Peer-Review ReportThe Risk of Getting Worse: Surgically Acquired Deficits, Perioperative Complications, and Functional Outcomes After Primary Resection of Glioblastoma
Introduction
Malignant gliomas are the most common primary brain tumors and the second most common cause of cancer-related death in the young adult age group (9, 46). The overall prognosis for patients with glioblastoma is poor, with median survival less than 1 year (44). Age at diagnosis and Karnofsky Performance Status (KPS) score are important and established prognostic factors in high-grade glioma patients (16, 22). According to current guidelines, surgery is warranted to establish a histopathologic diagnosis and to achieve safe, maximal, and feasible resection (10, 11, 28, 31). There is now level 2b data (Oxford Centre for Evidence-based Medicine) showing that gross total resection prolongs survival (36). The effect of mere cytoreductive debulkings on survival, functional outcome, and quality of life is not clarified. Regardless of operative technique, gross total resection is not achievable in the majority of unselected glioblastoma patients. The percentage of patients receiving gross total resection varies between studies, probably reflecting the considerable variations in inclusion criteria (34). The frequently cited retrospective study by Lacroix (22) and data from the 5-ALA (5-aminolevunilic study)–Glioma study (36) indicate that if other prognostic factors and treatment factors are adjusted for, surgical resections need to be extensive (>98% or complete) to affect survival. Thus, although the majority of glioblastoma patients are offered surgical treatment that does not even affect survival, it has been reported that surgically acquired motor and language deficits may have a negative impact on survival (26) and quality of life (19). Even though mere debulkings may relieve symptoms of mass effect, it is not known how long such effects sustain and to what degree the potential benefits exceed risks. In the present study, we explore the impact of surgical morbidity and functional outcome on survival in unselected glioblastoma patients.
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Materials and Methods
We retrospectively included all adult (≥18 years) cases operated for primary glioblastoma at the Department of Neurosurgery, St. Olavs University Hospital, in the 6-year period between January 1, 2004, and December 31, 2009. All included tumors were classified and graded by one neuropathologist. Neuropathologic classification was done according to the WHO classification for brain tumors (25). Patients were followed until death or through December 2010. No patients were lost to follow-up.
Data
Results
Of the 144 consecutive glioblastoma operations, 141 (98%) were resections whereas 3 (2%) were biopsies. The average patient age was 62 ± 12 years, and the mean KPS score at presentation was 73 ± 15. The median stay in the neurosurgical department was 5 days. In our study, gross total removal was achieved in 34% of the cases in which resection was performed (n = 141). The 1-year survival rate was 47.5%. Among patients operated through December 2008, the 2-year survival rate was 16.0%.
Discussion
Glioblastoma surgery is a delicate balance between achieving maximal tumor resection and inducing new deficits. Despite modern neuronavigation, imaging techniques, and neuromonitoring, a significant share of patients experience neurologic deterioration because of the operation. Patient selection greatly influences the results in surgical series of malignant glioma (34). Both in terms of resection grades and functional outcome, the results achieved with the SonoWand system are comparable to
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.