Original ArticleIs There an Indication for Intraoperative MRI in Subtotal Resection of Glioblastoma? A Multicenter Retrospective Comparative Analysis
Introduction
The present literature on glioblastoma (GB) surgery shows a strong benefit of gross total resection (GTR) on overall survival (OS).1 Still, counseling patients with highly eloquent GBs amenable only to subtotal resection (STR) remains challenging. Based on the current level of evidence, definitive conclusions concerning the oncologic benefit of STR are not possible. Although explicit data on this group of patients are scarce, a large meta-analysis demonstrated that STR shows a significant benefit for OS compared with biopsy alone without increased morbidity.2 Data from Marko et al.3 showed that there might by a linear association of resected tumor volume and survival promoting the strategy of a maximum safe resection in GB surgery. The additional use of intraoperative imaging methods, such as 5-aminolevulinic acid and intraoperative magnetic resonance imaging (iMRI), was shown to be beneficial to increase GTR rate in lesions eligible for complete removal of contrast enhancement.4, 5 Based on rates of residual tumor volume and thresholds of extent of resection (EOR) to influence survival published by Chaichana et al.,6 there might be a beneficial role of intraoperative imaging in lesions primarily amenable only to STR. High-field iMRI with field strength of ≥1.5T allows for an intraoperative update of neuronavigation and diffusion tensor imaging (DTI) data for fiber tracking.7 Thus, iMRI provides useful information on eloquent areas in addition to intraoperative mapping/monitoring (IOM). The aim of the present study was to assess the influence of use of iMRI on EOR in preoperatively intended STR of GB involving eloquent areas. Furthermore, we assessed clinical outcome and progression-free survival (PFS) and OS in this cohort.
Section snippets
Study Design
We performed a retrospective multicenter study in 3 neuro-oncologic centers (Klinikum Stuttgart/Katharinenhospital, University Medical Center Mainz, and University Medical Center Ulm/Günzburg) to evaluate patients undergoing STR with regard to clinical outcomes from 2008 to 2013. Ethical approval was received by the ethical board of Ulm University (No: 316/16). Owing to the retrospective nature of the study, no patient consent was required for this study. Inclusion criteria were age >18 years;
General Assessment
Our assessment included 70 patients with a GB diagnosis (World Health Organization grade IV); 33 patients underwent surgery with iMRI, and 37 patients underwent surgery without MRI. Table 1 presents the details of both cohorts. All patients had a complete follow-up. Except for the higher prevalence of patients with MGMT promoter methylation in the iMRI cohort and the higher number of unassessed MGMT promoter methylation status in the non-iMRI group, both cohorts showed similar general
Discussion
iMRI has been used for the past 20 years to assist surgery for various intracranial pathologies.9, 10, 11, 12, 13, 14, 15, 16 This technology was developed primarily to control for the significant shift of brain structures during the course of surgery (brain shift).17, 18 Based on the direct visualization of residual tumor and the option to update the imaging information of the neuronavigation system, iMRI has been shown to improve EOR compared with neuronavigation alone.4 The development of
Conclusions
Maximal safe resection is an important prognostic factor for patients with eloquent GBs. iMRI seems to be a relevant tool to achieve this goal. We recommend the mandatory use of IOM during all intended STRs.
Acknowledgments
We thank the Institute for Epidemiology and Medical Biometrics of Ulm University for extensive statistical counseling.
References (28)
- et al.
Intraoperative MRI guidance and extent of resection in glioma surgery: a randomised, controlled trial
Lancet Oncol
(2011) - et al.
Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial
Lancet Oncol
(2006) - et al.
Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial
Lancet Oncol
(2009) - et al.
Comparing 0.2 tesla with 1.5 tesla intraoperative magnetic resonance imaging analysis of setup, workflow, and efficiency
Acad Radiol
(2005) - et al.
Prognostic implications of extent of resection in glioblastoma: analysis from a large database
World Neurosurg
(2017) - et al.
Gross total but not incomplete resection of glioblastoma prolongs survival in the era of radiochemotherapy
Ann Oncol
(2013) - et al.
Validation and predictive power of Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis classes for malignant glioma patients: a report using RTOG 90-06
Int J Radiat Oncol Biol Phys
(1998) - et al.
Association of the extent of resection with survival in glioblastoma: a systematic review and meta-analysis
JAMA Oncol
(2016) - et al.
Biopsy versus partial versus gross total resection in older patients with high-grade glioma: a systematic review and meta-analysis
Neuro Oncol
(2015) - et al.
Extent of resection of glioblastoma revisited: personalized survival modeling facilitates more accurate survival prediction and supports a maximum-safe-resection approach to surgery
J Clin Oncol
(2014)
Establishing percent resection and residual volume thresholds affecting survival and recurrence for patients with newly diagnosed intracranial glioblastoma
Neuro Oncol
Preoperative and intraoperative diffusion tensor imaging-based fiber tracking in glioma surgery
Neurosurgery
Intraoperative diagnostic and interventional MRI in neurosurgery: first experience with an “open MR” system
Craniotomy for tumor treatment in an intraoperative magnetic resonance imaging unit
Neurosurgery
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Anesthetic challenges and outcomes for procedures in the intraoperative magnetic resonance imaging suite: A systematic review
2019, Journal of Clinical AnesthesiaCitation Excerpt :Introduction of a magnetic field within the surgical environment also necessitates modifications to the physical space and equipment, resulting in multiple changes to the usual workflow, communication, and patient care. The use of iMRI technology is supported by the available evidence, suggesting a benefit to neurosurgical patients undergoing intracranial tumor resections [9–12]. Several other applications are being investigated, including epilepsy and breast cancer surgery [13,14].
Counseling Patients with a Glioblastoma Amenable Only for Subtotal Resection: Results of a Multicenter Retrospective Assessment of Survival and Neurologic Outcome
2018, World NeurosurgeryCitation Excerpt :Data of our group from a retrospective multicenter series assessing exclusively patients with GB amenable only for stereotactic biopsy or for STR show that, especially in the latter group of patients, potential extent of resection (EoR) is mainly underestimated.7 Furthermore, we found that patients with GB amenable for a STR operated with intraoperative magnetic resonance imaging (iMRI) showed an improved OS compared with resection without use of additional intraoperative imaging.8 This finding might support the theory of a maximum safe resection approach in patients with an intended STR.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.