Natural history and surgical management of incidentally discovered low-grade gliomas

Potts, Matthew B.; Smith, Justin S.; Molinaro, Annette M.; Berger, Mitchel S.

doi:10.3171/2011.9.jns111068

Cited by 130 publications

(72 citation statements)

References 30 publications

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“…Interestingly, the spontaneous course of iLGG has recently been investigated, showing that this entity is a progressive tumor in all cases, with a median velocity of diametric expansion of approximately 3.5 mm/ year (that is, very close to the growth rate of symptomatic LGG) and leading to clinical transformation toward symptomatic LGG at a median interval of 48 months after radiological discovery. 16 A similar growth rate was confirmed by Potts et al, 19 based upon an experience with 35 iLGGs. These data demonstrate that iLGG is never stable.…”

Section: Discussionsupporting

confidence: 68%

Acute progression of untreated incidental WHO Grade II glioma to glioblastoma in an asymptomatic patient

Cochereau

Herbet

Rigau

et al. 2016

JNS

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WHO Grade II glioma (low-grade glioma [LGG]) is increasingly diagnosed as an incidental finding in patients undergoing MRI for many conditions. Recent data have demonstrated that such incidental LGGs are progressive tumors that undergo clinical transformation and ultimately become malignant. Although asymptomatic LGG seems to represent an earlier step in the natural course of a glioma than the symptomatic LGG, it is nonetheless impossible to predict at the individual level when the tumor will become malignant. The authors report the case of a 43-year-old woman with a right operculo-insular LGG that was incidentally diagnosed because of headaches. No treatment was proposed, and repeated MRI scans were performed for 6 years in another institution. Due to a slow but continuous growth of the lesion, the patient was finally referred to our center to undergo surgery. Interestingly, objective calculation of the velocity of the tumor’s diametric expansion demonstrated a sudden acceleration of the growth rate within the 5 months preceding surgery, with the development of contrast enhancement. Remarkably, the patient was still asymptomatic. An awake resection was performed with intraoperative electrical mapping. There was no functional worsening following surgery, as assessed on postoperative neuropsychological examination. Removal of 92% of signal abnormality on FLAIR MRI was achieved, with complete resection of the area of contrast enhancement. Neuropathological examination revealed a glioblastoma, and the patient was subsequently treated with concomitant radiotherapy and chemotherapy. Although a “wait and see” attitude has been advocated by some authors with respect to incidental LGG, our original case demonstrates that acute transformation to glioblastoma may nonetheless occur, even before the onset of any symptoms. Therefore, because the lack of symptoms does not protect from malignant transformation, we propose consideration of earlier resection in a more systematic manner in cases of incidental LGG.

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Section: Discussionsupporting

confidence: 68%

Acute progression of untreated incidental WHO Grade II glioma to glioblastoma in an asymptomatic patient

Cochereau

Herbet

Rigau

et al. 2016

JNS

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“…11, [17][18][19]29,35,36,43,52,53,80,81,[86][87][88][89]98,100,101,106 Due to the reported variability of success rates for completing an awake craniotomy, along with the many published techniques and methods of performing the procedure, we decided to review the extensive experience of a single surgeon with the goal of identifying the optimal techniques and regimen to maximize perioperative safety and minimize the risk of failure for patients undergoing awake craniotomies during the removal of a glioma.…”

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confidence: 99%

Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period

Hervey-Jumper¹,

Li²,

Lau³

et al. 2015

JNS

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323

119

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OBJECT Awake craniotomy is currently a useful surgical approach to help identify and preserve functional areas during cortical and subcortical tumor resections. Methodologies have evolved over time to maximize patient safety and minimize morbidity using this technique. The goal of this study is to analyze a single surgeon's experience and the evolving methodology of awake language and sensorimotor mapping for glioma surgery. METHODS The authors retrospectively studied patients undergoing awake brain tumor surgery between 1986 and 2014. Operations for the initial 248 patients (1986–1997) were completed at the University of Washington, and the subsequent surgeries in 611 patients (1997–2014) were completed at the University of California, San Francisco. Perioperative risk factors and complications were assessed using the latter 611 cases. RESULTS The median patient age was 42 years (range 13–84 years). Sixty percent of patients had Karnofsky Performance Status (KPS) scores of 90–100, and 40% had KPS scores less than 80. Fifty-five percent of patients underwent surgery for high-grade gliomas, 42% for low-grade gliomas, 1% for metastatic lesions, and 2% for other lesions (cortical dysplasia, encephalitis, necrosis, abscess, and hemangioma). The majority of patients were in American Society of Anesthesiologists (ASA) Class 1 or 2 (mild systemic disease); however, patients with severe systemic disease were not excluded from awake brain tumor surgery and represented 15% of study participants. Laryngeal mask airway was used in 8 patients (1%) and was most commonly used for large vascular tumors with more than 2 cm of mass effect. The most common sedation regimen was propofol plus remifentanil (54%); however, 42% of patients required an adjustment to the initial sedation regimen before skin incision due to patient intolerance. Mannitol was used in 54% of cases. Twelve percent of patients were active smokers at the time of surgery, which did not impact completion of the intraoperative mapping procedure. Stimulation-induced seizures occurred in 3% of patients and were rapidly terminated with ice-cold Ringer's solution. Preoperative seizure history and tumor location were associated with an increased incidence of stimulation-induced seizures. Mapping was aborted in 3 cases (0.5%) due to intraoperative seizures (2 cases) and patient emotional intolerance (1 case). The overall perioperative complication rate was 10%. CONCLUSIONS Based on the current best practice described here and developed from multiple regimens used over a 27-year period, it is concluded that awake brain tumor surgery can be safely performed with extremely low complication and failure rates regardless of ASA classification; body mass index; smoking status; psychiatric or emotional history; seizure frequency and duration; and tumor site, size, and pathology.

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Section: Discussionmentioning

confidence: 99%

“…First, incidentally found astrocytomas-defined by Potts et al 21 and Pallud et al 17 as "a finding on imaging that was obtained for a reason not attributable to the glioma, such as trauma or headache"-tend to have a better prognosis. Potts and colleagues 21 recently reported that patients with incidental supratentorial LGGs have a significantly higher rate of survival. Since the diagnosis in the majority of patients in the local cohort was rendered during a workup for headache, it is likely that the proportion of incidental tumors (using the above definition) is much greater among cerebellar gliomas than among supratentorial ones, in which seizures are a common presenting symptom.…”

Section: Discussionmentioning

confidence: 99%

“…Studies have focused on how prognosis may differ among LGGs with different growth rates, histological characteristics, presenImproved survival in the largest national cohort of adults with cerebellar versus supratentorial low-grade astrocytomas tations, and locations. 6,16,17,21,24,26,27 The majority of extant research on these tumors in adults has focused on supratentorial examples, although some authors have suggested that LGGs of the cerebellum may have a different presentation and prognosis. 9,11,24 Unfortunately, previous work examining cerebellar gliomas either has been focused on the pediatric population, in which these tumors are much more common, or has included very few cases.…”

mentioning

confidence: 99%

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Improved survival in the largest national cohort of adults with cerebellar versus supratentorial low-grade astrocytomas

Bagley¹,

Babu²,

Friedman³

et al. 2013

FOC

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Object Low-grade gliomas (LGGs) are indolent tumors that have the potential to dedifferentiate into malignant high-grade tumors. Recent studies have demonstrated that cerebellar low-grade tumors have a better prognosis than supratentorial tumors, although no study has focused on the risk factors for poor prognosis in cerebellar LGGs in adults. The authors of the current study aimed to address both of these concerns by using a large cohort derived from a national cancer registry and a smaller cohort derived from their institution's experience. Methods Adults with diagnosed Grade I and Grade II gliomas of the cerebellum were identified in the Surveillance, Epidemiology, and End Results (SEER) database. Multivariate Cox proportional hazard models were used to predict rates of survival, and the log-rank test was applied to evaluate differences in Kaplan-Meier survival curves. An institutional cohort was created by isolating all patients whose surgical pathology revealed an LGG of the cerebellum. Excluded from analysis were patients in whom a glioma was first diagnosed under the age of 18 years and those whose tumors could not be definitively determined to arise from the cerebellum. Results Data from the local cohort (11 patients) demonstrated that the most common presenting symptom was headache, which occurred in more than 70% of the cohort. Approximately half of the patients in this cohort had symptomatic improvement after treatment. Results from the SEER cohort (166 patients) revealed that adults with Grade I gliomas were slightly younger than those with Grade II tumors (p < 0.01), but no other demographic differences were observed. Patients with Grade I tumors were twice as likely to undergo gross-total resection (54% vs 21%), and those with Grade II gliomas were much more likely to receive postoperative radiation (3% vs 48%). Five-year survival was greater in the patients with Grade I gliomas than in those with Grade II lesions (91% vs 70%). Multivariate analysis revealed that an age ≥ 40 years (HR 7.30, 95% CI 3.55–15.0, p < 0.0001) and Grade II tumors (HR 2.76, 95% CI 1.12–6.84, p = 0.028) were risk factors for death, whereas female sex was protective (HR 0.28, 95% CI 0.14–0.59, p < 0.001). Log-rank tests revealed that a cerebellar location was protective (p < 0.0001), but this relationship was only true for Grade II tumors (p < 0.0001). Survival in patients with Grade I gliomas was not different based on the various lesion locations (p = 0.21). Conclusions Taken together, adults with cerebellar WHO Grade I and II astrocytomas have a much more favorable survival curve than those with similar supratentorial tumors. Research demonstrates that the primary driver of this phenomenon is the improved survival in patients with cerebellar Grade II gliomas.

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Natural history and surgical management of incidentally discovered low-grade gliomas

Abstract: In this retrospective cohort of surgically managed LGGs, incidentally discovered lesions were associated with improved patient survival as compared with symptomatic LGGs, with acceptable surgical risks.

Cited by 130 publications

References 30 publications

Acute progression of untreated incidental WHO Grade II glioma to glioblastoma in an asymptomatic patient

Acute progression of untreated incidental WHO Grade II glioma to glioblastoma in an asymptomatic patient

Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period

Improved survival in the largest national cohort of adults with cerebellar versus supratentorial low-grade astrocytomas

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