Association of the Extent of Resection With Survival in Glioblastoma

Brown, Timothy J.; Brennan, Matthew; Li, Michael; Church, Ephraim W.; Brandmeir, Nicholas; Rakszawski, Kevin; Patel, Akshal; Rizk, Elias; Suki, Dima; Sawaya, Raymond; Glantz, Michael

doi:10.1001/jamaoncol.2016.1373

Cited by 810 publications

(492 citation statements)

References 69 publications

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“…Gross total resection has been widely shown to be prognostic for improved outcomes compared to subtotal resection in glioblastoma (27,28); however, its role in extending survival in gliosarcoma, particularly in the TMZ era, is less understood. Prior database studies in the Surveillance, Epidemiology, and End Results (SEER) Program (23,29) and the National Cancer Database (NCDB) (30,31) have suggested a potential benefit of achieving GTR.…”

Section: Discussionmentioning

confidence: 99%

Evaluating Surgical Resection Extent and Adjuvant Therapy in the Management of Gliosarcoma

et al. 2020

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Introduction: Gliosarcomas are clinically aggressive tumors, histologically distinct from glioblastoma. Data regarding the impact of extent of resection and post-operative adjuvant therapy on gliosarcoma outcomes are limited.Methods: Patients with histologically confirmed gliosarcoma diagnosed between 1999 and 2019 were identified. Clinical, molecular, and radiographic data were assembled based on historical records. Comparisons of categorical variables used Pearson's Chi-square and Fisher's exact test while continuous values were compared using the Wilcoxon signed-rank test. Survival comparisons were assessed using Kaplan-Meier statistics and Cox regressions.Results: Seventy-one gliosarcoma patients were identified. Secondary gliosarcoma was not associated with worse survival when compared to recurrent primary gliosarcoma (median survival 9.8 [3.8 to 21.0] months vs. 7.6 [1.0 to 35.7], p = 0.7493). On multivariable analysis, receipt of temozolomide (HR = 0.02, 95% CI 0.001-0.21) and achievement of gross total resection (GTR; HR = 0.13, 95% CI 0.02-0.77) were independently prognostic for improved progression-free survival (PFS) while only receipt of temozolomide was independently associated with extended overall survival (OS) (HR = 0.03, 95% CI 0.001-0.89). In patients receiving surgical resection followed by radiotherapy and concomitant temozolomide, achievement of GTR was significantly associated with improved PFS (median 32.97 [7.1-79.6] months vs. 5.45 [1.8-26.3], p = 0.0092) and OS (median 56.73 months [7.8-104.5] vs. 14.83 [3.8 to 29.1], p = 0.0252). Conclusion:Multimodal therapy is associated with improved survival in gliosarcoma. Even in patients receiving aggressive post-operative multimodal management, total surgical removal of macroscopic disease remains important for optimal outcomes.

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Section: Discussionmentioning

confidence: 99%

Evaluating Surgical Resection Extent and Adjuvant Therapy in the Management of Gliosarcoma

et al. 2020

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“…Surgeons use ISM to maximize resection, primarily to increase the patient’s survival while minimizing the chances of morbidity and loss of neurological function [2, 24]. AC is the most frequently used form of ISM, by using electrocortical and subcortical mapping to differ eloquent brain tissue from brain or tumor tissue that is safe to resect.…”

Section: Discussionmentioning

confidence: 99%

“…However, patients with partial or subtotal resections will benefit less from radio- and chemotherapy as compared to patients with total resections [15–18, 20–22, 24]. Intraoperative stimulation mapping (ISM) allows the surgeon to prevent damage to eloquent cortical and subcortical areas during resection [2, 19]. There is compelling evidence that surgeons using ISM experience increased resection percentage while preserving quality of life in low-grade glioma (LGG).…”

Section: Introductionmentioning

confidence: 99%

Impact of intraoperative stimulation mapping on high-grade glioma surgery outcome: a meta-analysis

et al. 2018

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BackgroundIntraoperative stimulation mapping (ISM) using electrocortical mapping (awake craniotomy, AC) or evoked potentials has become a solid option for the resection of supratentorial low-grade gliomas in eloquent areas, but not as much for high-grade gliomas. This meta-analysis aims to determine whether the surgeon, when using ISM and AC, is able to achieve improved overall survival and decreased neurological morbidity in patients with high-grade glioma as compared to resection under general anesthesia (GA).MethodsA systematic search was performed to identify relevant studies. Adult patients were included who had undergone craniotomy for high-grade glioma (WHO grade III or IV) using ISM (among which AC) or GA. Primary outcomes were rate of postoperative complications, overall postoperative survival, and percentage of gross total resections (GTR). Secondary outcomes were extent of resection and percentage of eloquent areas.ResultsReview of 2049 articles led to the inclusion of 53 studies in the analysis, including 9102 patients. The overall postoperative median survival in the AC group was significantly longer (16.87 versus 12.04 months; p < 0.001) and the postoperative complication rate was significantly lower (0.13 versus 0.21; p < 0.001). Mean percentage of GTR was significantly higher in the ISM group (79.1% versus 47.7%, p < 0.0001). Extent of resection and preoperative patient KPS were indicated as prognostic factors, whereas patient KPS and involvement of eloquent areas were identified as predictive factors.ConclusionsThese findings suggest that surgeons using ISM and AC during their resections of high-grade glioma in eloquent areas experienced better surgical outcomes: a significantly longer overall postoperative survival, a lower rate of postoperative complications, and a higher percentage of GTR.Electronic supplementary materialThe online version of this article (10.1007/s00701-018-3732-4) contains supplementary material, which is available to authorized users.

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“…Mounting evidence indicates that aggressive cytoreductive surgery is associated with significantly improved survival outcomes, which could be due to surgery being influenced by the mutational status of the isocitrate dehydrogenase (IDH) gene (10)(11)(12). A previous meta-analysis based on 37 studies assessed whether greater extent of surgery affects survival outcomes in GBM patients and found that GTR is associated with significantly improved overall survival (OS) and progression-free survival (PFS) compared with subtotal resection (STR) (13). However, GTR and STR have not been comparatively assessed for their effects in elderly patients with high-grade glioma.…”

Section: Introductionmentioning

confidence: 99%

Gross Total vs. Subtotal Resection on Survival Outcomes in Elderly Patients With High-Grade Glioma: A Systematic Review and Meta-Analysis

et al. 2020

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Background: The optimal strategy for the management of high-grade glioma in the elderly (≥60.0 years) remains controversial, especially regarding the effects of surgical extent on survival outcomes. The purpose of this study was to compare gross total resection (GTR) with subtotal resection (STR) for treatment effects in elderly patients with high-grade glioma.Methods: Three electronic databases were systematically searched, including PubMed, EmBase, and the Cochrane library, from inception to August 2018. Hazard ratios (HRs) or odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were used to express summary effect estimates using the random-effects model. Nineteen retrospective observational studies involving a total of 10,815 elderly patients with high-grade glioma were included in this meta-analysis.Results: The summary results indicated that GTR was associated with a significant improvement in overall survival (OS) compared with STR (HR = 0.70, 95% CI = 0.64-0.77). In addition, elderly patients administered GTR showed lower risk of 3-month mortality (OR = 0.47, 95% CI = 0.24-0.93), 6-month mortality (OR = 0.38, 95% CI = 0.26-0.56), 9-month mortality (OR = 0.35, 95% CI = 0.25-0.49), and 1-year mortality (OR = 0.40, 95% CI = 0.29-0.56). Pooled OS data differed when stratified by publication year, country, sample size, disease status, and study quality.Conclusion: GTR seems to be more effective than STR in achieving longer survival in elderly patients with high-grade glioma.

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Association of the Extent of Resection With Survival in Glioblastoma

Abstract: This analysis represents the largest systematic review and only quantitative systematic review to date performed on this subject. Compared with STR, GTR substantially improves overall and progression-free survival, but the quality of the supporting evidence is moderate to low.

Cited by 810 publications

References 69 publications

Evaluating Surgical Resection Extent and Adjuvant Therapy in the Management of Gliosarcoma

Evaluating Surgical Resection Extent and Adjuvant Therapy in the Management of Gliosarcoma

Impact of intraoperative stimulation mapping on high-grade glioma surgery outcome: a meta-analysis

Gross Total vs. Subtotal Resection on Survival Outcomes in Elderly Patients With High-Grade Glioma: A Systematic Review and Meta-Analysis

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