Beyond resection boundaries for glioblastoma patients: is “primum non nocere” a key factor for prognosis?

Abstract

Purpose Maximal resection has a pivotal role in the treatment of glioblastoma, prolonging both progression free survival (PFS) and overall survival (OS). Increasingly, very few studies analyze the delicate equilibrium between maximal resection, clinical outcome and prognosis. The aim of this study is to determine the impact of neurological impairment on PFS, OS and access to adjuvant therapies. Methods this retrospective study encompassed patients operated for a GBM at Fondazione IRCCS San Gerardo dei Tintori Monza (IT), from 2015 to 2023. Histological diagnosis was performed according to 2021 WHO 2021. Patients were more than 18 years old, with pre and postoperative MRI, who underwent surgery and adjuvant treatments at our institution. Results A total of 231 patients fulfilled the criteria. Patients with improvement or complete regression of preoperative deficit had higher rate of access to adjuvant therapies (p = 0.023). Patients with hemiparesis at discharge had the worst PFS (median 4.60 months), Vs patients with aphasia, (6.60 months) Vs 9.67 for patients with normal examination (p < 0.0001). Median OS was 19.30 months for patients with hemianopia Vs 7.73 for patients with hemiparesis and 14.03 months with aphasia (p < 0.0001). Conclusion Hemianopia has no impact on patient’s prognosis, while hemiparesis and aphasia at discharge worsen both PFS and OS and prolong time-to-treatment. The “primum non nocere” principle must be the main policy: extend the resection at the cost of a minor deficit, preserve motor and language functions, encourage home cares for the most vulnerable patients.