A Crowdsourced Consensus on Supratotal Resection Versus Gross Total Resection for Anatomically Distinct Primary Glioblastoma

Abstract

BACKGROUND Gross total resection (GTR) of contrast-enhancing tumor is associated with increased survival in primary glioblastoma. Recently, there has been increasing interest in performing supratotal resections (SpTRs) for glioblastoma. OBJECTIVE To address the published results, which have varied in part due to lack of consensus on the definition and appropriate use of SpTR. METHODS A crowdsourcing approach was used to survey 21 neurosurgical oncologists representing 14 health systems nationwide. Participants were presented with 11 definitions of SpTR and asked to rate the appropriateness of each definition. Participants reviewed T1-weighed postcontrast and fluid-attenuated inversion-recovery magnetic resonance imaging for 22 anatomically distinct glioblastomas. Participants were asked to assess the tumor location's eloquence, the perceived equipoise of enrolling patients in a randomized trial comparing gross total to SpTR, and their personal treatment plans. RESULTS Most neurosurgeons surveyed (n = 18, 85.7%) agree that GTR plus resection of some noncontrast enhancement is an appropriate definition for SpTR. Overall, moderate inter-rater agreement existed regarding eloquence, equipoise, and personal treatment plans. The 4 neurosurgeons who had performed >10 SpTRs for glioblastomas in the past year were more likely to recommend it as their treatment plan (P < .005). Cases were divided into 3 anatomically distinct groups based upon perceived eloquence. Anterior temporal and right frontal glioblastomas were considered the best randomization candidates. CONCLUSION We established a consensus definition for SpTR of glioblastoma and identified anatomically distinct locations deemed most amenable to SpTR. These results may be used to plan prospective trials investigating the potential clinical utility of SpTR for glioblastoma.

A consensus definition of supratotal resection for anatomically distinct primary glioblastoma: an AANS/CNS Section on Tumors survey of neurosurgical oncologists

“…Most neurosurgeons surveyed (n=57, 80.3%) agree or strongly agree that GTR plus resection of any noncontrast enhanced disease is an appropriate de nition for SpTR (Table 2A). Compared to the cohort of expert neurosurgical oncologists who previously provided their opinions on this de nition, a two proportion z-test demonstrated that a similar fraction agreed or strongly agreed that it was tting (Experts: n=18, 85.7%; Tumor Section: n=57, 80.3%; p=0.575) [33]. GTR plus resection 1-2 cm beyond contrast-enhancing disease was the second most commonly endorsed de nition, with 52 (73.2%) neurosurgeons agreeing or strongly agreeing with this de nition of SpTR.…”

“…For each of the ten anatomically distinct GBM cases, survey respondents reviewed MR images and categorized the eloquence of the tumor's location, indicated whether it would be reasonable to randomize it to SpTR or GTR, and identi ed their personal treatment plan and any adjunct perioperative techniques they would use (Supplement). Consensus on each case's eloquence, equipoise, or treatment plan was de ned as at least 70% agreement among the respondents, following past conventions [32,33].…”

Preoperative Stereotactic Radiosurgery for Glioblastoma

“…Other surgical techniques, such as awake craniotomy with cortico-subcortical mapping and neuronavigational systems also play a critical role in appropriately selected cases thereby preserving neurologic function and bettering patient outcomes [ 62 , 71 , 72 ]. Some have also advocated for a supratotal resection for GBM [ 73 ].…”

The peritumoral brain zone in glioblastoma: where we are and where we are going

“…Several studies have shown the association between GBM preoperative magnetic resonance imaging (MRI) features and patients prognosis, but only a fraction of them have focused on imaging configuration of PBZ (Al‐Holou et al, 2020; Khalafallah et al, 2021; Molinaro et al, 2020). Moreover, the radiological identification of PBZ, intended as the normal brain tissue bordering the tumor, is problematic.…”

“…One of the concerns of the resection of the FLAIR peritumoral hyperintensities is the amount of the region that need to be resected to increase the patient OS because of studies reporting contradictory results (Certo et al, 2019; Molinaro et al, 2020; Vivas‐Buitrago et al, 2022). In addition, some authors consider some anatomical locations more suitable for supramarginal resection than others (Khalafallah et al, 2021). Among authors supporting resection of NE area in GBMs, some suggest that NE region resection should be not more than 60%, whereas other suggest to resect as much as possible (Molinaro et al, 2020; Pessina et al, 2017; Vivas‐Buitrago et al, 2022).…”