Combination of neoadjuvant chemotherapy followed by surgical resection as a new strategy for WHO grade II gliomas: a study of cognitive status and quality of life

Abstract

Diffuse WHO grade II (GIIG) may be unresectable when involving critical structures. To assess the feasibility and functional tolerance (cognition and quality of life) of an original therapeutic strategy combining neoadjuvant chemotherapy followed by surgical resection for initially inoperable GIIG. Ten patients underwent Temozolomide for unresectable GIIG, as initial treatment or at recurrence after previous partial resection, due to invasion of eloquent areas or bi-hemispheric diffusion preventing a total/subtotal removal. Functional outcome after both treatments was assessed, with evaluation of seven cognitive domains. Chemotherapy induced tumor shrinkage (median volume decrease 38.9%) in ipsilateral functional areas in six patients and in the contralateral hemisphere in four. Only four patients had a 1p19q codeletion. The tumor shrinkage made possible the resection (mean extent of resection 93.3%, 9 total or subtotal removals) of initially inoperable tumors. Postoperatively, three patients had no deficits, while verbal episodic memory and executive functions were slightly impaired in seven patients. However, global quality of life was roughly preserved on the EORTC QLQ C30 + BN 20 (median score: 66.7%). Role functioning score was relatively reduced (median score: 66.7%) whereas KPS was preserved (median score: 90, range 80-100). Seven patients became seizure-free while three improved. This combined treatment is feasible, efficient (surgery made possible by neoadjuvant chemotherapy) and well-tolerated (preservation of quality of life, no serious cognitive disturbances). Cognitive deficits seem mostly related to tumor location. Because KPS is not reliable enough, a detailed neuropsychological assessment should be systematically performed in GIIG.

Low-grade glioma surgery in eloquent areas: volumetric analysis of extent of resection and its impact on overall survival. A single-institution experience in 190 patients

“…Consequently, the definition of the best management of a residual tumor represents the main open question in clinical practice. 12,55 To this end, neoadjuvant chemotherapy was recently advocated for LGG management, with the aim of inducing tumor shrinkage before operation or reoperation. 12,19,55 As it is usually believed that postoperative tumor volume influences the prognosis for patients with this disease, 5,17,28,61 it may be more advantageous to start active treatment with radiotherapy or even chemotherapy.…”

“…12,55 To this end, neoadjuvant chemotherapy was recently advocated for LGG management, with the aim of inducing tumor shrinkage before operation or reoperation. 12,19,55 As it is usually believed that postoperative tumor volume influences the prognosis for patients with this disease, 5,17,28,61 it may be more advantageous to start active treatment with radiotherapy or even chemotherapy. [12][13][14] It is therefore of the utmost importance to develop a standard tool that enables an objective preoperative estimation of the postoperative tumor volume.…”

“…12,19,55 As it is usually believed that postoperative tumor volume influences the prognosis for patients with this disease, 5,17,28,61 it may be more advantageous to start active treatment with radiotherapy or even chemotherapy. [12][13][14] It is therefore of the utmost importance to develop a standard tool that enables an objective preoperative estimation of the postoperative tumor volume. Lang et al 30 first asserted that lesions with diffuse margins on T2-weighted MRI are less amenable to radical resection than those with sharp margins.…”

Epilepsy and Brain Tumors

“…These agents also help to improve seizure control (Pace et al, 2003;Kaloshi et al, 2007;Sherman et al, 2011;Ruda et al, 2012;Koekkoek et al, 2015). Administration of temozolomide results in 50% seizure reduction or more in 18-58% of patients with low-grade gliomas and in seizure freedom in 13-50% (Pace et al, 2003;Kaloshi et al, 2007;Sherman et al, 2011;Blonski et al, 2012;Koekkoek et al, 2015). Administration of PCV leads to seizure freedom in 13-60% of patients (Soffietti et al, 1998;Frenay et al, 2005;Lebrun et al, 2007).…”

Preserving quality of life is not incompatible with increasing overall survival in diffuse low-grade glioma patients

“…Second, if the tumor migrates along the white matter tracts, knowing that the plastic potential is very low at the subcortical level (preventing large resection) [10,16], chemotherapy can be administered. Of note, chemotherapy may preserve QoL, including cognitive functions [2], while significantly increasing survival [4]. Furthermore, chemotherapy can also induce shrinkage of the glioma, making possible a (re-)operation while preserving the functional status [1].…”