ObjectiveAge is considered a negative prognostic factor for High Grade Gliomas (HGGs) and many neurosurgeons remain skeptical about the benefits of aggressive treatment. New surgical and technological improvements may allow extended safe resection, with lower level of post-operative complications. This opportunity opens the unsolved question about the most appropriate HGG treatment in elderly patients. The aim of this study is to analyze if HGG maximal safe resection guided by an intraoperative multimodal imaging protocol coupled with neuromonitoring is associated with differences in outcome in elderly patients versus younger ones.MethodsWe reviewed 100 patients, 53 (53%) males and 47 (47%) females, with median (IQR) age of 64 (57; 72) years. Eight patients were diagnosed with Anaplastic Astrocytoma (AA), 92 with Glioblastoma (GBM). Surgery was aimed to achieve safe maximal resection. An intraoperative multimodal imaging protocol, including neuronavigation, neurophysiological monitoring, 5-ALA fluorescence, 11C MET-PET, navigated i-US system and i-CT, was used, and its impact on EOTR and clinical outcome in elderly patients was analyzed. We divided patients in two groups according to their age: <65 and >65 years, and surgical and clinical results (EOTR, post-operative KPS, OS and PFS) were compared. Yet, to better understand age-related differences, the same patient cohort was also divided into <70 and >70 years and all the above data reanalyzed.ResultsIn the first cohort division, we did not found KPS difference over time and survival analysis did not show significant difference between the two groups (p = 0.36 for OS and p = 0.49 for PFS). Same results were obtained increasing the age cut-off for age up to 70 years (p = 0.52 for OS and p = 0.92 for PFS).ConclusionsOur data demonstrate that there is not statistically significant difference in post-operative EOTR, KPS, OS, and PFS between younger and elderly patients treated with extensive tumor resection aided by a intraoperative multimodal protocol.
OBJECTIVENo consensus exists on the best treatment for recurrent high-grade glioma (HGG), particularly in terms of surgical indications, and scant data are available on the integrated use of multiple technologies to overcome intraoperative limits and pitfalls related to artifacts secondary to previous surgery and radiotherapy. Here, the authors report on their experience with the integration of multiple intraoperative tools in recurrent HGG surgery, analyzing their pros and cons as well as their effectiveness in increasing the extent of tumor resection. In addition, they present a review of the relevant literature on this topic.METHODSThe authors reviewed all cases in which recurrent HGG had been histologically diagnosed after a first surgery and the patient had undergone a second surgery involving neuronavigation with MRI, intraoperative CT (iCT), 11C-methionine–positron emission tomography (11C-MET-PET), 5-aminolevulinic acid (5-ALA) fluorescence, intraoperative neurophysiological monitoring (IONM), and intraoperative navigated ultrasound (iUS). All cases were classified according to tumor functional grade (1, noneloquent area; 2, near an eloquent area; 3, eloquent area).RESULTSTwenty patients with recurrent HGG were operated on using a multimodal protocol. The recurrent tumor functional grade was 1 in 4 patients, 2 in 8 patients, and 3 in the remaining 8 patients. In all patients but 2, 100% EOTR was obtained. Intraoperative 5-ALA fluorescence and navigated iUS showed low specificity and sensitivity. iCT detected tumor remnants in 3 cases. Postoperatively, 6 patients (30%) had worsening neurological conditions: 4 recovered within 90 days, 1 partially recovered, and 1 experienced a permanent deficit. The median Karnofsky Performance Status remained substantially unchanged over the follow-up period. The mean progression-free survival after the second surgery was 7.7 months (range 2–11 months). The mean overall survival was 25.4 months (range 10–52 months), excluding 2 long survivors. Two patients died within 60 days after surgery, and 3 patients were still under follow-up at the end of this study.CONCLUSIONSThis is the first study reporting the integration of neuronavigation, 5-ALA fluorescence, iUS, iCT, 11C-MET-PET, and IOM during microsurgical resection of recurrent glioma. The authors believe that the proposed multimodal protocol is useful to increase the safety, effectiveness, and EOTR in patients with recurrent HGG and brain alterations secondary to radio- and chemotherapy.
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