What Does Quality of Care Mean in Lower-Grade Glioma Patients: A Precision Molecular-Based Management of the Tumor or an Individualized Medicine Centered on Patient's Choices?

Deep learning-assisted radiomics facilitates multimodal prognostication for personalized treatment strategies in low-grade glioma

Determining the optimal course of treatment for low grade glioma (LGG) patients is challenging and frequently reliant on subjective judgment and limited scientific evidence. Our objective was to develop a comprehensive deep learning assisted radiomics model for assessing not only overall survival in LGG, but also the likelihood of future malignancy and glioma growth velocity. Thus, we retrospectively included 349 LGG patients to develop a prediction model using clinical, anatomical, and preoperative MRI data. Before performing radiomics analysis, a U2-model for glioma segmentation was utilized to prevent bias, yielding a mean whole tumor Dice score of 0.837. Overall survival and time to malignancy were estimated using Cox proportional hazard models. In a postoperative model, we derived a C-index of 0.82 (CI 0.79-0.86) for the training cohort over 10 years and 0.74 (Cl 0.64-0.84) for the test cohort. Preoperative models showed a C-index of 0.77 (Cl 0.73-0.82) for training and 0.67 (Cl 0.57-0.80) test sets. Our findings suggest that we can reliably predict the survival of a heterogeneous population of glioma patients in both preoperative and postoperative scenarios. Further, we demonstrate the utility of radiomics in predicting biological tumor activity, such as the time to malignancy and the LGG growth rate.

Oncological and functional neurosurgery: Perspectives for the decade regarding diffuse gliomas

For decades, diffuse glioma (DG) studies mostly focused on oncological considerations, whereas functional outcomes received less attention. Currently, because overall survival has increased in DG, especially in low-grade glioma (overall survival > 15 years), quality of life including neurocognitive and behavioral aspects should be assessed and preserved more systematically, particularly regarding surgery. Indeed, early maximal tumor removal results in greater survival in both high-grade and low-grade gliomas, leading to propose "supra-marginal" resection, with excision of the peritumoral zone in diffuse neoplasms. To minimize functional risks while maximizing the extent of resection, traditional "tumor-mass resection" is replaced by "connectome-guided resection" conducted under awake mapping, taking into account inter-individual brain anatomo-functional variability. A better understanding of the dynamic interplay between DG progression and reactional neuroplastic mechanisms is critical to adapt a personalized multistage therapeutic strategy, with integration of functional neurooncological (re)operation(s) in a multimodal management scheme including repeated medical therapies. Because the therapeutic armamentarium remains limited, the aims of this paradigmatic shift are to predict one/several step(s) ahead glioma behavior, its modifications, and compensatory neural networks reconfiguration over time in order to optimize the onco-functional benefit of each treatment - either in isolation or in combination with others - in human beings bearing a chronic tumoral disease while enjoying an active familial and socio-professional life as close as possible to their expectations. Thus, new ecological endpoints such as return to work should be incorporated into future DG trials. "Preventive neurooncology" might also be envisioned, by proposing a screening policy to discover and treat incidental glioma earlier.

Beyond Avoiding Hemiplegia after Glioma Surgery: The Need to Map Complex Movement in Awake Patient to Preserve Conation

Improving the onco-functional balance has always been a challenge in glioma surgery, especially regarding motor function. Given the importance of conation (i.e., the willingness which leads to action) in patient's quality of life, we propose here to review the evolution of its intraoperative assessment through a reminder of the increasing knowledge of its neural foundations-based upon a meta-networking organization at three levels. Historical preservation of the primary motor cortex and pyramidal pathway (first level), which was mostly dedicated to avoid hemiplegia, has nonetheless shown its limits to prevent the occurrence of long-term deficits regarding complex movement. Then, preservation of the movement control network (second level) has permitted to prevent such more subtle (but possibly disabling) deficits thanks to intraoperative mapping with direct electrostimulations in awake conditions. Finally, integrating movement control in a multitasking evaluation during awake surgery (third level) enabled to preserve movement volition in its highest and finest level according to patients' specific demands (e.g., to play instrument or to perform sports). Understanding these three levels of conation and its underlying cortico-subcortical neural basis is therefore critical to propose an individualized surgical strategy centered on patient's choice: this implies an increasingly use of awake mapping and cognitive monitoring regardless of the involved hemisphere. Moreover, this also pleads for a finer and systematic assessment of conation before, during and after glioma surgery as well as for a stronger integration of fundamental neurosciences into clinical practice.

A Personalized Longitudinal Strategy in Low-Grade Glioma Patients: Predicting Oncological and Neural Interindividual Variability and Its Changes over Years to Think One Step Ahead

Diffuse low-grade glioma (LGG) is a rare cerebral cancer, mostly involving young adults with an active life at diagnosis. If left untreated, LGG widely invades the brain and becomes malignant, generating neurological worsening and ultimately death. Early and repeat treatments for this incurable tumor, including maximal connectome-based surgical resection(s) in awake patients, enable postponement of malignant transformation while preserving quality of life owing to constant neural network reconfiguration. Due to considerable interindividual variability in terms of LGG course and consecutive cerebral reorganization, a multistage longitudinal strategy should be tailored accordingly in each patient. It is crucial to predict how the glioma will progress (changes in growth rate and pattern of migration, genetic mutation, etc.) and how the brain will adapt (changes in patterns of spatiotemporal redistribution, possible functional consequences such as epilepsy or cognitive decline, etc.). The goal is to anticipate therapeutic management, remaining one step ahead in order to select the optimal (re-)treatment(s) (some of them possibly kept in reserve), at the appropriate time(s) in the evolution of this chronic disease, before malignization and clinical worsening. Here, predictive tumoral and non-tumoral factors, and their ever-changing interactions, are reviewed to guide individual decisions in advance based on patient-specific markers, for the treatment of LGG.

Factors Associated With Long-term Survival in Women Who Get Pregnant After Surgery for WHO Grade II Glioma

BACKGROUND AND OBJECTIVES

Women with a WHO grade II glioma (GIIG) often question clinicians on the effects of pregnancy on their disease. Previous reports have indicated a higher risk of glioma progression during and after pregnancy. Here, the aim was to investigate post-pregnancy outcomes and predictive factors impacting overall survival in female patients who underwent GIIG surgery.

METHODS

Inclusion criteria were adult women who have been pregnant after a GIIG resection and with a stable oncological status at the time of pregnancy (no ongoing oncological treatment, no contrast enhancement, no debilitating clinical condition). Relevant cases were identified from a databank (1998-2021) of patients who underwent surgical resection for a histologically-confirmed GIIG in our department.

RESULTS

Among 345 GIIG women within their reproductive years (age<45y), 16 patients (4.6%, mean age at delivery: 30.9±5.1 years) were pregnant (twice in 5 cases). The mean interval between the last oncological treatment (surgery alone in 11 patients while followed by chemotherapy and/or radiotherapy in 5 patients) and pregnancy was 3.5 years (range 0.75-10 years). Two patients experienced seizures during pregnancy. The delivery was vaginal and uneventful in all cases but one (1 caesarean). All children had normal mental and physical development. The glioma behavior changed in 7 patients (43.7%), with an acceleration of the velocity of diameter expansion (VDE) and/or the occurrence of a contrast enhancement during or within the 3 months after pregnancy, resulting in medical treatment and/or reoperation in the early post-partum period in 7 cases. The median clinical follow-up from delivery was 5.3 years (range 1.25-11.6 years). Four other patients received delayed adjuvant therapy for glioma progression. Seven patients (43.7%) died at a median time from delivery of 3.9 years (range 1.25-5.9 years). Overall, the median survival from delivery was 5.75 years. Crucially, patients who underwent a complete surgical resection and patients with stable lesions before pregnancy lived longer (log rank, p=0.046 and p=0.0026, respectively).

CONCLUSIONS

Tumor residual volume and tumor speed growth are strong predictive factors conditioning post-pregnancy long-term survival in patients with GIIG. Identifying patients at risk is critical to provide relevant counsel to GIIG women with a desire for motherhood.