Intraoperative magnetic resonance imaging versus standard neuronavigation for the neurosurgical treatment of glioblastoma: A randomized controlled trial

Abstract

Background:Although the added value of increasing extent of glioblastoma resection is still debated, multiple technologies can assist neurosurgeons in attempting to achieve this goal. Intraoperative magnetic resonance imaging (iMRI) might be helpful in this context, but to date only one randomized trial exists.Methods:We included 14 adults with a supratentorial tumor suspect for glioblastoma and an indication for gross total resection in this randomized controlled trial of which the interim analysis is presented here. Participants were assigned to either ultra-low-field strength iMRI-guided surgery (0.15 Tesla) or to conventional neuronavigation-guided surgery (cNN). Primary endpoint was residual tumor volume (RTV) percentage. Secondary endpoints were clinical performance, health-related quality of life (HRQOL) and survival.Results:Median RTV in the cNN group is 6.5% with an interquartile range of 2.5-14.75%. Median RTV in the iMRI group is 13% with an interquartile range of 3.75-27.75%. A Mann-Whitney test showed no statistically significant difference between these groups (P =0.28). Median survival in the cNN group is 472 days, with an interquartile range of 244-619 days. Median survival in the iMRI group is 396 days, with an interquartile range of 191-599 days (P =0.81). Clinical performance did not differ either. For HRQOL only descriptive statistics were applied due to a limited sample size.Conclusion:This interim analysis of a randomized trial on iMRI-guided glioblastoma resection compared with cNN-guided glioblastoma resection does not show an advantage with respect to extent of resection, clinical performance, and survival for the iMRI group. Ultra-low-field strength iMRI does not seem to be cost-effective compared with cNN, although the lack of a valid endpoint for neurosurgical studies evaluating extent of glioblastoma resection is a limitation of our study and previous volumetry-based studies on this topic.

Creating an Intraoperative MRI Suite for the Musculoskeletal Tumor Center

“…Because of the high rate of residual tumor found on intraoperative imaging, the authors [4,8] described repeat surgical resection as an effective way to decrease the residual tumor volume retained-an afforded benefit owing to real-time assessment with the patient under anesthesia. In contrast, a 2014 randomized control trial comparing standard neuronavigation versus iMRI for resection of glioblastoma showed no difference with respect to the extent of resection, clinical performance, or overall survival [11]. Despite this lack of observed difference, the authors maintained that iMRI is useful in the appropriate situation.…”

“…The use of intraoperative MRI (iMRI) technology is a well-described neurosurgical technique that can enhance the probability of complete tumor excision, with several reports suggesting promising results for selected intracranial procedures [4,8,11]. Although these real-time MRI scans are characterized by small imaging fields, the visualized portal can be adequate for tumor localization and assessing adequacy of tumor resection in select orthopaedic oncology procedures where surrounding anatomy cannot be relied on to guide surgical resection, such as in the context of distorted anatomic fields through prior serial operations or radiation [9].…”

Economics, Innovation, and Quality Improvement in Neurosurgery

“…A recent interim analysis of a small, randomized, controlled trial comparing iMRI with conventional neuronavigation-guided surgery for suspected supratentorial glioblastomas did not show any advantage with respect to extent of resection, clinical performance, or survival for iMRI. 35 However, this is contrasted by the only other randomized, controlled trial, which found a statistically improved extent of resection in the iMRI group but without endpoints assessing quality of life or length of survival. 36 Given the current evidence, there is no clear quality improvement obtained from the added expense of iMRI, but this is an area in which further investigation is needed.…”

Intraoperative assistive technologies—the way ahead

“…Further, no new data is presented (except the study by Wu et al, itself a conference proceeding which is hardly any robust evidence as of now, at least till the study is completed). Further, it is appropriate to point out that almost at the same time another prospective controlled trial for IOMR was published by Kubben et al [3]. This is actually a negative IOMR study.…”