Is It Worth Considering Multicentric High-Grade Glioma a Surgical Disease? Analysis of Our Clinical Experience and Literature Review

Abstract

Introduction. The simultaneous presence of multiple foci of high-grade glioma is a rare condition with a poor prognosis. By definition, if an anatomical connection through white matter bundles cannot be hypothesized, multiple lesions are defined as multicentric glioma (MC); on the other hand, when this connection exists, it is better defined as multifocal glioma (MF). Whether surgery can be advantageous for these patients has not been established yet. The aim of our study was to critically review our experience and to compare it to the existing literature. Materials and Methods. Retrospective analysis of patients operated on for MC HGG in two Italian institutions was performed. Distinction between MC and MF was achieved through revision of MR FLAIR images. Clinical and radiological preoperative and postoperative data were analyzed through chart revision and phone interviews. The same data were extracted from literature review. Univariate and multivariate analyses were conducted for the literature review only, and the null hypothesis was rejected for a p-value ≥ 0.05. Results. Sixteen patients met the inclusion criteria; male predominance and an average age of 66.5 years were detected. Sensory/motor deficit was the main onset symptom both in clinical study and literature review. A tendency to operate on the largest symptomatic lesion was reported and GTR was reached in the majority of cases. GBM was the histological diagnosis in most part of the patients. OS was 8.7 months in our series compared to 7.5 months from the literature review. Age ≤ 70 years, a postoperative KPS ≥ 70, a GTR/STR, a second surgery and adjuvant treatment were shown to be significantly associated with a better prognosis. Pathological examination revealed that MC HGG did not originate by LGG. Conclusions. MC gliomas are rare conditions with high malignancy and a poor prognosis. A maximal safe resection should be attempted whenever possible, especially in younger patients with life-threatening large mass.

NMI: a potential biomarker for tumor prognosis and immunotherapy

“…According to the different types of origin, gliomas can be divided into three types: astrocytoma, oligoastrocytoma and oligodendroglioma ( Davis, 2018 ). Common indicators for prognosis monitoring mainly include 1p/19q codeletion, IDH mutation, G-CIMP phenotype, TP53 mutation, and MGMT methylation ( Baldock et al, 2014 ; Gusyatiner and Hegi, 2018 ; Guerrini et al, 2021 ). IDH mutation is currently recognized as an indicator of better prognosis.…”

Prognostic factors affecting outcome of multifocal or multicentric glioblastoma: A scoping review

“…The authors concluded that radiotherapy with concurrent TMZ is a potentially feasible treatment option for multifocal GBM. [13] Guerrini et al [6] reported OS of 8.7 months in mGBM (n = 16). Age ≤70 years, a post-operative KPS ≥70, gross or subtotal excision, and adjuvant treatment were shown to be associated with a significantly better prognosis.…”

“…Age ≤70 years, a post-operative KPS ≥70, gross or subtotal excision, and adjuvant treatment were shown to be associated with a significantly better prognosis. [6] One of the largest studies was reported by Haque et al [14] The authors evaluated demographic and clinical characteristics of solitary and mGBM from National Cancer Database (NCDB) analysis (2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016). Out of 45,268 total patients, 7785 (17.2%) had multifocal GBM.…”

“…Multifocality was divided (i) glioblastoma infiltration in a singular lobe, (ii) infiltration of>1 lobe within 1 hemisphere, and (iii) tumor infiltration of both hemispheres Armocida et al, 2021 [12] Tumors classified as Type I: Multicentric or multifocal supratentorial enhancing-contrast lesion at first diagnostic MRI Type II: Single enhancing contrast lesion Baro et al, 2022 [25] Patients with multiple lesions were defined as those having at least two separate foci of enhancing tumor on MRI, separated by at least 1 cm Fleischmann et al, 2021 [13] Based on MRI with contrast-enhanced T1 and T2 or FLAIR sequences, only patients with multifocal growth pattern at the time of first diagnosis were included Multifocal: At least two independent contrast-enhancing foci in the MRI T1 contrast-enhanced sequence Guerrini et al, 2021 [6] To distinguish between MC and MF, FLAIR T2-weighted MRI sequences were used and in case a diffusion pathway was found between one or more lesions, the case was classified as a MF glioma. Haque et al, 2020 [14] Not mentioned Hassaneen et al, 2011 [24] Group A: Multifocal or multicentric glioblastomas, who underwent resection of all lesions through multiple craniotomies in a single session (patients with multifocal glioblastomas who were treated via a single craniotomy were excluded) two subgroups based on MR imaging-documented tumor characteristics Group A1 (multicentric lesions) widely separated lesions having no connection when visualized on FLAIR MR sequences and no identified route of dissemination Group A2 (multifocal lesions) multiple separate lesions seen to be connected on FLAIR sequences and/or there was evidence of leptomeningeal, subependymal, or CSF dissemination Kasper et al, 2021 [15] Multifocality was defined as separate (distance greater than 1 cm) contrast-enhancing lesions, independently from FLAIR hyperintensity.…”

“…Various studies have shown that distinction of multifocal or multicentricity has little prognostic significance and indeed can be spectrum of same process of disease evolution. [ 6 ] Except few, most of the studies reported that mGBM has poorer outcome. [ 6 ] Strong correlation of survival is observed with extent of resection (EOR) and Karnofsky performance status (KPS) at presentation.…”