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

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

Current Trends in Glioblastoma Treatment

Glioblastoma (also called glioblastoma multiforme – GBM) is a primary brain neoplasm, representing about 55% of all gliomas. It is a very aggressive and infiltrative tumor. Glioblastoma is usually highly malignant, with more than 90% 5-year mortality and a median survival of about 14.6 months. Compared to other cancers, the survival rate has not greatly changed over time and no current treatment is curative for this disease. Because the tumor has a heterogeneous cell population containing several types of cells, the treatment for GBM is one of the most challenging in clinical oncology. This chapter will discuss the current approaches in glioblastoma treatment, including resection techniques, chemotherapy and radiation therapy

Safe surgery for glioblastoma: Recent advances and modern challenges.

One of the major challenges during glioblastoma surgery is balancing between maximizing extent of resection and preventing neurological deficits. Several surgical techniques and adjuncts have been developed to help identify eloquent areas both preoperatively (fMRI, nTMS, MEG, DTI) and intraoperatively (imaging (ultrasound, iMRI), electrostimulation (mapping), cerebral perfusion measurements (fUS)), and visualization (5-ALA, fluoresceine)). In this review, we give an update of the state-of-the-art management of both primary and recurrent glioblastomas. We will review the latest surgical advances, challenges, and approaches that define the onco-neurosurgical practice in a contemporary setting and give an overview of the current prospective scientific efforts

Multiformni glioblastom lokaliziran u motornom korteksu: specifičnosti u odnosu na gliome niskog stupnja iste lokalizacije - analiza serije od šezdeset bolesnika

The verified presence of a glioblastoma multiforme (GBM ) tumor in the motor area of the brain, in a patient lacking preoperative neurological deficit, offers no certainty that the tumor can be radically removed without the possibility of causing postoperative motor deficit. We present a series of 60 patients hospitalized at the Clinical Department of Neurosurgery, Clinical Center of Serbia in Belgrade between October 2011 and February 2015, harboring tumors located within and in the vicinity of the motor zone of the brain. By using Karnofsky‘s index (KI), the pre- and postoperative conditions of the patients were evaluated. Regarding electrical stimulation of the motor cortex, significantly lower values of the electrical current intensity, frequency, and pulse wave duration (p<0.01) were needed for triggering motor response in case of GBM tumor compared to a slowly growing tumor (low-grade). Patients with low-grade gliomas (LGG) had statistically significantly higher KI values pre- and postoperatively than patients with GBM (p<0.01). Using electrical stimulation of the cortex, a higher grade of resection of LGG could be achieved as compared with the group presenting with GBM (c2=5.281; df=1; p<0.05). Our findings and review of the results reported by other authors underline the necessity of routine application of electrical stimulation of the cerebral cortex in order to identify the primary motor field (M1).Jasna prezentacija tumora mozga u području motorne zone kod bolesnika koji prijeoperacijski nisu imali slabost ekstremiteta nije jamstvo da se on može radikalno odstraniti bez poslijeoperacijskog neurološkog deficita. Prikazujemo niz od 60 ispitanika sa supratentorijalnim tumorima lokaliziranim u i oko motorne zone mozga, koji su hospitalizirani na Institutu za neurokirurgiju KCS u Beogradu u razdoblju od listopada 2011. do veljače 2015. godine. Procjena prije- i poslijeoperacijskog stanja bolesnika je vrednovana ljestvicom Karnofski indeksa (KI). Iz serije su isključeni bolesnici s recidivom tumora i bolesnici čiji je KI kod prijma bio manji od 70. Tijekom procedure elektrostimulacije motornog korteksa potrebne su značajno manje vrijednosti jačine struje, frekvencije i pulsnog vala (p<0,01) za izazivanje motornog odgovora u slučaju postojanja tipa tumora multiformnog glioblastoma (glioblastoma multiforme, GBM ) u odnosu na spororastuće gliome (niskog stupnja) mozga. Nađena je statistički značajna razlika u prije- i poslijeoperacijskim vrijednostima KI (F=48,856; df=1; p<0,01; Eta2=0,457), naime, bolesnici s gliomima niskog stupnja imali su statistički značajno veću vrijednost KI prije- i poslijeoperacijski u odnosu na vrijednosti KI kod skupine bolesnika s GBM (p<0,01). Uporabom elektrostimulacije korteksa postignut je veći stupanj radikalnosti kirurške resekcije glioma niskog stupnja u odnosu na skupinu bolesnika s GBM (c2=5,281; df=1; p<0,05). Kirurgija tumora lokaliziranih u motornom korteksu predstavlja izazov zbog pratećeg rizika od de novo nastanka motornog deficita. Naši rezultati kao i rezultati drugih autora pokazuju neophodnost rutinske primjene direktne elektrostimulacije moždane kore radi identifikacije primarnog motornog polja (M1)

Motor Evoked Potentials in Supratentorial Glioma Surgery

Primary brain tumors, that is gliomas, are frequently located close to or within functional motor areas and motor tracts and therefore represent a major neurosurgical challenge. Preservation of the patients’ motor functions, while achieving a maximum resection of tumor, can be only achieved by monitoring and locating motor areas and motor tracts intraoperatively. The intraoperative use of motor evoked potentials (MEPs) represents the current gold standard to do so. However, intraoperative MEP monitoring and mapping can be quite challenging and require a profound knowledge of the MEP technique, brain anatomy and physiology and anesthesia. In this chapter, a systematic review of PubMed listed literature on MEP monitoring and mapping in glioma surgery is presented. The benefits, limitations, technical pearls and pitfalls are discussed from the perspective of an experienced neurosurgical/neurophysiological team