Original ArticleSurgical Resection of Anterior and Posterior Butterfly Glioblastoma
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
References (51)
- et al.
Integrins: molecular determinants of glioma invasion
J Clin Neurosci
(2007) - et al.
Corpus callosotomy in children
Neurosurg Clin N Am
(1995) - et al.
Retractorless surgery for third ventricle tumor resection through the transcallosal approach
Clin Neurol Neurosurg
(2017) - et al.
The anterior subcallosal approach to third ventricular and suprasellar lesions: anatomical description and technical note
World Neurosurg
(2016) - et al.
Complications of glioma surgery
Handb Clin Neurol
(2016) - et al.
Long-term surgical and seizure outcomes of frontal low-grade gliomas
Int J Surg
(2016) - et al.
Paradoxically greater interhemispheric transfer deficits in partial than complete callosal agenesis
Neuropsychologia
(1998) - et al.
Corpus callosotomy in refractory idiopathic generalized epilepsy
Seizure
(2006) - et al.
Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma
N Engl J Med
(2005) - et al.
An extent of resection threshold for newly diagnosed glioblastomas
J Neurosurg
(2011)
Extent of surgical resection is independently associated with survival in patients with hemispheric infiltrating low-grade gliomas
Neurosurgery
Role of extent of resection in the long-term outcome of low-grade hemispheric gliomas
J Clin Oncol
Cost of migration: invasion of malignant gliomas and implications for treatment
J Clin Oncol
Migration of human glioma cells on myelin
Neurosurgery
Glioma invasion in the central nervous system
Neurosurgery
Membrane-type 1 matrix metalloprotease (MT1-MMP) enables invasive migration of glioma cells in central nervous system white matter
J Cell Biol
The incidence of interhemispheric extension of glioblastoma multiforme through the corpus callosum
J Neurosurg
A method for safely resecting anterior butterfly gliomas: the surgical anatomy of the default mode network and the relevance of its preservation
J Neurosurg
Butterfly glioblastomas: a retrospective review and qualitative assessment of outcomes
J Neurooncol
The butterfly effect on glioblastoma: is volumetric extent of resection more effective than biopsy for these tumors?
J Neurooncol
A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival
J Neurosurg
Butterfly glioma of the corpus callosum
J Cancer Res Ther
Glioblastoma multiforme: radiologic-pathologic correlation
Radiographics
Lesions of the corpus callosum: MR imaging and differential considerations in adults and children
AJR Am J Roentgenol
An MRI review of acquired corpus callosum lesions
J Neurol Neurosurg Psychiatry
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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.