon K Cheng
- 2Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York.,9Department of Epidemiology, Mailman School of Public Health, and Department of Medicine, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York; and
| | - Adam M Sonabend
- 10Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tony J C Wang
- 2Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York.,7Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center
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Navarro-Main B, Jiménez-Roldán L, González Leon P, Castaño-León AM, Lagares A, Pérez-Nuñez Á. Neuropsychological management of the awake patient surgery: A protocol based on 3-year experience with glial tumors. Neurocirugia (Astur) 2020; 31:279-288. [PMID: 32317143 DOI: 10.1016/j.neucir.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/12/2020] [Accepted: 02/15/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Glial brain tumours usually require neurosurgical treatment and they are associated with cognitive, emotional and behavioural impairments. Awake intraoperative brain mapping is the gold standard technique used to optimize the onco-functional balance. Neuropsychological assessment and intervention have relevance in this type of procedures. Currently, there is a lack of protocolled structure for the neuropsychological intervention being able to satisfy patient needs. METHOD A retrospective descriptive study of 52 patients was performed, all of them with a diagnosis of glial tumour. The structure of the protocol developed in our centre is reported, also data of neuropsychological evaluation, comparing baseline performance with both immediate posterior performance, and long term performance. RESULTS We describe our experience in each step of the intervention, highlighting the development of eight neurocognitive protocols for intraoperative brain mapping. The results of the neuropsychological examination objectify deficits in the immediate after surgery assessment which are reduced in the long-term assessment. CONCLUSIONS We emphasize the need of providing and structuring the cognitive and emotional aspects of patients suffering from any pathology that entails acquired brain damage in hospital environment. This type of approach is aimed at increasing the quality of life of cancer patients by structuring and optimizing tasks during their surgical intervention and attending to the neuropsychological difficulties they suffer.
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Affiliation(s)
- Blanca Navarro-Main
- Servicio de Neurocirugía, Hospital 12 de Octubre, Madrid, España; Instituto de Investigación Biomédica i+12, Madrid, España; Departamento de Psicología Básica II, Facultad de Psicología UNED, Madrid, España.
| | - Luis Jiménez-Roldán
- Servicio de Neurocirugía, Hospital 12 de Octubre, Madrid, España; Instituto de Investigación Biomédica i+12, Madrid, España; Departamento de Cirugía, Facultad de Medicina UCM, Madrid, España
| | - Pedro González Leon
- Servicio de Neurocirugía, Hospital 12 de Octubre, Madrid, España; Instituto de Investigación Biomédica i+12, Madrid, España; Departamento de Cirugía, Facultad de Medicina UCM, Madrid, España
| | - Ana M Castaño-León
- Servicio de Neurocirugía, Hospital 12 de Octubre, Madrid, España; Instituto de Investigación Biomédica i+12, Madrid, España; Departamento de Cirugía, Facultad de Medicina UCM, Madrid, España
| | - Alfonso Lagares
- Servicio de Neurocirugía, Hospital 12 de Octubre, Madrid, España; Instituto de Investigación Biomédica i+12, Madrid, España; Departamento de Cirugía, Facultad de Medicina UCM, Madrid, España
| | - Ángel Pérez-Nuñez
- Servicio de Neurocirugía, Hospital 12 de Octubre, Madrid, España; Instituto de Investigación Biomédica i+12, Madrid, España; Departamento de Cirugía, Facultad de Medicina UCM, Madrid, España
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Rigolo L, Essayed WI, Tie Y, Norton I, Mukundan S, Golby A. Intraoperative Use of Functional MRI for Surgical Decision Making after Limited or Infeasible Electrocortical Stimulation Mapping. J Neuroimaging 2019; 30:184-191. [PMID: 31867823 DOI: 10.1111/jon.12683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/09/2019] [Accepted: 11/11/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Functional magnetic resonance imaging (fMRI) is becoming widely recognized as a key component of preoperative neurosurgical planning, although intraoperative electrocortical stimulation (ECS) is considered the gold standard surgical brain mapping method. However, acquiring and interpreting ECS results can sometimes be challenging. This retrospective study assesses whether intraoperative availability of fMRI impacted surgical decision-making when ECS was problematic or unobtainable. METHODS Records were reviewed for 191 patients who underwent presurgical fMRI with fMRI loaded into the neuronavigation system. Four patients were excluded as a bur-hole biopsy was performed. Imaging was acquired at 3 Tesla and analyzed using the general linear model with significantly activated pixels determined via individually determined thresholds. fMRI maps were displayed intraoperatively via commercial neuronavigation systems. RESULTS Seventy-one cases were planned ECS; however, 18 (25.35%) of these procedures were either not attempted or aborted/limited due to: seizure (10), patient difficulty cooperating with the ECS mapping (4), scarring/limited dural opening (3), or dural bleeding (1). In all aborted/limited ECS cases, the surgeon continued surgery using fMRI to guide surgical decision-making. There was no significant difference in the incidence of postoperative deficits between cases with completed ECS and those with limited/aborted ECS. CONCLUSIONS Preoperative fMRI allowed for continuation of surgery in over one-fourth of patients in which planned ECS was incomplete or impossible, without a significantly different incidence of postoperative deficits compared to the patients with completed ECS. This demonstrates additional value of fMRI beyond presurgical planning, as fMRI data served as a backup method to ECS.
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Affiliation(s)
- Laura Rigolo
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Walid Ibn Essayed
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yanmei Tie
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Isaiah Norton
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Srinivasan Mukundan
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alexandra Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Stimulation-related intraoperative seizures during awake surgery: a review of available evidences. Neurosurg Rev 2019; 43:87-93. [PMID: 31797239 DOI: 10.1007/s10143-019-01214-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/08/2019] [Accepted: 11/13/2019] [Indexed: 01/01/2023]
Abstract
Awake surgery is a well-defined procedure with a very low morbidity. In particular, stimulation-related intraoperative seizure (IOS) is a commonly discussed and serious complication associated with awake surgery. Here, we reviewed the literature on awake surgery and IOS and sought to obtain evidences on the predictive factors of IOS and on the effect of IOS on postoperative outcomes. We conducted a comprehensive search of the Embase, MEDLINE, and Cochrane Central Register of Controlled Trials databases to identify potentially relevant articles from 2000 to 2019. We used combinations of the following search terms: "intraoperative seizure awake craniotomy," "awake surgery seizures," and pertinent associations; the search was restricted to publications in English and only to papers published in the last 20 years. The search returned 141 articles, including 39 papers that reported the IOS rate during awake craniotomy. The reported IOS rates ranged between 0 and 24% (mean, 7.7%). Only few studies have assessed the relationships between awake surgery and IOS, and hence, drawing clear conclusions is difficult. Nevertheless, IOS does not cause permanent and severe postoperative deficits, but can affect the patient's status perioperatively and the hospitalization duration. Anterior tumor location is an important perioperative factor associated with high IOS risk, whereas having seizures at tumor diagnosis does not seem to influence. However, the role of antiepileptic drug administration and prophylaxis remains unclear. In conclusion, given the difficulty in identifying predictors of IOS, we believe that prompt action at onset and awareness of appropriate management methods are vital.
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Kavouridis VK, Boaro A, Dorr J, Cho EY, Iorgulescu JB, Reardon DA, Arnaout O, Smith TR. Contemporary assessment of extent of resection in molecularly defined categories of diffuse low-grade glioma: a volumetric analysis. J Neurosurg 2019; 133:1291-1301. [PMID: 31653812 PMCID: PMC7348099 DOI: 10.3171/2019.6.jns19972] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 06/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While the effect of increased extent of resection (EOR) on survival in diffuse infiltrating low-grade glioma (LGG) patients is well established, there is still uncertainty about the influence of the new WHO molecular subtypes. The authors designed a retrospective analysis to assess the interplay between EOR and molecular classes. METHODS The authors retrospectively reviewed the records of 326 patients treated surgically for hemispheric WHO grade II LGG at Brigham and Women's Hospital and Massachusetts General Hospital (2000-2017). EOR was calculated volumetrically and Cox proportional hazards models were built to assess for predictive factors of overall survival (OS), progression-free survival (PFS), and malignant progression-free survival (MPFS). RESULTS There were 43 deaths (13.2%; median follow-up 5.4 years) among 326 LGG patients. Median preoperative tumor volume was 31.2 cm3 (IQR 12.9-66.0), and median postoperative residual tumor volume was 5.8 cm3 (IQR 1.1-20.5). On multivariable Cox regression, increasing postoperative volume was associated with worse OS (HR 1.02 per cm3; 95% CI 1.00-1.03; p = 0.016), PFS (HR 1.01 per cm3; 95% CI 1.00-1.02; p = 0.001), and MPFS (HR 1.01 per cm3; 95% CI 1.00-1.02; p = 0.035). This result was more pronounced in the worse prognosis subtypes of IDH-mutant and IDH-wildtype astrocytoma, for which differences in survival manifested in cases with residual tumor volume of only 1 cm3. In oligodendroglioma patients, postoperative residuals impacted survival when exceeding 8 cm3. Other significant predictors of OS were age at diagnosis, IDH-mutant and IDH-wildtype astrocytoma classes, adjuvant radiotherapy, and increasing preoperative volume. CONCLUSIONS The results corroborate the role of EOR in survival and malignant transformation across all molecular subtypes of diffuse LGG. IDH-mutant and IDH-wildtype astrocytomas are affected even by minimal postoperative residuals and patients could potentially benefit from a more aggressive surgical approach.
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Affiliation(s)
- Vasileios K. Kavouridis
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Alessandro Boaro
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jeffrey Dorr
- Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elise Y. Cho
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - J. Bryan Iorgulescu
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David A. Reardon
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Omar Arnaout
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Timothy R. Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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24
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Zhu P, Du XL, Blanco AI, Ballester LY, Tandon N, Berger MS, Zhu JJ, Esquenazi Y. Impact of facility type and volume in low-grade glioma outcomes. J Neurosurg 2019; 133:1313-1323. [PMID: 31561219 DOI: 10.3171/2019.6.jns19409] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The object of this study was to investigate the impact of facility type (academic center [AC] vs non-AC) and facility volume (high-volume facility [HVF] vs low-volume facility [LVF]) on low-grade glioma (LGG) outcomes. METHODS This retrospective cohort study included 5539 LGG patients (2004-2014) from the National Cancer Database. Patients were categorized by facility type and volume (non-AC vs AC, HVF vs LVF). An HVF was defined as the top 1% of facilities according to the number of annual cases. Outcomes included overall survival, treatment receipt, and postoperative outcomes. Kaplan-Meier and Cox proportional-hazards models were applied. The Heller explained relative risk was computed to assess the relative importance of each survival predictor. RESULTS Significant survival advantages were observed at HVFs (HR 0.67, 95% CI 0.55-0.82, p < 0.001) and ACs (HR 0.84, 95% CI 0.73-0.97, p = 0.015), both prior to and after adjusting for all covariates. Tumor resection was 41% and 26% more likely to be performed at HVFs vs LVFs and ACs vs non-ACs, respectively. Chemotherapy was 40% and 88% more frequently to be utilized at HVFs vs LVFs and ACs vs non-ACs, respectively. Prolonged length of stay (LOS) was decreased by 42% and 24% at HVFs and ACs, respectively. After tumor histology, tumor pattern, and codeletion of 1p19q, facility type and surgical procedure were the most important contributors to survival variance. The main findings remained consistent using propensity score matching and multiple imputation. CONCLUSIONS This study provides evidence of survival benefits among LGG patients treated at HVFs and ACs. An increased likelihood of undergoing resections, receiving adjuvant therapies, having shorter LOSs, and the multidisciplinary environment typically found at ACs and HVFs are important contributors to the authors' finding.
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Affiliation(s)
- Ping Zhu
- 1Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston
- 2Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health
| | - Xianglin L Du
- 2Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health
| | - Angel I Blanco
- 1Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Leomar Y Ballester
- 3Department of Pathology and Laboratory Medicine, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Nitin Tandon
- 1Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Mitchel S Berger
- 4Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Jay-Jiguang Zhu
- 1Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Yoshua Esquenazi
- 1Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston
- 5Center for Precision Health, School of Biomedical Informatics, University of Texas Health Science Center at Houston, Texas; and
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25
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Muller L, Rolston JD, Fox NP, Knowlton R, Rao VR, Chang EF. Direct electrical stimulation of human cortex evokes high gamma activity that predicts conscious somatosensory perception. J Neural Eng 2019; 15:026015. [PMID: 29160232 DOI: 10.1088/1741-2552/aa9bf9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Direct electrical stimulation (DES) is a clinical gold standard for human brain mapping and readily evokes conscious percepts, yet the neurophysiological changes underlying these percepts are not well understood. APPROACH To determine the neural correlates of DES, we stimulated the somatosensory cortex of ten human participants at frequency-amplitude combinations that both elicited and failed to elicit conscious percepts, meanwhile recording neural activity directly surrounding the stimulation site. We then compared the neural activity of perceived trials to that of non-perceived trials. MAIN RESULTS We found that stimulation evokes distributed high gamma activity, which correlates with conscious perception better than stimulation parameters themselves. SIGNIFICANCE Our findings suggest that high gamma activity is a reliable biomarker for perception evoked by both natural and electrical stimuli.
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Affiliation(s)
- Leah Muller
- Department of Biological Engineering, University of California, San Francisco, San Francisco, CA, United States of America. Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, United States of America
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26
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Kinslow CJ, Garton ALA, Rae AI, Marcus LP, Adams CM, McKhann GM, Sisti MB, Connolly ES, Bruce JN, Neugut AI, Sonabend AM, Canoll P, Cheng SK, Wang TJC. Extent of resection and survival for oligodendroglioma: a U.S. population-based study. J Neurooncol 2019; 144:591-601. [PMID: 31407129 DOI: 10.1007/s11060-019-03261-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/03/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND National guidelines recommend maximal safe resection of low-grade and high-grade oligodendrogliomas. However, there is no level 1 evidence to support these guidelines, and recent retrospective studies on the topic have yielded mixed results. OBJECTIVE To assess the association between extent of resection (EOR) and survival for oligodendrogliomas in the general U.S. POPULATION METHODS Cases diagnosed between 2004 and 2013 were selected from the Surveillance, Epidemiology, and End-Results (SEER) Program and retrospectively analyzed for treatment, prognostic factors, and survival times. Cases that did not undergo tumor de-bulking surgery (e.g. no surgery or biopsy alone) were compared to subtotal resection (resection) and gross-total resection (GTR). The primary end-points were overall survival (OS) and cause-specific survival (CSS). An external validation cohort with 1p/19q-codeleted tumors was creating using the TCGA and GSE16011 datasets. RESULTS 3135 Cases were included in the final analysis. The 75% survival time (75ST) and 5-year survival rates were 47 months and 70.8%, respectively. Subtotal resection (STR, 75ST = 50 months) and GTR (75ST = 61 months) were associated with improved survival times compared to cases that did not undergo surgical debulking (75ST = 20 months, P < 0.001 for both), with reduced hazard ratios (HRs) after controlling for other factors (HR 0.81 [0.68-0.97] and HR 0.65 [0.54-0.79], respectively). GTR was associated with improved OS in both low-grade and anaplastic oligodendroglioma subgroups (HR 0.74 [0.58-0.95], HR 0.60 [0.44-0.82], respectively) while STR fell short of significance in the subgroup analysis. All findings were corroborated by multivariable analysis of CSS and externally validated in a cohort of patients with 1p19q-codeleted tumors. CONCLUSION Greater EOR is associated with improved survival in oligodendrogliomas. Our findings in this U.S. population-based cohort support national guidelines.
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Affiliation(s)
- Connor J Kinslow
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, BNH B011, New York, NY, 10032, USA
| | - Andrew L A Garton
- Department of Neurological Surgery, NewYork-Presbyterian Hospital / Weill Cornell Medical Center, 525 E 68th Street, New York, NY, 10065, USA
| | - Ali I Rae
- Department of Neurological Surgery, Oregon Health & Sciences University, 3181 SW Sam Jackson Pkwy, Portland, OR, 97239, USA
| | - Logan P Marcus
- Department of Radiation Oncology, Stanford University, 875 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Christopher M Adams
- Division of Biostatistics, New York State Psychiatric Institute, Columbia University Irving Medical Center, 722 West 168th Street, New York, NY, 10032, USA
| | - Guy M McKhann
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY, 10032, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA
| | - Michael B Sisti
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY, 10032, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY, 10032, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY, 10032, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA
| | - Alfred I Neugut
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA.,Department of Epidemiology, Mailman School of Public Health, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 722 West 168th St, New York, NY, 10032, USA
| | - Adam M Sonabend
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL, 60611, USA
| | - Peter Canoll
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA.,Departments of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St. Nicholas Ave Rm.1001, New York, NY, 10032, USA
| | - Simon K Cheng
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, BNH B011, New York, NY, 10032, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA
| | - Tony J C Wang
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, BNH B011, New York, NY, 10032, USA. .,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA.
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Khan KA, Jain SK, Sinha VD, Sinha J. Preoperative Diffusion Tensor Imaging: A Landmark Modality for Predicting the Outcome and Characterization of Supratentorial Intra-Axial Brain Tumors. World Neurosurg 2019; 124:e540-e551. [PMID: 30639605 DOI: 10.1016/j.wneu.2018.12.146] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE In view of the few large prospective studies available on the role of preoperative diffusion tensor imaging (DTI), and the potential of DTI in showing the relationship between tumor and white matter tracts, we studied the role of preoperative DTI in planning a safe surgical corridor, predicting the neurologic and surgical outcome and tumor characterization in supratentorial intra-axial brain tumors. METHODS We included 128 cases. Preoperative neurologic status and tumor volume were assessed. A magnetic resonance imaging (MRI)-based surgical plan was decided and reviewed for changes after DTI (site of corticotomy or limit of resection) by senior faculty of neurosurgery and neuroradiologist. Tracts were classified as displaced, infiltrated, or disrupted. Postoperative neurologic and surgical outcome was assessed along with evaluation of association of DTI with tumor type. RESULTS DTI-based change in surgical corridor was seen in 60 patients (47%). Sixty-six patients harbored low-grade gliomas, 48 had high-grade gliomas, and 14 had metastastic lesions. Resectability (maximum safe resection) was higher in patients with displaced fibers and lower in those with disrupted/infiltrated fibers, which was statistically significant. Fewer patients had neurologic deterioration in the displaced category (7.1%) compared with the disrupted/infiltrated category (13.9%). Although no significant association could be established between neurologic outcome and fiber type, displaced fibers were associated mainly with low-grade glioma (71%), whereas disrupted/infiltrated fibers were associated mainly with high-grade glioma (66%); this correlation was significant. CONCLUSIONS Preoperative DTI is a landmark tool for planning a safe surgical corridor and predicting the tumor type along with neurologic and surgical outcome of patients.
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Affiliation(s)
| | - Shashi Kant Jain
- Department of Neurosurgery, Sawai Maan Singh Medical College, Jaipur, India.
| | - Virendra Deo Sinha
- Department of Neurosurgery, Sawai Maan Singh Medical College, Jaipur, India
| | - Jyotsna Sinha
- Department of Radiology, Getwell Clinic, Jaipur, India
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van Ierschot F, Bastiaanse R, Miceli G. Evaluating Spelling in Glioma Patients Undergoing Awake Surgery: a Systematic Review. Neuropsychol Rev 2018; 28:470-495. [DOI: 10.1007/s11065-018-9391-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/07/2018] [Indexed: 01/20/2023]
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Conti Nibali M, Rossi M, Sciortino T, Riva M, Gay LG, Pessina F, Bello L. Preoperative surgical planning of glioma: limitations and reliability of fMRI and DTI tractography. J Neurosurg Sci 2018; 63:127-134. [PMID: 30290696 DOI: 10.23736/s0390-5616.18.04597-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Brain mapping techniques (intraoperative neurophysiology and neuropsychology) represent the gold standard in glioma surgery, and particularly in glioma resection. Since the introduction of MRI in the clinical practice, several advanced applications have been developed, like functional MRI (fMRI) and diffusion imaging-based tractography (DTI), which both have an application in glioma surgery. fMRI allows to identify cortical areas related to a specific function, DTI allows to reconstruct a model of the sub-cortical connectivity. This paper describes the clinical application of fMRI and DTI, enlightening sensitivity and specificity in comparison to gold standard and underlining their limitations in surgical decision making.
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Affiliation(s)
- Marco Conti Nibali
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy -
| | - Marco Rossi
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy
| | - Tommaso Sciortino
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy
| | - Marco Riva
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy
| | - Lorenzo G Gay
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy
| | - Federico Pessina
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Lorenzo Bello
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Humanitas Research Hospital, IRCCS, University of Milan, Milan, Italy
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Selective Inhibition of Volitional Hand Movements after Stimulation of the Dorsoposterior Parietal Cortex in Humans. Curr Biol 2018; 28:3303-3309.e3. [DOI: 10.1016/j.cub.2018.08.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 07/26/2018] [Accepted: 08/09/2018] [Indexed: 11/21/2022]
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Foster CH, Morone PJ, Cohen-Gadol A. Awake craniotomy in glioma surgery: is it necessary? J Neurosurg Sci 2018; 63:162-178. [PMID: 30259721 DOI: 10.23736/s0390-5616.18.04590-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The awake craniotomy has evolved from its humble beginnings in ancient cultures to become one of the most eloquent modern neurosurgical procedures. The development of intraoperative mapping techniques like direct electrostimulation of the cortex and subcortical white matter have further argued for its place in the neurosurgeon's armamentarium. Yet the suitability of the awake craniotomy with intraoperative functional mapping (ACWM) to optimize oncofunctional balance after peri-eloquent glioma resection continues to be a topic of active investigation as new methods of intraoperative monitoring and some unfavorable outcome data question its necessity. EVIDENCE ACQUISITION The neurosurgery and anesthesiology literatures were scoured for English-language studies that analyzed or reviewed the ACWM or its components as applied to glioma surgery via the PubMed, ClinicalKey, and OvidMEDLINE® databases or via direct online searches of journal archives. EVIDENCE SYNTHESIS Information on background, conceptualization, standard techniques, and outcomes of the ACWM were provided and compared. We parceled the procedure into its components and qualitatively described positive and negative outcome data for each. Findings were presented in the context of each study without attempt at quantitative analysis or reconciliation of heterogeneity between studies. Certain illustrative studies were highlighted throughout the review. Overarching conclusions were drawn based on level of evidence, expert opinion, and predominate concordance of data across studies in the literature. CONCLUSIONS Most investigators and studies agree that the ACWM is the best currently available approach to optimize oncofunctional balance in this difficult-to-treat patient population. This qualitative review synthesizes the most currently available data on the topic to provide contemporaneous insight into how and why the ACWM has become a favorite operation of neurosurgeons worldwide for the resection of gliomas from eloquent brain.
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Affiliation(s)
- Chase H Foster
- Department of Neurological Surgery, George Washington University Hospital, Washington D.C., USA -
| | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Aaron Cohen-Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
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Abstract
Object: The objective is to evaluate the role of diffusion tensor imaging (DTI) in intra-axial brain tumor cases (gliomas and metastasis). To preoperatively assess the integrity and location of white matter (WM) tracts and plan the surgical corridor to cause least damage to the WM tracts with minimum postoperative new neurological deficits. Materials and Methods: A total of 34 patients were included in this study. Pre-operative contrast-enhanced magnetic resonance imaging and DTI scans of the patients were taken into consideration. Pre- and post-operative neurological examinations were performed and the outcome was assessed. Results: Preoperative planning of surgical corridor and extent of resection were planned so that maximum possible resection could be achieved without disturbing the WM tracts. DTI indicated the involvement of fiber tracts. A total of 21 (61.7%) patients had a displacement of tracts only and they were not invaded by tumor. A total of 11 (32.3%) patients had an invasion of tracts by the tumor, whereas in 4 (11.7%) patients the tracts were disrupted. Postoperative neurologic examination revealed deterioration of motor power in 4 (11.7%) patients, deterioration of language function in 3 (8.82%) patients, and memory in one patient. Total resection was achieved in 11/18 (61.1%) patients who had displacement of fibers, whereas it was achieved in 5/16 (31.2%) patients when there was infiltration/disruption of tracts. Conclusion: DTI provides crucial information regarding the infiltration of the tract and their displaced course due to the tumor. This study indicates that it is a very important tool for the preoperative planning of surgery. The involvement of WM tracts is a strong predictor of the surgical outcome.
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Affiliation(s)
- Amitesh Dubey
- Department of Neurosurgery, SMS Medical College, Jaipur, Rajasthan, India
| | - Rashim Kataria
- Department of Neurosurgery, SMS Medical College, Jaipur, Rajasthan, India
| | - Virendra Deo Sinha
- Department of Neurosurgery, SMS Medical College, Jaipur, Rajasthan, India
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Opoku-Darko M, Lang ST, Artindale J, Cairncross JG, Sevick RJ, Kelly JJP. Surgical management of incidentally discovered diffusely infiltrating low-grade glioma. J Neurosurg 2017; 129:19-26. [PMID: 28984519 DOI: 10.3171/2017.3.jns17159] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Occasionally, diffusely infiltrating low-grade gliomas (LGGs) are identified as incidental findings in patients who have no signs or symptoms that can be ascribed to the tumors. The diagnosis of incidental, asymptomatic LGGs has become more frequent due to the vast increase in access to medical imaging technology. While management of these lesions remains controversial, early surgery has been suggested to improve outcome. The authors set out to identify and review the characteristics and surgical outcomes of patients who underwent surgical intervention for incidental LGG. METHODS All cases of LGG surgically treated between 2004 and 2016 at the authors' institution were analyzed to identify those that were discovered incidentally. Patients with incidentally discovered LGGs were identified, and their cases were retrospectively reviewed. An "incidental" finding was defined as an abnormality on imaging that was obtained for a reason not attributable to the glioma, such as trauma, headache, screening, or research participation. Kaplan-Meier analysis was performed to determine actuarial rates of overall survival, progression-free survival, and malignant progression-free survival. RESULTS In 34 (6.8%) of 501 adult patients who underwent surgery for LGG, the tumors were discovered incidentally. Headache (26%, n = 9) and screening (21%, n = 7) were the most common indications for brain imaging in this group. Four of these 34 patients had initial biopsy after the tumor was identified on imaging. In 5 cases, the patients opted for immediate resection; the remaining cases were managed with a "watch-and-wait" approach, with intervention undertaken only after radiological or clinical evidence of disease progression. The mean duration of follow-up for all 34 cases was 5 years. Twelve patients (35.3%) had disease progression, with an average time to progression of 43.8 months (range 3-105 months). There were 5 cases (14.7%) of malignant progression and 4 deaths (11.8%). Oligodendroglioma was diagnosed in 16 cases (47%) and astrocytoma in 15 (44%). Twenty-five patients (74%) had IDH1 mutation and demonstrated prolonged survival. Only 2 patients had mild surgery-related complications, and 16 patients (47%) developed epilepsy during the course of the disease. CONCLUSIONS In this retrospective analysis of cases of incidentally discovered LGGs, the tumors were surgically removed with minimal surgical risk. In patients with incidental LGGs there is improved overall survival relative to median survival for patients with symptomatic LGGS, which is likely attributable to the underlying favorable biology of the disease indicated by the presence of IDH1 mutation in 74% of the cases.
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Affiliation(s)
| | | | | | - J Gregory Cairncross
- 2The Arne Charbonneau Cancer Institute, and.,Departments of3Clinical Neurosciences and
| | | | - John J P Kelly
- 1Division of Neurosurgery.,2The Arne Charbonneau Cancer Institute, and
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Successful Insular Glioma Removal in a Deaf Signer Patient During an Awake Craniotomy Procedure. World Neurosurg 2017; 98:883.e1-883.e5. [DOI: 10.1016/j.wneu.2016.08.098] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 08/20/2016] [Accepted: 08/23/2016] [Indexed: 11/20/2022]
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Ghinda CD, Duffau H. Network Plasticity and Intraoperative Mapping for Personalized Multimodal Management of Diffuse Low-Grade Gliomas. Front Surg 2017; 4:3. [PMID: 28197403 PMCID: PMC5281570 DOI: 10.3389/fsurg.2017.00003] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 01/16/2017] [Indexed: 01/07/2023] Open
Abstract
Gliomas are the most frequent primary brain tumors and include a variety of different histological tumor types and malignancy grades. Recent achievements in terms of molecular and imaging fields have created an unprecedented opportunity to perform a comprehensive interdisciplinary assessment of the glioma pathophysiology, with direct implications in terms of the medical and surgical treatment strategies available for patients. The current paradigm shift considers glioma management in a comprehensive perspective that takes into account the intricate connectivity of the cerebral networks. This allowed significant improvement in the outcome of patients with lesions previously considered inoperable. The current review summarizes the current theoretical framework integrating the adult human brain plasticity and functional reorganization within a dynamic individualized treatment strategy for patients affected by diffuse low-grade gliomas. The concept of neuro-oncology as a brain network surgery has major implications in terms of the clinical management and ensuing outcomes, as indexed by the increased survival and quality of life of patients managed using such an approach.
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Affiliation(s)
- Cristina Diana Ghinda
- Department of Neurosurgery, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Neuroscience Division, University of Ottawa, Ottawa, ON, Canada
| | - Hugues Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France; Brain Plasticity, Stem Cells and Glial Tumors Team, National Institute for Health and Medical Research (INSERM), Montpellier, France
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D'Andrea G, Trillo' G, Picotti V, Raco A. Functional Magnetic Resonance Imaging (fMRI), Pre-intraoperative Tractography in Neurosurgery: The Experience of Sant' Andrea Rome University Hospital. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 124:241-250. [PMID: 28120080 DOI: 10.1007/978-3-319-39546-3_36] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND The goal of neurosurgery for cerebral intraparenchymal neoplasms of the eloquent areas is maximal resection with the preservation of normal functions, and minimizing operative risk and postoperative morbidity. Currently, modern technological advances in neuroradiological tools, neuronavigation, and intraoperative magnetic resonance imaging (MRI) have produced great improvements in postoperative morbidity after the surgery of cerebral eloquent areas. The integration of preoperative functional MRI (fMRI), intraoperative MRI (volumetric and diffusion tensor imaging [DTI]), and neuronavigation, defined as "functional neuronavigation" has improved the intraoperative detection of the eloquent areas. METHODS We reviewed 142 patients operated between 2004 and 2010 for intraparenchymal neoplasms involving or close to one or more major white matter tracts (corticospinal tract [CST], arcuate fasciculus [AF], optic radiation). All the patients underwent neurosurgery in a BrainSUITE equipped with a 1.5 T MR scanner and were preoperatively studied with fMRI and DTI for tractography for surgical planning. The patients underwent MRI and DTI during surgery after dural opening, after the gross total resection close to the white matter tracts, and at the end of the procedure. We evaluated the impact of fMRI on surgical planning and on the selection of the entry point on the cortical surface. We also evaluated the impact of preoperative and intraoperative DTI, in order to modify the surgical approach, to define the borders of resection, and to correlate this modality with subcortical neurophysiological monitoring. We evaluated the impact of the preoperative fMRI by intraoperative neurophysiological monitoring, performing "neuronavigational" brain mapping, following its data to localize the previously elicited areas after brain shift correction by intraoperative MRI. RESULTS The mean age of the 142 patients (89 M/53 F) was 59.1 years and the lesion involved the CST in 66 patients (57 %), the language pathways in 24 (21 %), and the optic radiations in 25 (22 %). The integration of tractographic data into the volumetric dataset for neuronavigation was technically possible in all cases. In all patients intraoperative DTI demonstrated a shift of the bundle position caused by the surgical procedure; its dislocation was both outward and inward in the range of +6 mm and -2 mm. CONCLUSION We found a high concordance between fMRI/DTI and intraoperative brain mapping; their combination improves the sensitivity of each technique, reducing pitfalls and so defining "functional neuronavigation", increasing the definition of eloquent areas and also reducing the time of surgery.
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Affiliation(s)
- Giancarlo D'Andrea
- Institute of Neurosurgery, S Andrea Hospital, University of Rome "La Sapienza", V. L. Mantegazza 8, 00152, Rome, Italy.
| | - Giuseppe Trillo'
- Institute of Neurosurgery, S Andrea Hospital, University of Rome "La Sapienza", V. L. Mantegazza 8, 00152, Rome, Italy
| | - Veronica Picotti
- Institute of Neurosurgery, S Andrea Hospital, University of Rome "La Sapienza", V. L. Mantegazza 8, 00152, Rome, Italy
| | - Antonino Raco
- Institute of Neurosurgery, S Andrea Hospital, University of Rome "La Sapienza", V. L. Mantegazza 8, 00152, Rome, Italy
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Chang EF, Breshears JD, Raygor KP, Lau D, Molinaro AM, Berger MS. Stereotactic probability and variability of speech arrest and anomia sites during stimulation mapping of the language dominant hemisphere. J Neurosurg 2017; 126:114-121. [DOI: 10.3171/2015.10.jns151087] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Functional mapping using direct cortical stimulation is the gold standard for the prevention of postoperative morbidity during resective surgery in dominant-hemisphere perisylvian regions. Its role is necessitated by the significant interindividual variability that has been observed for essential language sites. The aim in this study was to determine the statistical probability distribution of eliciting aphasic errors for any given stereotactically based cortical position in a patient cohort and to quantify the variability at each cortical site.
METHODS
Patients undergoing awake craniotomy for dominant-hemisphere primary brain tumor resection between 1999 and 2014 at the authors' institution were included in this study, which included counting and picture-naming tasks during dense speech mapping via cortical stimulation. Positive and negative stimulation sites were collected using an intraoperative frameless stereotactic neuronavigation system and were converted to Montreal Neurological Institute coordinates. Data were iteratively resampled to create mean and standard deviation probability maps for speech arrest and anomia. Patients were divided into groups with a “classic” or an “atypical” location of speech function, based on the resultant probability maps. Patient and clinical factors were then assessed for their association with an atypical location of speech sites by univariate and multivariate analysis.
RESULTS
Across 102 patients undergoing speech mapping, the overall probabilities of speech arrest and anomia were 0.51 and 0.33, respectively. Speech arrest was most likely to occur with stimulation of the posterior inferior frontal gyrus (maximum probability from individual bin = 0.025), and variance was highest in the dorsal premotor cortex and the posterior superior temporal gyrus. In contrast, stimulation within the posterior perisylvian cortex resulted in the maximum mean probability of anomia (maximum probability = 0.012), with large variance in the regions surrounding the posterior superior temporal gyrus, including the posterior middle temporal, angular, and supramarginal gyri. Patients with atypical speech localization were far more likely to have tumors in canonical Broca's or Wernicke's areas (OR 7.21, 95% CI 1.67–31.09, p < 0.01) or to have multilobar tumors (OR 12.58, 95% CI 2.22–71.42, p < 0.01), than were patients with classic speech localization.
CONCLUSIONS
This study provides statistical probability distribution maps for aphasic errors during cortical stimulation mapping in a patient cohort. Thus, the authors provide an expected probability of inducing speech arrest and anomia from specific 10-mm2 cortical bins in an individual patient. In addition, they highlight key regions of interindividual mapping variability that should be considered preoperatively. They believe these results will aid surgeons in their preoperative planning of eloquent cortex resection.
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Affiliation(s)
- Edward F. Chang
- Departments of 1Neurological Surgery,
- 2Physiology, and
- 3Center for Integrative Neuroscience, University of California, San Francisco; and
- 4Center for Neural Engineering and Prostheses, University of California, Berkeley, and University of California, San Francisco, California
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Ghinda D, Zhang N, Lu J, Yao CJ, Yuan S, Wu JS. Contribution of combined intraoperative electrophysiological investigation with 3-T intraoperative MRI for awake cerebral glioma surgery: comprehensive review of the clinical implications and radiological outcomes. Neurosurg Focus 2016; 40:E14. [PMID: 26926054 DOI: 10.3171/2015.12.focus15572] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE This study aimed to assess the clinical efficiency of combined awake craniotomy with 3-T intraoperative MRI (iMRI)-guided resection of gliomas adjacent to eloquent cortex performed at a single center. It also sought to explore the contribution of iMRI to surgeons' learning process of maximal safe resection of gliomas. METHODS All patients who underwent an awake craniotomy and iMRI for resection of eloquent area glioma during the 53 months between January 2011 and June 2015 were included. The cases were analyzed for short- and long-term neurological outcome, progression-free survival (PFS), overall survival (OS), and extent of resection (EOR). The learning curve was assessed after dividing the cohort into Group A (first 27 months) and Group B (last 26 months). Statistical analyses included univariate logistic regression analysis on clinical and radiological variables. Kaplan-Meier and Cox regression models were used for further analysis of OS and PFS. A p value < 0.05 was considered statistically significant. RESULTS One hundred six patients were included in the study. Over an average follow-up period of 24.8 months, short- and long-term worsening of the neurological function was noted in 48 (46.2%) and 9 (8.7%) cases, respectively. The median and mean EOR were 100% and 92%, respectively, and complete radiographic resection was achieved in 64 (60.4%) patients. The rate of gross-total resection (GTR) in the patients with low-grade glioma (89.06% ± 19.6%) was significantly lower than that in patients with high-grade glioma (96.4% ± 9.1%) (p = 0.026). Thirty (28.3%) patients underwent further resection after initial iMRI scanning, with a 10.1% increase of the mean EOR. Multivariate Cox proportional hazards modeling demonstrated that the final EOR was a significant predictor of PFS (HR 0.225, 95% CI 0.070-0.723, p = 0.012). For patients with high-grade glioma, the GTR (p = 0.033), the presence of short-term motor deficit (p = 0.027), and the WHO grade (p = 0.005) were independent prognostic factors of OS. Performing further resection after the iMRI (p = 0.083) and achieving GTR (p = 0.05) demonstrated a PFS benefit trend for the patients affected by a low-grade glioma. Over time, the rate of performing further resection after an iMRI decreased by 26.1% (p = 0.005). A nonsignificant decrease in the rate of short-term (p = 0.101) and long-term (p = 0.132) neurological deficits was equally noted. CONCLUSIONS Combined awake craniotomy and iMRI is a safe and efficient technique allowing maximal safe resection of eloquent area gliomas with possible subsequent OS and PFS benefits. Although there is a learning curve for applying this technique, it can also improve the surgeon's ability in eloquent glioma surgery.
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Affiliation(s)
- Diana Ghinda
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; and.,Department of Neurosurgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Nan Zhang
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; and
| | - Junfeng Lu
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; and
| | - Cheng-Jun Yao
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; and
| | - Shiwen Yuan
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; and
| | - Jin-Song Wu
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; and
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Ius T, Turella L, Pauletto G, Isola M, Maieron M, Sciacca G, Budai R, D'Agostini S, Eleopra R, Skrap M. Quantitative Diffusion Tensor Imaging Analysis of Low-Grade Gliomas: From Preclinical Application to Patient Care. World Neurosurg 2016; 97:333-343. [PMID: 27744082 DOI: 10.1016/j.wneu.2016.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/29/2016] [Accepted: 10/01/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Preoperative diffusion tensor tractography (DTT) has recently been used to aid in the mapping of functional pathways to limit damage associated with resection of low-grade gliomas (LGGs). OBJECTIVE To assess the predictive capacity of DTT as a biomarker of postoperative motor outcomes in patients with LGGs involving the corticospinal tract (CST). CST parameters obtained using a quantitative fiber tracking approach were used to investigate the reliability of the DTT biomarker by comparing their values in the tumoral (Tcst) and healthy (Hcst) hemispheres. METHODS Thirty-seven patients with LGGs involving the CST were enrolled. Quantification of structural differences between the Tcst and Hcst were analyzed according to the novel biomarker (NF index), defined as follows: (Hcst NF - Tcst NF)/Hcst NF, where NF represents the number of fibers in each region. Logistic regression analysis was used to examine associations among clinical postoperative outcomes and NF index values, tumoral patterns, and premotor/motor evoked potentials. RESULTS NF values significantly differed between the Tcst and Hcst. Analysis of the NF index showed that patients with a preoperative NF index <0.22 had a significantly lower risk of developing transient postoperative deficits (area under the curve, 0.92; 95% binomial confidence interval, 0.834-1). Patients with less pronounced differences in NF between the Tcst and Hcst also experienced better clinical outcomes. CONCLUSIONS The NF index may be a useful biomarker for predicting clinical outcomes in patients with LGGs. Furthermore, the NF index may provide a preoperative estimate of the patient's potential for recovery from possible postsurgical neurologic deficits.
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Affiliation(s)
- Tamara Ius
- Department of Neurosurgery, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy.
| | - Luca Turella
- CIMeC - Center for Mind/Brain Sciences, University of Trento, Trento, Italy
| | - Giada Pauletto
- Department of Neurology, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy
| | - Miriam Isola
- Department of Medical and Biological Sciences, Section of Statistics, University of Udine, Udine, Italy
| | - Marta Maieron
- Department of Physics, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy
| | - Giovanni Sciacca
- Department of Neurosurgery, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy
| | - Riccardo Budai
- Department of Neurology, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy
| | - Serena D'Agostini
- Department of Neuroradiology, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy
| | - Roberto Eleopra
- Department of Neurology, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy
| | - Miran Skrap
- Department of Neurosurgery, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy
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Clinical considerations and surgical approaches for low-grade gliomas in deep hemispheric locations: insular lesions. Childs Nerv Syst 2016; 32:1875-93. [PMID: 27659830 DOI: 10.1007/s00381-016-3183-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 07/06/2016] [Indexed: 12/31/2022]
Abstract
Insula and paralimbic region represent a common location for gliomas in adulthood. However, limbic and paralimbic tumors are rare in children. Reports of pediatric insular tumors are scarce in literature, and most of them are included in adult's series, so their management and outcome can be outlined only after extracting data from these reports. Due to their predominantly low grade, they usually have a benign course for some time, what make them ideal candidates for total resection. However, their intricate location and spread to key areas, including the temporal lobe, make them a surgical challenge. The transsylvian route, with or without resection of the frontal and/or temporal operculae, which requires exposure of part or all of the insula is commonly selected for insular tumor approaches. Intraoperative functional mapping is a standard procedure for resection of central region tumors in adults. In children and young individuals, awake craniotomy is not always possible and surgical planning usually relay on functional and anatomical preoperative studies. The main goal when approaching an insular tumor is to achieve the largest extent of resection to increase overall patient survival while preserving the functional status, minimizing postoperative morbidity and increasing the quality of life. The extent of resection seems to be correlated also with the control of associated (and usually intractable) epilepsy.
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41
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Boëx C, Momjian S, Schaller K. Letter to the Editor: Electric current application for motor tract mapping. J Neurosurg 2016; 124:1881-3. [PMID: 27081901 DOI: 10.3171/2015.12.jns152830] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Vincent M, Rossel O, Hayashibe M, Herbet G, Duffau H, Guiraud D, Bonnetblanc F. The difference between electrical microstimulation and direct electrical stimulation – towards new opportunities for innovative functional brain mapping? Rev Neurosci 2016; 27:231-58. [DOI: 10.1515/revneuro-2015-0029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/17/2015] [Indexed: 11/15/2022]
Abstract
AbstractBoth electrical microstimulation (EMS) and direct electrical stimulation (DES) of the brain are used to perform functional brain mapping. EMS is applied to animal fundamental neuroscience experiments, whereas DES is performed in the operating theatre on neurosurgery patients. The objective of the present review was to shed new light on electrical stimulation techniques in brain mapping by comparing EMS and DES. There is much controversy as to whether the use of DES during wide-awake surgery is the ‘gold standard’ for studying the brain function. As part of this debate, it is sometimes wrongly assumed that EMS and DES induce similar effects in the nervous tissues and have comparable behavioural consequences. In fact, the respective stimulation parameters in EMS and DES are clearly different. More surprisingly, there is no solid biophysical rationale for setting the stimulation parameters in EMS and DES; this may be due to historical, methodological and technical constraints that have limited the experimental protocols and prompted the use of empirical methods. In contrast, the gap between EMS and DES highlights the potential for new experimental paradigms in electrical stimulation for functional brain mapping. In view of this gap and recent technical developments in stimulator design, it may now be time to move towards alternative, innovative protocols based on the functional stimulation of peripheral nerves (for which a more solid theoretical grounding exists).
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Affiliation(s)
- Marion Vincent
- 1INRIA, Université de Montpellier, LIRMM, équipe DEMAR, F-34095 Montpellier, France
| | - Olivier Rossel
- 1INRIA, Université de Montpellier, LIRMM, équipe DEMAR, F-34095 Montpellier, France
| | - Mitsuhiro Hayashibe
- 1INRIA, Université de Montpellier, LIRMM, équipe DEMAR, F-34095 Montpellier, France
| | | | | | - David Guiraud
- 1INRIA, Université de Montpellier, LIRMM, équipe DEMAR, F-34095 Montpellier, France
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Zadeh G, Khan OH, Vogelbaum M, Schiff D. Much debated controversies of diffuse low-grade gliomas. Neuro Oncol 2016; 17:323-6. [PMID: 26114668 PMCID: PMC4483107 DOI: 10.1093/neuonc/nou368] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Gelareh Zadeh
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (G.Z., O.H.K.); Division of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.V.); Division of Neuro-Oncology, University of Virginia Medical Center, Charlottesville, Virginia (D.S.)
| | - Osaama H Khan
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (G.Z., O.H.K.); Division of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.V.); Division of Neuro-Oncology, University of Virginia Medical Center, Charlottesville, Virginia (D.S.)
| | - Michael Vogelbaum
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (G.Z., O.H.K.); Division of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.V.); Division of Neuro-Oncology, University of Virginia Medical Center, Charlottesville, Virginia (D.S.)
| | - David Schiff
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (G.Z., O.H.K.); Division of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.V.); Division of Neuro-Oncology, University of Virginia Medical Center, Charlottesville, Virginia (D.S.)
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Fouke SJ, Benzinger T, Gibson D, Ryken TC, Kalkanis SN, Olson JJ. The role of imaging in the management of adults with diffuse low grade glioma: A systematic review and evidence-based clinical practice guideline. J Neurooncol 2015; 125:457-79. [PMID: 26530262 DOI: 10.1007/s11060-015-1908-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 08/29/2015] [Indexed: 01/24/2023]
Abstract
QUESTION What is the optimal imaging technique to be used in the diagnosis of a suspected low grade glioma, specifically: which anatomic imaging sequences are critical for most accurately identifying or diagnosing a low grade glioma (LGG) and do non-anatomic imaging methods and/or sequences add to the diagnostic specificity of suspected low grade gliomas? TARGET POPULATION These recommendations apply to adults with a newly diagnosed lesion with a suspected or histopathologically proven LGG. RECOMMENDATION LEVEL II In patients with a suspected brain tumor, the minimum magnetic resonance imaging (MRI) exam should be an anatomic exam with both T2 weighted and pre- and post-gadolinium contrast enhanced T1 weighted imaging. CRITICAL IMAGING FOR THE IDENTIFICATION AND DIAGNOSIS OF LOW GRADE GLIOMA: LEVEL II In patients with a suspected brain tumor, anatomic imaging sequences should include T1 and T2 weighted and Fluid Attenuation Inversion Recovery (FLAIR) MR sequences and will include T1 weighted imaging after the administration of gadolinium based contrast. Computed tomography (CT) can provide additional information regarding calcification or hemorrhage, which may narrow the differential diagnosis. At a minimum, these anatomic sequences can help identify a lesion as well as its location, and potential for surgical intervention. IMPROVEMENT OF DIAGNOSTIC SPECIFICITY WITH THE ADDITION OF NON-ANATOMIC (PHYSIOLOGIC AND ADVANCED IMAGING) TO ANATOMIC IMAGING: LEVEL II Class II evidence from multiple studies and a significant number of Class III series support the addition of diffusion and perfusion weighted MR imaging in the assessment of suspected LGGs, for the purposes of discriminating the potential for tumor subtypes and identification of suspicion of higher grade diagnoses. LEVEL III Multiple series offer Class III evidence to support the potential for magnetic resonance spectroscopy (MRS) and nuclear medicine methods including positron emission tomography and single-photon emission computed tomography imaging to offer additional diagnostic specificity although these are less well defined and their roles in clinical practice are still being defined. QUESTION Which imaging sequences or parameters best predict the biological behavior or prognosis for patients with LGG? TARGET POPULATION These recommendations apply to adults with a newly diagnosed lesion with a suspected or histopathologically proven LGG. RECOMMENDATION Anatomic and advanced imaging methods and prognostic stratification LEVEL III Multiple series suggest a role for anatomic and advanced sequences to suggest prognostic stratification among low grade gliomas. Perfusion weighted imaging, particularly when obtained as a part of diagnostic evaluation (as recommended above) can play a role in consideration of prognosis. Other imaging sequences remain investigational in terms of their role in consideration of tumor prognosis as there is insufficient evidence to support more formal recommendations as to their use at this time. QUESTION What is the optimal imaging technique to be used in the follow-up of a suspected (or biopsy proven) LGG? TARGET POPULATION This recommendation applies to adults with a newly diagnosed low grade glioma. RECOMMENDATIONS LEVEL II In patients with a diagnosis of LGG, anatomic imaging sequences should include T2/FLAIR MR sequences and T1 weighted imaging before and after the administration of gadolinium based contrast. Serial imaging should be performed to identify new areas of contrast enhancement or significant change in tumor size, which may signify transformation to a higher grade. LEVEL III Advanced imaging utility may depend on tumor subtype. Multicenter clinical trials with larger cohorts are needed. For astrocytic tumors, baseline and longitudinal elevations in tumor perfusion as assessed by dynamic susceptibility contrast perfusion MRI are associated with shorter time to tumor progression, but can be difficult to standardize in clinical practice. For oligodendrogliomas and mixed gliomas, MRS may be helpful for identification of progression.
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Affiliation(s)
- Sarah Jost Fouke
- Swedish Neuroscience Institute, 751 Northeast Blakely Drive, Suite 4020, Seattle, WA, USA.
| | | | - Daniel Gibson
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Timothy C Ryken
- Department of Neurosurgery, Kansas University Medical Center, Kansas City, KS, USA
| | - Steven N Kalkanis
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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45
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Khan OH, Mason W, Kongkham PN, Bernstein M, Zadeh G. Neurosurgical management of adult diffuse low grade gliomas in Canada: a multi-center survey. J Neurooncol 2015; 126:137-149. [PMID: 26454818 PMCID: PMC4683163 DOI: 10.1007/s11060-015-1949-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 10/05/2015] [Indexed: 11/21/2022]
Abstract
Adult diffuse low-grade gliomas are slow growing, World Health Organization grade II lesions with insidious onset and ultimate anaplastic transformation. The timing of surgery remains controversial with polarized practices continuing to govern patient management. As a result, the management of these patients is variable. The goal of this questionnaire was to evaluate practice patterns in Canada. An online invitation for a questionnaire including diagnostic, preoperative, perioperative, and postoperative parameters and three cases with magnetic resonance imaging data with questions to various treatment options in these patients was sent to practicing neurosurgeons and trainees. Survey was sent to 356 email addresses with 87 (24.7 %) responses collected. The range of years of practice was less than 10 years 36 % (n = 23), 11–20 years 28 % (n = 18), over 21 years 37 % (n = 24). Twenty-two neurosurgery students of various years of training completed the survey. 94 % (n = 47) of surgeons and trainees (n = 20) believe that we do not know the “right treatment”. 90 % of surgeons do not obtain formal preoperative neurocognitive assessments. 21 % (n = 13) of surgeons and 23 % of trainees (n = 5) perform a biopsy upon first presentation. A gross total resection was believed to increase progression free survival (surgeons: 75 %, n = 46; trainees: 95 %, n = 21) and to increase overall survival (surgeons: 64 %, n = 39, trainees: 68 %, n = 15). Intraoperative MRI was only used by 8 % of surgeons. Awake craniotomy was the procedure of choice for eloquent tumors by 80 % (n = 48) of surgeons and 100 % of trainees. Of those surgeons who perform awake craniotomy 93 % perform cortical stimulation and 38 % performed subcortical stimulation. Using the aid of three hypothetical cases with progressive complexities in tumor eloquence there was a trend for younger surgeons to operate earlier, and use awake craniotomy to obtain greater extent of resection with the aid of cortical stimulation when compared to senior surgeons who still more often preferred a “wait-and-see” approach. Despite the limitations of an online survey study, it has offered insights into the variability in surgeon practice patterns in Canada and the need for a consensus on the workup and surgical management of this disease.
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Affiliation(s)
- Osaama H Khan
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.
| | - Warren Mason
- Princess Margaret Hospital, 610 University Avenue Suite 18-717, Toronto, ON, M5G 2M9, Canada
| | - Paul N Kongkham
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Mark Bernstein
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
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46
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Stereotactic interstitial brachytherapy for the treatment of oligodendroglial brain tumors. Strahlenther Onkol 2015; 191:936-44. [PMID: 26307628 DOI: 10.1007/s00066-015-0887-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 08/07/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE We evaluated the treatment of oligodendroglial brain tumors with interstitial brachytherapy (IBT) using (125)iodine seeds ((125)I) and analyzed prognostic factors. PATIENTS AND METHODS Between January 1991 and December 2010, 63 patients (median age 43.3 years, range 20.8-63.4 years) suffering from oligodendroglial brain tumors were treated with (125)I IBT either as primary, adjuvantly after incomplete resection, or as salvage therapy after tumor recurrence. Possible prognostic factors influencing disease progression and survival were retrospectively investigated. RESULTS The actuarial 2-, 5-, and 10-year overall and progression-free survival rates after IBT for WHO II tumors were 96.9, 96.9, 89.8 % and 96.9, 93.8, 47.3 %; for WHO III tumors 90.3, 77, 54.9 % and 80.6, 58.4, 45.9 %, respectively. Magnetic resonance imaging demonstrated complete remission in 2 patients, partial remission in 13 patients, stable disease in 17 patients and tumor progression in 31 patients. Median time to progression for WHO II tumors was 87.6 months and for WHO III tumors 27.8 months. Neurological status improved in 10 patients and remained stable in 20 patients, while 9 patients deteriorated. There was no treatment-related mortality. Treatment-related morbidity was transient in 11 patients. WHO II, KPS ≥ 90 %, frontal location, and tumor surface dose > 50 Gy were associated with increased overall survival (p ≤ 0.05). Oligodendroglioma and frontal location were associated with a prolonged progression-free survival (p ≤ 0.05). CONCLUSION Our study indicates that IBT achieves local control rates comparable to surgery and radio-/chemotherapy treatment, is minimally invasive, and safe. Due to the low rate of side effects, IBT may represent an attractive option as part of a multimodal treatment schedule, being supplementary to microsurgery or as a salvage therapy after chemotherapy and conventional irradiation.
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47
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Morsy AA, Ng WH. Awake craniotomy using electromagnetic navigation technology without rigid pin fixation. J Clin Neurosci 2015; 22:1827-9. [PMID: 26249245 DOI: 10.1016/j.jocn.2015.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 04/04/2015] [Accepted: 04/05/2015] [Indexed: 11/19/2022]
Abstract
We report our institutional experience using an electromagnetic navigation system, without rigid head fixation, for awake craniotomy patients. The StealthStation® S7 AxiEM™ navigation system (Medtronic, Inc.) was used for this technique. Detailed preoperative clinical and neuropsychological evaluations, patient education and contrast-enhanced MRI (thickness 1.5mm) were performed for each patient. The AxiEM Mobile Emitter was typically placed in a holder, which was mounted to the operating room table, and a non-invasive patient tracker was used as the patient reference device. A monitored conscious sedation technique was used in all awake craniotomy patients, and the AxiEM Navigation Pointer was used for navigation during the procedure. This offers the same accuracy as optical navigation, but without head pin fixation or interference with intraoperative neurophysiological techniques and surgical instruments. The application of the electromagnetic neuronavigation technology without rigid head fixation during an awake craniotomy is accurate, and offers superior patient comfort. It is recommended as an effective adjunctive technique for the conduct of awake surgery.
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Affiliation(s)
- Ahmed A Morsy
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; Department of Neurosurgery, Zagazig University, Zagazig, Egypt
| | - Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; Neuroscience Academic Clinical Programme, SingHealth Duke-NUS, Singapore.
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48
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Schucht P, Seidel K, Beck J, Murek M, Jilch A, Wiest R, Fung C, Raabe A. Intraoperative monopolar mapping during 5-ALA-guided resections of glioblastomas adjacent to motor eloquent areas: evaluation of resection rates and neurological outcome. Neurosurg Focus 2015; 37:E16. [PMID: 25434385 DOI: 10.3171/2014.10.focus14524] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Resection of glioblastoma adjacent to motor cortex or subcortical motor pathways carries a high risk of both incomplete resection and postoperative motor deficits. Although the strategy of maximum safe resection is widely accepted, the rates of complete resection of enhancing tumor (CRET) and the exact causes for motor deficits (mechanical vs vascular) are not always known. The authors report the results of their concept of combining monopolar mapping and 5-aminolevulinic acid (5-ALA)-guided surgery in patients with glioblastoma adjacent to eloquent tissue. METHODS The authors prospectively studied 72 consecutive patients who underwent 5-ALA-guided surgery for a glioblastoma adjacent to the corticospinal tract (CST; < 10 mm) with continuous dynamic monopolar motor mapping (short-train interstimulus interval 4.0 msec, pulse duration 500 μsec) coupled to an acoustic motor evoked potential (MEP) alarm. The extent of resection was determined based on early (< 48 hours) postoperative MRI findings. Motor function was assessed 1 day after surgery, at discharge, and at 3 months. RESULTS Five patients were excluded because of nonadherence to protocol; thus, 67 patients were evaluated. The lowest motor threshold reached during individual surgery was as follows (motor threshold, number of patients): > 20 mA, n = 8; 11-20 mA, n = 13; 6-10 mA, n = 10; 4-5 mA, n = 13; and 1-3 mA, n = 23. Motor deterioration at postsurgical Day 1 and at discharge occurred in 30% (n = 20) and 10% (n = 7) of patients, respectively. At 3 months, 3 patients (4%) had a persisting postoperative motor deficit, 2 caused by vascular injury and 1 by mechanical injury. The rates of intra- and postoperative seizures were 1% and 0%, respectively. Complete resection of enhancing tumor was achieved in 73% of patients (49/67) despite proximity to the CST. CONCLUSIONS A rather high rate of CRET can be achieved in glioblastomas in motor eloquent areas via a combination of 5-ALA for tumor identification and intraoperative mapping for distinguishing between presumed and actual motor eloquent tissues. Continuous dynamic mapping was found to be a very ergonomic technique that localizes the motor tissue early and reliably.
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49
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Magerkurth J, Mancini L, Penny W, Flandin G, Ashburner J, Micallef C, De Vita E, Daga P, White MJ, Buckley C, Yamamoto AK, Ourselin S, Yousry T, Thornton JS, Weiskopf N. Objective Bayesian fMRI analysis-a pilot study in different clinical environments. Front Neurosci 2015; 9:168. [PMID: 26029041 PMCID: PMC4428130 DOI: 10.3389/fnins.2015.00168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/26/2015] [Indexed: 11/13/2022] Open
Abstract
Functional MRI (fMRI) used for neurosurgical planning delineates functionally eloquent brain areas by time-series analysis of task-induced BOLD signal changes. Commonly used frequentist statistics protect against false positive results based on a p-value threshold. In surgical planning, false negative results are equally if not more harmful, potentially masking true brain activity leading to erroneous resection of eloquent regions. Bayesian statistics provides an alternative framework, categorizing areas as activated, deactivated, non-activated or with low statistical confidence. This approach has not yet found wide clinical application partly due to the lack of a method to objectively define an effect size threshold. We implemented a Bayesian analysis framework for neurosurgical planning fMRI. It entails an automated effect-size threshold selection method for posterior probability maps accounting for inter-individual BOLD response differences, which was calibrated based on the frequentist results maps thresholded by two clinical experts. We compared Bayesian and frequentist analysis of passive-motor fMRI data from 10 healthy volunteers measured on a pre-operative 3T and an intra-operative 1.5T MRI scanner. As a clinical case study, we tested passive motor task activation in a brain tumor patient at 3T under clinical conditions. With our novel effect size threshold method, the Bayesian analysis revealed regions of all four categories in the 3T data. Activated region foci and extent were consistent with the frequentist analysis results. In the lower signal-to-noise ratio 1.5T intra-operative scanner data, Bayesian analysis provided improved brain-activation detection sensitivity compared with the frequentist analysis, albeit the spatial extents of the activations were smaller than at 3T. Bayesian analysis of fMRI data using operator-independent effect size threshold selection may improve the sensitivity and certainty of information available to guide neurosurgery.
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Affiliation(s)
- Joerg Magerkurth
- Department for Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London London, UK ; Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, University College London London, UK
| | - Laura Mancini
- Department for Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London London, UK
| | - William Penny
- Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, University College London London, UK
| | - Guillaume Flandin
- Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, University College London London, UK
| | - John Ashburner
- Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, University College London London, UK
| | - Caroline Micallef
- Department for Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London London, UK
| | - Enrico De Vita
- Department for Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London London, UK
| | - Pankaj Daga
- Centre for Medical Image Computing, University College London London, UK
| | - Mark J White
- Department for Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London London, UK
| | | | - Adam K Yamamoto
- Department for Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London London, UK
| | - Sebastien Ourselin
- Centre for Medical Image Computing, University College London London, UK
| | - Tarek Yousry
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London London, UK
| | - John S Thornton
- Department for Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London London, UK
| | - Nikolaus Weiskopf
- Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, University College London London, UK
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50
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Ramakrishna R, Hebb A, Barber J, Rostomily R, Silbergeld D. Outcomes in Reoperated Low-Grade Gliomas. Neurosurgery 2015; 77:175-84; discussion 184. [DOI: 10.1227/neu.0000000000000753] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Low-grade gliomas (LGGs) comprise a diverse set of intrinsic brain tumors that correlate strongly with survival. Data on the effect of reoperation are sparse.
OBJECTIVE:
To evaluate the effect of reoperation on patients with LGG.
METHODS:
Fifty-two consecutive patients with reoperated LGGs treated at the University of Washington between 1986 and 2004 were identified and evaluated in a retrospective analysis.
RESULTS:
The average overall survival (OS) for this cohort was 12.95 ± 0.96 years. The overall 10-year survival rate was 57%. The absence of any residual tumor at either the first or second operation was associated with significantly increased OS. Negative prognostic variables for OS included the use of upfront radiation and pathology at recurrence. The average overall progression-free survival to the first recurrence (PFS1) was 6.23 ± 0.51 years. Positive prognostic factors for improved PFS1 included the use of upfront radiation therapy. Variables not associated with differences in PFS1 included the use of upfront chemotherapy, enhancement, pathology, extent of resection, the presence of residual tumor, and Karnofsky Performance Scale score <80. The average overall progression-free survival to the second recurrence was 2.73 ± 0.39 years. Pathology at recurrence was associated with significant differences in progression-free survival to the second recurrence, as was extent of resection at time of first recurrence, and Karnofsky Performance Scale score <80.
CONCLUSION:
This is among the largest studies to assess variables associated with outcome in patients with reoperated LGG. Reresection appears to provide significant benefit, and extent of resection remains the strongest predictor of OS.
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Affiliation(s)
- Rohan Ramakrishna
- Weill Cornell Medical College, New York Presbyterian Hospital, Department of Neurological Surgery, New York, New York
| | - Adam Hebb
- Colorado Neurological Institute, Englewood, Colorado
| | - Jason Barber
- University of Washington, School of Medicine, Department of Neurological Surgery, Seattle, Washington
| | - Robert Rostomily
- University of Washington, School of Medicine, Department of Neurological Surgery, Seattle, Washington
| | - Daniel Silbergeld
- University of Washington, School of Medicine, Department of Neurological Surgery, Seattle, Washington
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