Elsevier

World Neurosurgery

Volume 110, February 2018, Pages e612-e620
World Neurosurgery

Original Article
Surgical Resection of Anterior and Posterior Butterfly Glioblastoma

https://doi.org/10.1016/j.wneu.2017.11.059Get rights and content

Background

Evidence suggests a survival benefit for patients with glioblastoma who undergo maximal safe surgical resection. Not all glioblastomas are amenable to surgical resection and anatomic location is one potentially limiting factor. Glioblastomas that invade the corpus callosum and cross midline to the contralateral hemisphere—butterfly glioblastomas (bGBMs)—are one subgroup of tumors traditionally deemed inoperable.

Methods

We evaluate the management of bGBMs at our institution to assess whether surgical resection is feasible, safe, and more effective than biopsy. We retrospectively reviewed our institutional brain tumor registry for all adult patients treated for glioblastoma (World Health Organization grade IV) between 2004 and 2016 to identify all bGBMs.

Results

Survival between biopsy and resection was assessed using the Kaplan-Meier model. Twenty-nine (3.8%) of 764 newly diagnosed GBMs were identified as bGBM. Of these, 9 patients (31.0%) underwent surgical resection and 20 patients (69.0%) underwent biopsy. Five patients (55.6%) in the surgical resection group had 98% extent of resection or greater. Median survival of our entire cohort of patients was 3.3 months. Median survival was higher in the surgical resection groups (7.8 vs. 2.8 months; P = 0.0019). Increased age is independently associated with increased risk of death, and adjuvant therapy is independently associated with prolonged survival.

Conclusions

Surgical resection of butterfly glioblastoma prolongs survival without increased risk of permanent neurologic deficit. Both anterior and posterior bGBMs can be resected safely.

Introduction

Glioblastoma (GBM), the most common malignant glioma, is an aggressive brain cancer with poor prognosis. The natural history of GBM remains unfavorable; however, evidence demonstrates prolonged survival with maximal safe surgical resection followed by adjuvant radiotherapy and temozolomide chemotherapy.1, 2, 3, 4 Like all infiltrating glial neoplasms, GBM typically spreads along white matter tracts.5, 6, 7, 8, 9, 10 Growth and infiltration in certain tracts and eloquent areas of the brain, such as the corpus callosum, can render these tumors only partially resectable or unresectable. GBM with extension along the corpus callosum often depicts a pattern reminiscent of a butterfly on magnetic resonance imaging (MRI), hence the name butterfly glioblastoma (bGBM). Invasion of the corpus callosum confers increased risk of tumor dissemination to the contralateral hemisphere, preoperative functional deficits, and even poorer prognosis. Early attempts at surgical resection of bGBM caused devastating neurologic deficits, including abulia and akinetic mutism in some patients.11 For these reasons, combined with the critical anatomic location, bGBMs are traditionally deemed inoperable. Thus, bGBMs have been managed with biopsy followed by adjuvant chemoradiotherapy, biopsy followed by palliative care, or by palliation alone. Few modern studies have demonstrated that resection of anterior bGBM can be performed safely.11, 12, 13 Nonetheless, a paucity of data exists to guide neurosurgeons about the optimal surgical management for this disease. We hypothesized that appropriately selected patients with bGBM could benefit from maximal safe resection. We set out to examine patients with bGBM treated at our institution to evaluate surgical interventions performed, the safety of surgical resection, and its impact on outcome and survival.

Section snippets

Patient Selection

The study was approved by the Health Research Ethics Board of Alberta Cancer Committee. We performed a retrospective review of our institutional brain tumor registry of all adult patients (age ≥18years) who underwent biopsy or surgical resection for glioblastoma (World Health Organization [WHO] grade IV) from October 2004 to October 2016 at the Foothills Medical Center. Diagnosis was reported by a neuropathologist and available in patient medical records. Patients with low-grade glioma, prior

Patient and Clinical Characteristics

Seven hundred sixty-four patients with newly diagnosed glioblastoma (WHO grade IV) were treated between October 2004 and October 2016 at our institution. Of these patients, 29 (3.8%) were found to harbor bGBM as diagnosed on MRI (Figure 1) and confirmed on histopathologic analysis. Patient demographics and clinical characteristics are summarized in Table 1. The age at diagnosis for the entire cohort was 59.8 ± 2.2 years (mean ± SEM), and 18 patients (62.0%) were male. Cognitive decline and

Discussion

Evidence suggests that maximal safe surgical resection and adjuvant treatment prolong survival for patients with GBM. Not all GBMs are thought to be amenable to surgical resection or aggressive therapy, in part because of their anatomic location. GBMs that infiltrate the corpus callosum (i.e., bGBM) are one such group. The corpus callosum is densely packed with white matter fascicles, making it generally resistant to infiltration.15, 16, 17 Hence, lesions that spread along the corpus calloum15,

Conclusion

Considering the findings of this study, we assert that bGBM, involving either the anterior or posterior segments of the corpus callosum, can be safely resected and that surgical resection prolongs survival. We believe that surgery reduces the tumor burden, thus giving patients a chance to undergo adjuvant treatment, and provides tissue for molecular interrogation. The decision to operate on bGBM must consider both patient and surgeon factors. Selections should be individualized, considering the

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    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.

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