Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review

Abstract

Purpose The extent of resection (EOR) is an independent prognostic factor for overall survival (OS) in adult patients with Glioma Grade 4 (GG4). The aim of the neuro-oncology section of the Italian Society of Neurosurgery (SINch®) was to provide a general overview of the current trends and technical tools to reach this goal. Methods A systematic review was performed. The results were divided and ordered, by an expert team of surgeons, to assess the Class of Evidence (CE) and Strength of Recommendation (SR) of perioperative drugs management, imaging, surgery, intraoperative imaging, estimation of EOR, surgery at tumor progression and surgery in elderly patients. Results A total of 352 studies were identified, including 299 retrospective studies and 53 reviews/meta-analysis. The use of Dexamethasone and the avoidance of prophylaxis with anti-seizure medications reached a CE I and SR A. A preoperative imaging standard protocol was defined with CE II and SR B and usefulness of an early postoperative MRI, with CE II and SR B. The EOR was defined the strongest independent risk factor for both OS and tumor recurrence with CE II and SR B. For intraoperative imaging only the use of 5-ALA reached a CE II and SR B. The estimation of EOR was established to be fundamental in planning postoperative adjuvant treatments with CE II and SR B and the stereotactic image-guided brain biopsy to be the procedure of choice when an extensive surgical resection is not feasible (CE II and SR B). Conclusions A growing number of evidences evidence support the role of maximal safe resection as primary OS predictor in GG4 patients. The ongoing development of intraoperative techniques for a precise real-time identification of peritumoral functional pathways enables surgeons to maximize EOR minimizing the post-operative morbidity.

Resection of positive tissue on methionine‐PET is associated with improved survival in glioblastomas

“…The association between resection of the MET uptake area and outcomes should be investigated with consideration of MGMT mutations. Postoperative MRI was conducted at a later stage than recommended in the current guidelines (Grabowski et al., 2014 ; Ius et al., 2023 ), which may have hindered our ability to accurately assess the postoperative Gd area (Garcia‐Ruiz et al., 2021 ). On the other hand, the threshold of Gd‐EOR > 70% we used for comparison is typically applied to postoperative MRIs performed at shorter intervals.…”

“…This treatment has been shown to improve the survival rate (Grabowski et al., 2014 ; Lacroix et al., 2001 ; Lopez‐Rivera et al., 2021 ; Sanai et al., 2011 ). The intraoperative use of 5‐aminolevulinic acid (5‐ALA; Christodoulides & Lavrador, 2021 ), a neuro‐navigation system based on MRI images of the tumor, and awake surgery are common techniques employed to achieve maximum resection while preserving normal functional tissue (Ius et al., 2023 ; Youngblood et al., 2021 ). Recently, the usefulness of fluorescence imaging during GBM surgery has been reported (Cao et al., 2022 ; Li et al., 2018 ; Shen et al., 2021 ; Shi et al., 2022 ).…”

Dexamethasone Use in Perioperative Neuroscience: Boon or Bane, or Both?

“…13 Neuro-oncology surgeons in Europe have recently called on clinicians prescribing dexamethasone to glioma patients to be wary of these potential complications and use dexamethasone judiciously. 14 In addition to the aforementioned adverse effects, dexamethasone is also associated with myopathy, altered appetite, poor sleep, mood disturbance, and other effects, including psychosis, mania, depression, anxiety, delirium, and dementia. Studies indicate that these are not rare occurrences, occurring in up to 5% to 10% of patients receiving high-dose steroids.…”

“…In vitro, in vivo, and clinical studies have reported conflicting evidence on glioblastoma cell aggressiveness with dexamethasone, but with some reporting increased glioma stem cell proliferation and angiogenesis 13 . Neuro-oncology surgeons in Europe have recently called on clinicians prescribing dexamethasone to glioma patients to be wary of these potential complications and use dexamethasone judiciously 14 …”

Machine learning to improve interpretability of clinical, radiological and panel-based genomic data of glioma grade 4 patients undergoing surgical resection

“…Glioma grade 4 (GG4) tumors, which include astrocytoma IDH-mutant grade 4 and the astrocytoma IDH wt (that currently defines the glioblastoma class) are the most common and aggressive primary tumors of the central nervous system [ 1 – 3 ]. Compelling evidence, based on objective tumor volume analysis, supports the role of the extent of resection (EOR) in high grade glioma patients as the first step of patients management.…”