Elsevier

World Neurosurgery

Volume 76, Issue 6, December 2011, Pages 572-579
World Neurosurgery

Peer-Review Report
The Risk of Getting Worse: Surgically Acquired Deficits, Perioperative Complications, and Functional Outcomes After Primary Resection of Glioblastoma

https://doi.org/10.1016/j.wneu.2011.06.014Get rights and content

Objective

Gross total resection (GTR) prolongs survival but is unfortunately not achievable in the majority of patients with glioblastoma multiforme (GBM). Cytoreductive debulkings may relieve symptoms of mass effect, but it is unknown how long such effects sustain and to what degree the potential benefits exceed risks. We explore the impact of surgical morbidity on functional outcome and survival in unselected GBM patients.

Methods

We retrospectively included 144 consecutive adult patients operated on for primary GBM at a single institution between 2004 and 2009. Reporting of adverse events was done in compliance with Good Clinical Practice Guidelines.

Results

A total of 141 (98%) operations were resections and 3 (2%) were biopsies. A decrease in Karnofsky performance status (KPS) scores was observed in 39% of patients after 6 weeks. There was a significant decrease between pre- and postoperative KPS scores (P < 0.001). Twenty-two (15.3%) patients had surgically acquired neurological deficits. Among patients who underwent surgical resection, those with surgically acquired neurological deficits were less likely to receive radiotherapy (P < 0.001), normofractioned radiotherapy (P = 0.010), and chemotherapy (P = 0.003). Twenty-eight (19.4%) patients had perioperative complications. Among patients who underwent surgical resection, those with perioperative complications were less likely to receive normofractioned radiotherapy (P = 0.010) and chemotherapy (P = 0.009). Age (P = 0.019), surgically acquired neurological deficits (P < 0.001), and surgical complications (P = 0.006) were significant predictors for worsened functional outcome after 6 weeks. GTR (P = 0.035), perioperative complications (P = 0.008), radiotherapy (P < 0.001), and chemotherapy (P = 0.045) were independent factors associated with 12-month postoperative survival.

Conclusion

Patients with perioperative complications and surgically acquired deficits were less likely to receive adjuvant therapy. While cytoreductive debulking may not improve survival in GBM, it may decrease the likelihood of patients receiving adjuvant therapy that does.

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.

Section snippets

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

References (48)

  • M. Brell et al.

    Factors influencing surgical complications of intra-axial brain tumours

    Acta Neurochir (Wien)

    (2000)
  • S.S. Brem et al.

    Central nervous system cancers

    J Natl Compr Canc Netw

    (2011)
  • N. Butowski et al.

    Historical controls for phase II surgically based trials requiring gross total resection of glioblastoma multiforme

    J Neurooncol

    (2007)
  • S.M. Chang et al.

    Patterns of care for adults with newly diagnosed malignant glioma

    JAMA

    (2005)
  • S.M. Chang et al.

    Glioma Outcomes I: Perioperative complications and neurological outcomes of first and second craniotomies among patients enrolled in the Glioma Outcome Project

    J Neurosurg

    (2003)
  • I. Ciric et al.

    Supratentorial gliomas: surgical considerations and immediate postoperative resultsGross total resection versus partial resection

    Neurosurgery

    (1987)
  • B.C. Devaux et al.

    Resection, biopsy, and survival in malignant glial neoplasmsA retrospective study of clinical parameters, therapy, and outcome

    J Neurosurg

    (1993)
  • R. Diez Valle et al.

    Surgery guided by 5-aminolevulinic fluorescence in glioblastoma: volumetric analysis of extent of resection in single-center experience

    J Neurooncol

    (2011)
  • C. Fadul et al.

    Morbidity and mortality of craniotomy for excision of supratentorial gliomas

    Neurology

    (1988)
  • H.A. Fine et al.

    Meta-analysis of radiation therapy with and without adjuvant chemotherapy for malignant gliomas in adults

    Cancer

    (1993)
  • D. Frappaz et al.

    Summary version of the Standards, Options and Recommendations for the management of adult patients with intracranial glioma (2002)

    Br J Cancer

    (2003)
  • S. Gulati et al.

    Surgical resection of high-grade gliomas in eloquent regions guided by blood oxygenation level dependent functional magnetic resonance imaging, diffusion tensor tractography, and intraoperative navigated 3D ultrasound

    Minim Invasive Neurosurg

    (2009)
  • S.S. Kim et al.

    Awake craniotomy for brain tumors near eloquent cortex: correlation of intraoperative cortical mapping with neurological outcomes in 309 consecutive patients

    Neurosurgery

    (2009)
  • A.S. Jakola et al.

    Quality of life in patients with intracranial gliomas: the impact of modern image-guided surgery

    J Neurosurg

    (2011)
  • Cited by (138)

    • Disparities in Neuro-Oncology

      2023, Current Neurology and Neuroscience Reports
    View all citing articles on Scopus

    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.

    View full text