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Simon M, Hagemann A, Gajadin S, Signorelli F, Vincent AJ. Surgical treatment for insular gliomas. A systematic review and meta-analysis on behalf of the EANS neuro-oncology section. BRAIN & SPINE 2024; 4:102828. [PMID: 38859917 PMCID: PMC11163152 DOI: 10.1016/j.bas.2024.102828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024]
Abstract
Introduction The appropriate surgical management of insular gliomas is controversial. Management strategies vary considerably between centers. Research question To provide robust resection, functional and epilepsy outcome figures, study growth patterns and tumor classification paradigms, analyze surgical approaches, mapping/monitoring strategies, surgery for insular glioblastoma, as well as molecular findings, and to identify open questions for future research. Material and methods On behalf of the EANS Neuro-oncology Section we performed a systematic review and meta-analysis (using a random-effects model) of the more current (2000-2023) literature in accordance with the PRISMA guidelines. Results The pooled postoperative motor and speech deficit rates were 6.8% and 3.6%. There was a 79.6% chance for postoperative epilepsy control. The postoperative KPI was 80-100 in 83.5% of cases. Functional monitoring/mapping paradigms (which may include awake craniotomies) seem mandatory. (Additional) awake surgery may result in slightly better functional but also worse resection outcomes. Transcortical approaches may carry a lesser rate of (motor) deficits than transsylvian surgeries. Discussion and conclusions This paper provides an inclusive overview and analysis of current surgical management of insular gliomas. Risks and complication rates in experienced centers do not necessarily compare unfavorably with the results of routine neuro-oncological procedures. Limitations of the current literature prominently include a lack of standardized outcome reporting. Questions and issues that warrant more attention include surgery for insular glioblastomas and how to classify the various growth patterns of insular gliomas.
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Affiliation(s)
- Matthias Simon
- Dept. of Neurosurgery, Bethel Clinic, University of Bielefeld Medical Center OWL, Bielefeld, Germany
| | | | - Sanjana Gajadin
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Francesco Signorelli
- Division of Neurosurgery, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University "Aldo Moro", Bari, Italy
| | - Arnaud J.P.E. Vincent
- Division of Neurosurgery, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University "Aldo Moro", Bari, Italy
| | - for the EANS Neuro-oncology Section
- Dept. of Neurosurgery, Bethel Clinic, University of Bielefeld Medical Center OWL, Bielefeld, Germany
- Society for Epilepsy Research, Bielefeld, Germany
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
- Division of Neurosurgery, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University "Aldo Moro", Bari, Italy
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Zhang JJY, Lee KS, Wang DD, Hervey-Jumper SL, Berger MS. Seizure outcome after resection of insular glioma: a systematic review, meta-analysis, and institutional experience. J Neurosurg 2022; 138:1242-1253. [PMID: 36242570 PMCID: PMC10404476 DOI: 10.3171/2022.8.jns221067] [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: 05/05/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gliomas arising from the insular cortex can be epileptogenic, with a significant proportion of patients having medically refractory epilepsy. The impact of surgery on seizure control for such tumors is not well established. In this study, the authors aimed to investigate seizure outcomes after resection of insular gliomas using a meta-analysis and institutional experience. METHODS Three databases (Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials) were systematically searched for published studies of seizure outcomes after insular glioma resection from database inception to March 27, 2021. In addition, data were retrospectively collected on all adults (age > 17 years) who had undergone insular glioma resection between June 1997 and June 2015 at the authors' institution. Primary outcome measures were seizure freedom rates at 1 year and the last follow-up. Secondary outcome measures consisted of persistent postoperative neurological deficit beyond 90 days, mortality, and tumor progression or recurrence. RESULTS Eight studies reporting on 453 patients who had undergone 460 operations were included in the meta-analysis. The pooled mean age of the patients was 42 years. The pooled percentages of patients with extents of resection (EORs) ≥ 90%, 70%-89%, and < 70% were 55%, 33%, and 11%, respectively. The pooled seizure freedom rate at 1 year was 73% for Engel class IA and 78% for Engel class I. The pooled seizure freedom rate at the last follow-up was 60% for Engel class IA and 79% for Engel class I. The pooled percentage of persistent neurological deficit beyond 90 days was 3%. At the authors' institution, 109 patients had undergone resection of insular glioma. A greater EOR was the only significant independent predictor of seizure freedom after surgery (HR 0.290, p = 0.017). The optimal threshold for seizure freedom corresponded to an EOR of 81%. Patients with an EOR > 81% had a significantly higher seizure freedom rate (OR 2.16, p = 0.048). CONCLUSIONS Maximal safe resection can be performed with minimal surgical morbidity to achieve favorable seizure freedom rates in both the short and long term. When gross-total resection is not possible, an EOR > 81% confers the greatest sensitivity and specificity for achieving seizure freedom. Systematic review registration no.: CRD42021249404 (https://www.crd.york.ac.uk/prospero/).
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Affiliation(s)
- John J Y Zhang
- 1Department of Neurological Surgery, University of California, San Francisco, California.,2Department of Neurosurgery, National Neuroscience Institute, Singapore; and
| | - Keng Siang Lee
- 1Department of Neurological Surgery, University of California, San Francisco, California.,3Bristol Medical School, University of Bristol, United Kingdom
| | - Doris D Wang
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Shawn L Hervey-Jumper
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Mitchel S Berger
- 1Department of Neurological Surgery, University of California, San Francisco, California
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Li G, Rodrigues A, Kim L, Garcia C, Jain S, Zhang M, Hayden-Gephart M. 5-Aminolevulinic Acid Imaging of Malignant Glioma. Surg Oncol Clin N Am 2022; 31:581-593. [DOI: 10.1016/j.soc.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pepper J, Cuthbert H, Scott T, Ughratdar I, Wykes V, Watts C, D'Urso P, Karabatsou K, Moor CC, Albanese E. Seizure Outcome After Surgery for Insular High-Grade Glioma. World Neurosurg 2021; 154:e718-e723. [PMID: 34343689 DOI: 10.1016/j.wneu.2021.07.114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The insular cortex is an eloquent island of mesocortex surrounded by vital structures making this region relatively challenging to neurosurgeons. Historically, lesions in this region were considered too high risk to approach given the strong chance of poor surgical outcome. Advances in recent decades have meant that surgeons can more safely access this eloquent region. Seizure outcome after excision of insular low-grade gliomas is well reported, but little is known about seizure outcomes after excision of insular high-grade gliomas. METHODS A retrospective analysis was performed of all patients presenting with new-onset seizures during 2015-2019 who underwent excision of an insular high-grade glioma at 3 regional neurosurgical centers in the United Kingdom. RESULTS We identified 38 patients with a mean (SD) age of 45.7 (15.3) years with median follow-up of 21 months. At long-term follow-up, of 38 patients, 23 were seizure-free (Engel class I), 2 had improved seizures (Engel class II), 6 had poor seizure control (Engel class III/IV), and 7 died. CONCLUSIONS Excision of insular high-grade gliomas is safe and results in excellent postoperative seizure control.
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Affiliation(s)
- Joshua Pepper
- Department of Neurosurgery, University Hospital of North Midlands, Stoke on Trent, United Kingdom.
| | - Hadleigh Cuthbert
- Department of Neurosurgery, University Hospital of North Midlands, Stoke on Trent, United Kingdom
| | - Teresa Scott
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Ismail Ughratdar
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Victoria Wykes
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Colin Watts
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Pietro D'Urso
- Department of Neurosurgery, Salford Royal Hospital, Salford, United Kingdom
| | | | - Carl-Christian Moor
- Department of Neurology, University Hospital of North Midlands, Stoke on Trent, United Kingdom
| | - Erminia Albanese
- Department of Neurosurgery, University Hospital of North Midlands, Stoke on Trent, United Kingdom
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Dadario NB, Khatri D, Reichman N, Nwagwu CD, D'Amico RS. 5-Aminolevulinic Acid-Shedding Light on Where to Focus. World Neurosurg 2021; 150:9-16. [PMID: 33684574 DOI: 10.1016/j.wneu.2021.02.118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Surgical management of gliomas is predicated on "safe maximal resection" across all histopathologic grades because progression-free survival and overall survival are positively affected by the increasing extent of resection. Administration of the prodrug 5-aminolevulinic acid (5-ALA) induces tumor fluorescence with high specificity and sensitivity for malignant high-grade glioma (HGG). Fluorescence-guided surgery (FGS) using 5-ALA improves the extent of resection in the contrast-enhancing and nonenhancing tumor components in HGG. It has also shown preliminary usefulness in other central nervous system tumors, but with certain limitations. METHODS We review and discuss the state of 5-ALA FGS for central nervous system tumors and identify the limitations in its use as a guide for future clinical optimization. RESULTS 5-ALA FGS provides maximum clinical benefits in the treatment of newly diagnosed glioblastoma. 5-ALA fluorescence specificity is limited in low-grade glioma, recurrent HGG, and non-glial tumors. Several promising intraoperative adjuncts to 5-ALA FGS have been developed to expand its indications and improve the clinical efficacy and usefulness of 5-ALA FGS. CONCLUSIONS 5-ALA FGS improves the clinical outcomes in HGG. However, further optimization of the diagnostic performance and clinical use of 5-ALA FGS is necessary for low-grade glioma and recurrent HGG tumors. Neurosurgical oncology will benefit from the novel use of advanced technologies and intraoperative visualization techniques outlined in this review, such as machine learning, hand-held fibe-optic probes, augmented reality, and three-dimensional exoscope assistance, to optimize the clinical usefulness and operative outcomes of 5-ALA FGS.
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Affiliation(s)
- Nicholas B Dadario
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA; Rutgers Robert Wood Johnson School of Medicine, Rutgers University, New Brunswick, New Jersey, USA
| | - Deepak Khatri
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Noah Reichman
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Chibueze D Nwagwu
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA.
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Das KK, Singh A, Khatri D, Gosal JS, Bhaisora K, Mehrotra A, Gogoi S, Behari S. The Dilemma of Multifocality in Insular Tumors: Multicentricity versus Metastasis. Asian J Neurosurg 2021; 16:72-77. [PMID: 34211870 PMCID: PMC8202396 DOI: 10.4103/ajns.ajns_458_20] [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] [Received: 10/05/2020] [Revised: 12/23/2020] [Accepted: 02/04/2021] [Indexed: 11/05/2022] Open
Abstract
Background and Purpose: Multifocality and metastasis from insular glioma are extremely rare. Pathological insights and elaboration of the clinical course of this condition will contribute to their better understanding. Materials and Methods: Among 123 consecutively operated insular gliomas, 5 patients (4.2%) presented with a multifocal tumor. The clinico-radiological, histo-molecular, and treatment outcomes were noted and compared with the unifocal insular glioma cohort. Results: Among the five patients, all were males and involved the right insular lobe. Three patients presented with synchronous tumors, while two patients developed metachronous multifocal tumors. The histology of the insular tumor was Grade I glioma in 1, Grade II astrocytoma with p53 mutation in 2, and anaplastic astrocytoma and glioblastoma in one patient each. Histological confirmation of the second lesion was performed in two patients, showing the same histology of the insular tumor. Interconnection between the tumors was apparent through cerebrospinal fluid pathways in four patients, while no such connection could be established in one patient. Barring the patient of Grade I glioma, the rest of the patients died within months of the diagnosis. Conclusion: Multifocal insular glioma is rare and probably represents a biologically more aggressive tumor. Insular glioma that touches the ventricle appears a common denominator for multifocality. True multicentricity is rare. The prognosis in insular glioma with multifocality is poor in non-Grade I gliomas.
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Affiliation(s)
- Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amanjot Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Deepak Khatri
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jaskaran Singh Gosal
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Kamlesh Bhaisora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sudarsana Gogoi
- Department of Pathology, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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