Re-operation is a safe and effective therapeutic strategy in recurrent WHO grade II gliomas within eloquent areas

Background  To analyze the functional and oncological results after re-operation for recurrent WHO grade II Glioma located in eloquent regions. Method  We reviewed a consecutive series of 19 patients with GIIG within functional areas who underwent two operations separated by at least 1 year. Intraoperative electrical stimulation mapping was used in all operations for recurrence and in 14 of the initial procedures. A specific rehabilitation was provided. Findings  At the first operation, we performed 14 subtotal and 5 partial resections. Eighteen patients returned to a normal socio-professional life. Nine patients received adjuvant treatment. At the second operation, we performed 1 total, 13 subtotal and 5 partial resections. Three patients with a preoperative neurological deficit improved, 13 remained unchanged, and 3 slight new deficits appeared. In 14 of the 17 patients with preoperative chronic epilepsy, the seizures were reduced or disappeared. Sixteen patients returned to a normal socio-professional life. Pathohistological examination showed that 11 tumours had progressed to high-grade glioma. The median time between the two operations was 4.1 years (range 1 to 7.8 years) and the median follow-up from initial diagnosis was 6.6 years (range 2.3 to 14.3 years). No deaths occurred during the follow-up period. Conclusions  Repeat operations guided by intra-operative electrical stimulation is an efficacious treatment for recurrent grade II glioma in an eloquent area. Sources of financial support  Juan Martino receives specific founding from the Post-MIR Wenceslao López-Albo’s grant. Fundación “Marqués de Valdecilla”, IFIMAV, Santander, Cantabria, Spain.     

Awake surgery for incidental WHO grade II gliomas involving eloquent areas

Background  

WHO grade II glioma (G2G) is a pre-malignant tumor, usually revealed by seizures in young patients living normal lives. G2G grows constantly and will inevitably become anaplastic. Surgical resection significantly increases the overall survival by delaying malignant transformation. Recently, a similar natural history was demonstrated in a patient with incidental G2G, with continuous growth and risk of anaplasia. Here, the aim was to study for the first time the functional results and extent of resection in a prospective series of patients who underwent resection for incidental G2G within eloquent areas.     

Surgical resection of gliomas WHO grade II and III located in the opercular region

Summary Background. Surgery in the opercular region especially in the dominant hemisphere impose a major challenge for the neurosurgeon due to the close vicinity to functional important motor and speech areas. The purpose of the present study is to analyse on a homogenous patient group pre- and postoperative functional deficits with regard to different speech qualities (e.g. aphasia, apraxia), and to correlate these data with MR and intraoperative monitoring results. Method. Fourteen patients with suspected low grade astrocytomas in the opercular region consecutively treated by surgery were eligible for this study (histology revealed 3 WHO grade III tumours). Degree and duration of postoperative deficits were retrospectively evaluated according to tumour location and boundaries on MR, intraoperative neuromonitoring results and extent of tumour resection. Findings. Postoperatively, 8 patients showed speech or language disturbances, in 4 patients combined with motor deficits mainly of the contralateral upper extremity. Fifty percent of the neuropsychologically tested patients exhibited speech apraxia while the other 50% had a true aphasic syndrome. Recovery of the latter deficits was in general faster and more complete. The severity and duration of postoperative deficits was in good correlation with the distance of the resection margin to the next positive stimulation point(s), and a distance of more than 0.5cm proved to avoid major impairments. The distribution of functional important stimulation points in relation to the tumour extension was not predictable, and – unexpectedly – up to 50% of these sites were found overlaying the tumour. Interpretation. Surgery for WHO grade II and III gliomas in the opercular region can result in speech apraxia or an aphasic syndrome with or without concomitant motor deficits. Intraoperative cortical electrical stimulation is essential in resecting tumours in the opercular region to avoid permanent morbidity.     

神经导航辅助切除邻近重要功能区神经胶质瘤

目的介绍神经导航系统在切除邻近重要功能区神经胶质瘤( 简称胶质瘤)手术中的初步应用体会. 方法 2000年6月～2001年2月,应用Brain LAB公司VectorVision2导航系统辅助切除邻近重要功能区胶质瘤11例,并对神经导航用于胶质瘤手术的优越性、精确性以及注意事项进行分析. 结果本组病例中,平均注册误差为(1.5±0.7) mm,术后近期复查CT或MRI证实肿瘤全切除率为81.8%,患者临床症状均得到改善,肢体活动等重要神经功能未受明显影响,无手术并发症. 结论神经导航系统对于切除邻近重要功能区胶质瘤具有定位准确、动态示踪、微侵袭、安全可靠等特点 ,有助于提高胶质瘤的全切除率及降低手术并发症的发生.     

Occipital WHO grade II gliomas: oncological,surgical and functional considerations

Background  

Diffuse WHO grade II glioma (GIIG) involving the occipital lobe is a rare entity. Its surgical resection remains controversial as it implies inducing a permanent visual deficit. For the first time to our knowledge, we report a consecutive surgical series of patients who underwent an occipital lobectomy for an LGG invading visual structures.     

The use of motor mapping to aid resection of eloquent gliomas

Surgery remains one of the oldest and still most important forms of treatment for patients with glioma. The advantages of surgical resection for glioma must be balanced with the potential of operative morbidity to surrounding eloquent brain. To that end, advances in functional brain mapping allow for safer operations with more aggressive surgical resections. A brief history of motor mapping as well as its present day use in aiding resection of eloquent gliomas is discussed.     

Long-term brain plasticity allowing a multistage surgical approach to World Health Organization Grade II gliomas in eloquent areas

Although the goal of surgery for World Health Organization Grade II gliomas is maximal extent of resection, complete tumor removal is not always possible when the glioma involves eloquent areas. The authors propose a multistage surgical approach to highly crucial areas that are classically considered inoperable, enabling optimization of the extent of resection while avoiding permanent cognitive deficits due to induced functional reshaping in the interim between the 2 consecutive operations. To demonstrate such plasticity, the authors used a combination of sequential functional MR imaging and intraoperative electrical stimulation mapping before and during surgeries spaced by several years in 2 patients who each underwent 2 separate resections of Grade II gliomas located in the left dominant premotor area. During several years of follow-up after the first procedure, both patients had unremarkable examination results and normal socioprofessional lives. There was no malignant transformation. Based on their experience with these cases, the authors suggest that in cases of incomplete glioma removal, a second operation before anaplasia should be considered, made possible by brain reorganization after the first operation.     

Use of language mapping to aid in resection of gliomas in eloquent brain regions

Studies looking at resection in high-grade gliomas have had mixed results. The authors briefly review the literature regarding the value of the extent of resection. They proceed to the preoperative and intraoperative tools available to the neurosurgeon to distinguish eloquent from noneloquent language cortex and fibers, including the emerging roles of functional magnetic resonance imaging diffusion tensor imaging tractography and direct cortical/subcortical stimulation in the surgical management of tumors in eloquent areas. Finally, the authors evaluate the postoperative course of these patients and the effect of language deficits on their quality of life.     

Spontaneous speech of patients with gliomas in eloquent areas before and early after surgery

Background

Glioma patients often complain about problems in daily conversation. A detailed spontaneous speech analysis could provide more insight in these communicative problems; no previous studies are reported.

Objective

To select sensitive parameters in spontaneous speech pre- and post-operatively in patients with gliomas in eloquent areas.

Methods

We included 27 patients and 21 healthy controls. In addition to a naming and category fluency test, spontaneous speech was collected 1 month pre-operatively and 3 months post-operatively, and analysed with the variables: Self-corrections, Repetitions, Lexical Diversity, Incomplete Sentences and Mean Length of Utterance (MLUw). A correlation analysis was performed between the linguistic variables and tumour characteristics (grade, localisation and volume), treatment related factors, and between the linguistic variables and the language tasks.

Results

Pre-operatively, patients produced more Incomplete Sentences than the controls (p?<?0.001). Post-operatively, patients’ utterance length (MLUw) (p?<?0.05) was also deviant. The quality of the spontaneous speech was influenced by tumour grade and localisation. There was no influence of tumour volume or treatment-related factors. Pre- and post-operatively, patients’ performance on the naming and the fluency task deviated from normal (p?<?0.001). The majority of the linguistic variables did not correlate with the language tasks, pointing to a measurement of distinct linguistic aspects.

Conclusion

Pre- and post-operatively there was a disorder in naming, category fluency and spontaneous speech, partly influenced by tumour characteristics. A spontaneous speech analysis appeared to be a valuable addition to standardised language tasks. Both measurements are important tools to obtain a complete linguistic profile.     

Inter- and intrapatients comparison of WHO grade II glioma kinetics before and after surgical resection

Grade II gliomas grow slowly and linearly (at rates about 4 mm/year) before undergoing anaplastic transformation. In order to analyze how surgery may affect radiological grade II glioma kinetics, we restrospectively reviewed our national database searching for patients operated on for a supratentorial grade II glioma between 1997 and 2007. We selected patients with at least two postoperative MRI with a minimal delay of 6 months. For each patient, postoperative residues were segmented on successive MRIs. Velocities of diameter expansion were estimated by linear regression of mean diameter evolution for each patient. Fifty-four patients fulfilled inclusion criteria. Median postoperative follow-up was 1.6 years with, on average, 3.4 MRI examinations per patient. Postoperative growth rates of mean diameter were normally distributed, around a mean value of 4.3 mm/year (SD?=?3.2 mm/year). Statistical analysis showed no difference between this distribution and the distribution of preoperative growth rates in a previous series of 143 grade II gliomas. For a subset of 23 patients, delay between first MRI and surgery made it possible to estimate also preoperative growth rates. Intrapatient comparison revealed that growth rates were grossly unchanged for 80% of cases. In summary, inter- and intrapatient comparison of pre- and postoperative growth rates proves that surgery does not change grade II glioma dynamics, thus, acting as a cytoreduction.     

Usefulness of direct electrical stimulations during surgery for gliomas located within eloquent brain regions

Glioma surgery in functional areas has undergone a dramatic development these last few years, thanks to improvements in both intraoperative functional imaging and direct electrical stimulation of cortical areas or association pathways. The goal of these techniques to achieve complete as possible surgical removal of tumors located in eloquent areas (sensitive, motor and language areas) with minimal risk of permanent sequelae. To be reliable, a rigorous methodology is required. Current cortical mapping is very easy to achieve, whereas mapping of association pathways will require much more experience. In case of tumors located in somatosensorial or language areas, the difficulties related to accurate sub cortical localization are combined with these of local anesthesia and the best task choice to evaluate the integrity of cognitive functions. These functional techniques allow total or sub total removal in 52% to 76.2% of patients. Transient worsening is observed in 13% to 80% of the patients; the rate of permanent sequelae averages 4%.     

Fronto-mesial WHO grade II and III gliomas: specific aspects of tumours arising from the anterior cingulate gyrus

A total 17 fronto-mesial grade II and III gliomas among a total of 64 frontal grade II and III gliomas underwent surgical resection between January 2003 and June 2007. Eleven fronto-mesial gliomas originated from the anterior cingulate gyrus, while the others originated from the genu of the corpus callosum. None of the grade II or III gliomas originated from the gyrus rectus. Anterior cingulate gliomas exhibited distinct features with regard to presenting symptoms, MRI, histopathology and prognosis. Epilepsy was the dominant presenting symptom of anterior cingulate tumours. Five of the 11 gliomas had a sharp border on MRI. Four of the 11 were histopathologically classified as WHO grade II and seven as WHO grade III and an oligodendrocytic component was apparent in eight of the 11 specimens. Comparison of the post-operative survival with the entire set of frontal gliomas showed a trend that anterior cingulate tumours had a more favourable prognosis.     

Proof of principle: supramarginal resection of cerebral metastases in eloquent brain areas

Background

Cerebral metastases are not sharply delimitatable; therefore, microsurgical circumferential stripping of intracerebral metastases is often insufficient for preventing local tumor recurrence. Supramarginal resection significantly improves local tumor control but was suggested not to be suitable for metastases in eloquent brain areas. Therefore, we retrospectively analyzed a series of patients with cerebral metastases situated in eloquent areas for newly occurring neurologic deficits after supramarginal resection performed as awake surgery.

Methods

A retrospective analysis was performed for all patients who underwent supramarginal resection for a cerebral metastasis performed as awake surgery between June 2011 and April 2012. All metastases were localized in eloquent brain areas. Pre- and postsurgical neurologic status was documented as well as data regarding the primary cancer and histopathologic data. Postoperative MRI within 72?h was scheduled routinely to verify complete resection.

Results

A total of 19 patients underwent awake surgery for a cerebral metastasis in eloquent brain areas. Surgery was well tolerated in all patients. Neurologic symptoms improved in five patients after surgery. In three patients, neurologic deficits existing before surgery worsened. The postoperative median National Institute of Health Stroke Scale (NIHSS) score did not differ from the preoperative value.

Conclusions

Awake surgery is a feasible tool for metastases in eloquent areas, minimizing postoperative neurologic deficits and morbidity. Therefore, eloquently situated metastases may also be eligible for supramarginal resection. Further studies are needed in order to analyze the benefit of this method in achieving better tumor control.     

功能神经导航及术中磁共振成像在语言区胶质瘤手术中的应用

目的 探讨功能神经导航及高场强术中磁共振成像(iMRI)在脑语言区胶质瘤手术中的临床应用价值.方法 自2009年4月至2010年4月,48例语言区胶质瘤患者接受了功能神经导航及iMRI辅助下的手术.使用血氧水平依赖功能MRI(BOLD-fMRI)显示语言区皮层,同时采用弥散张量成像(DTI)技术重建弓形束,将上述语言功...     

IDH wild-type WHO grade II diffuse low-grade gliomas. A heterogeneous family with different outcomes. Systematic review and meta-analysis

Neurosurgical Review - WHO grade II diffuse low-grade gliomas (DLGGs) were recently divided into sub-groups on the basis of their molecular profiles. IDH wild-type (IDH-wt) tumors seem to be...     

Clinical experiences with oligoastrocytomas WHO grade II and III

Between April 1991 and June 2002, 39 patients with an histologically proven oligoastrocytoma WHO grade II and III were operated on in our department. Twenty-two patients were male and 17 female. Mean age was 42 years (20–67 years). The tumor was localized in the frontal lobe in 22 patients, in the temporal lobe in seven patients, in the parietal lobe in nine patients and in the occipital lobe in one patient. The leading clinical symptoms were seizures in 33 patients. Seventeen patients were operated on under local anesthesia. One operation was performed in 22 patients, two operations in eight, three operations in five, four operations in three and six operations in one patient. Histological examination showed oligoastrocytoma WHO grade II in 12 patients and WHO grade III in 27 patients. Postoperative radiotherapy was performed in 33 patients and chemotherapy in six patients. One female patient developed spinal drop metastases 10 months after the operation. One patient with a primary oligoastrocytoma grade II and five patients with a primary oligoastrocytoma grade III died during follow-up. The follow-up period was between 6 months and 25 years (mean 7 years 6 months).     

Prognostic factors in supratentorial WHO grade II astrocytoma in adults

The records of 33 adult patients with supratentorial World Health Organization grade II astrocytoma (A-II) treated between January 1980 and April 1997 at our hospitals were retrospectively reviewed. All tumours were surgically resected or biopsied and their MIB-1 labelling indices (LIs) were less than 1.5%. The median time to tumour progression after the initial surgery was 60 months, and the 5- and 10-year tumour progression-free rates were 53 and 39%, respectively. The median survival time was 107 months, and the 5- and 10-year survival rates were 66 and 43%, respectively. The major cause of death was tumour recurrence with malignant transformation, comprising 93% of all deaths due to unrestrained tumour growth. In a univariate analysis for survival rate by log-rank test, age (< 60 years), Karnofsky Performance Scale score (90-100%), tumour location (except for the basal ganglia), and extent of surgery (more than biopsy) were revealed to be significant positive prognostic factors. A Cox proportional hazard multivariate regression analysis confirmed that the age was the only independent, significant positive prognostic factor in this series. The survival time after the initial surgery in patients without radiotherapy tended to be prolonged compared with those of the patients with radiotherapy. Of the 26 patients who received radiotherapy, however, the survival time after the initial surgery in the nine patients with intraoperative radiotherapy was significantly prolonged compared with the 17 patients who received sole external beam radiotherapy. Gender, symptoms, histology, p53 LI, enhancement on CT/MRI, cyst, calcification and chemotherapy were not shown to be significant prognostic factors. The optimal management strategy for A-II is expected to be established by clarification of the natural history with cytological and molecular biological analyses of the biological features of this disease.     

Neuronavigation and resection of lesions located in eloquent brain areas under local anesthesia and neuropsychological-neurophysiological monitoring.

BACKGROUND: The aim of this study was to determine the safety and maximal extension of tumor resection achievable with a combination of awake craniotomy under local anesthesia, neuronavigation, and continuous neuropsychological and neurophysiological monitoring in patients with lesions within the eloquent brain. METHODS: We have performed 55 resections of different pathologies with neuronavigation on 52 patients from January 1998 to December 2002. Mean age was 49 years, the male to female ratio was 37 to 15. All patients underwent a continuous examination by a neuropsychologist and repetitive cortical stimulations during the resection, and a 3-month postoperative neurological examination to determine functional outcome. Neurological outcome and results of resection of patients with gliomas were compared to a control group of 27 patients with lesions in the central region who were operated under general anesthesia during the same time period. RESULTS: Tumor resection was stopped when a macroscopic total cytoreduction was achieved, or at the onset of neurological dysfunction. There was a higher rate of complete tumor resection (77% vs. 33%) and a lower rate of neurological deterioration (33% vs. 12%) in the study group compared to the control group. Overall, a complete resection in the study group was achieved in 40 patients (72%), a partial resection in 28%. Five patients developed a new deficit during surgery which resolved completely after a change of surgical strategy, 14 patients had a new deficit after surgery which improved within 3 months in 6 patients. There was no operative mortality. CONCLUSION: The combination of neuronavigation with cortical stimulation and repetitive neurological and language examinations allows a more radical resection of tumors in eloquent brain areas, otherwise considered as inoperable.