Reoperation for recurrent malignant gliomas: what are your indications?

Second surgery for recurrent glioblastoma: A concise overview of the current literature

Optimal treatment for recurrent glioblastoma continues to evolve. Currently, however, there is no consensus in the literature on the role of reoperation in the management of these patients, as several studies provide evidence for a longer overall survival in selected patients with recurrent glioblastoma who underwent second surgery and other studies report a limited impact of second surgery in the clinical course. In this paper, a review of the current literature was performed to analyze the role of reoperation in patients with recurrent glioblastoma and to report the overall survival from diagnosis, progression-free survival and quality of life. Using PubMed and Ovid Medline databases, we performed a review of the literature of the last seven years, finding a total of 28 studies and 2279 patients who underwent second surgery, that were included in the final analysis. The median overall survival from diagnosis and the median survival from second surgery were 18.5 months and 9.7 months, respectively. Extent of resection at reoperation improves overall survival, even in patients with subtotal resection at initial operation. Preoperative performance status and age are important predictors of a longer survival, reason why younger patients with a good preoperative performance status could benefit from reoperation.

Prognostic factors for survival in 676 consecutive patients with newly diagnosed primary glioblastoma

Reliable data on large cohorts of patients with glioblastoma are needed because such studies differ importantly from trials that have a strong bias toward the recruitment of younger patients with a higher performance status. We analyzed the outcome of 676 patients with histologically confirmed newly diagnosed glioblastoma who were treated consecutively at a single institution over a 7-year period (1997-2003) with follow-up to April 30, 2006. Survival probabilities were 57% at 1 year, 16% at 2 years, and 7% at 3 years. Progression-free survival was 15% at 1 year. Prolongation of survival was significantly associated with surgery in patients with a good performance status, whatever the patient's age, with an adjusted hazard ratio of 0.55 (p < 0.001) or a 45% relative decrease in the risk of death. Radiotherapy and chemotherapy improved survival, with adjusted hazard ratios of 0.61 (p = 0.001) and 0.89 (p = 0.04), respectively, regardless of age, performance status, or residual tumor volume. Recurrence occurred in 99% of patients throughout the follow-up. Reoperation was performed in one-fourth of these patients but was not effective, whether performed within 9 months (hazard ratio, 0.86; p = 0.256) or after 9 months (hazard ratio, 0.98; p = 0.860) of initial surgery, whereas second-line chemotherapy with procarbazine, lomustine, and vincristine (PCV) or with temozolomide improved survival (hazard ratio, 0.77; p = 0.008). Surgery followed by radiotherapy and chemotherapy should be considered in all patients with glioblastoma, and these treatments should not be withheld because of increasing age alone. The benefit of second surgery at recurrence is uncertain, and new trials are needed to assess its effectiveness. Chemotherapy with PCV or temozolomide seems to be a reasonable option at tumor recurrence.

Prognostic factors for survival in 676 consecutive patients with newly diagnosed primary glioblastoma

Reliable data on large cohorts of patients with glioblastoma are needed because such studies differ importantly from trials that have a strong bias toward the recruitment of younger patients with a higher performance status. We analyzed the outcome of 676 patients with histologically confirmed newly diagnosed glioblastoma who were treated consecutively at a single institution over a 7-year period (1997-2003) with follow-up to April 30, 2006. Survival probabilities were 57% at 1 year, 16% at 2 years, and 7% at 3 years. Progression-free survival was 15% at 1 year. Prolongation of survival was significantly associated with surgery in patients with a good performance status, whatever the patient's age, with an adjusted hazard ratio of 0.55 (p < 0.001) or a 45% relative decrease in the risk of death. Radiotherapy and chemotherapy improved survival, with adjusted hazard ratios of 0.61 (p = 0.001) and 0.89 (p = 0.04), respectively, regardless of age, performance status, or residual tumor volume. Recurrence occurred in 99% of patients throughout the follow-up. Reoperation was performed in one-fourth of these patients but was not effective, whether performed within 9 months (hazard ratio, 0.86; p = 0.256) or after 9 months (hazard ratio, 0.98; p = 0.860) of initial surgery, whereas second-line chemotherapy with procarbazine, lomustine, and vincristine (PCV) or with temozolomide improved survival (hazard ratio, 0.77; p = 0.008). Surgery followed by radiotherapy and chemotherapy should be considered in all patients with glioblastoma, and these treatments should not be withheld because of increasing age alone. The benefit of second surgery at recurrence is uncertain, and new trials are needed to assess its effectiveness. Chemotherapy with PCV or temozolomide seems to be a reasonable option at tumor recurrence.

Hydrogen-1 MR spectroscopy of the peritumoral zone in patients with cerebral glioma: assessment of the value of the method

RATIONALE AND OBJECTIVES

The determination of tumor boundaries, especially in high-grade glioma, is critically important for the proper planning of treatment, but the standard diagnostic imaging methods do not enable precise delimitation of the extent of tumor cell infiltration into the surrounding tissue. The objective of this study was to assess the usefulness of hydrogen-1 (H-1) magnetic resonance (MR) spectroscopy for determining the extent of gliomatous infiltrate in the "uncertain zone'--the peritumoral area that appears unchanged on standard diagnostic MR images.

MATERIALS AND METHODS

The study group consisted of 64 patients with cerebral glioma scheduled for tumor resection and subsequent radiation therapy. All patients were examined prior to resection with MR imaging and MR spectroscopy. MR spectra were obtained from examination of the solid part of the tumor and from two peritumoral volumes of interest located approximately along the axis of surgical access to the tumor. MR spectra obtained from a group of 32 healthy volunteers were used as control data.

RESULTS

Analysis of the consequent voxels in the peritumoral zone revealed statistically significant differences in lipid/creatine and lactate/creatine metabolite ratios between patient subgroups with recurrent malignant lesions and without recurrent lesions. Significant differences also were found between the patient group and the control group in most metabolite ratios assessed.

CONCLUSION

H-1 MR spectroscopic demonstration of metabolic changes in the peritumoral zone can guide treatment for cerebral glioma, enabling the physician to identify patients who have a high risk of recurrence.

Reoperation in recurrent high-grade gliomas: literature review of prognostic factors and outcome

Two percent of cancer deaths are caused by malignant primary brain tumors, and most of these are high-grade gliomas. Despite the treatment given, malignant gliomas recur early. Mean survival is less than 12 months, and only 20% of patients survive for more than 2 years. This rapid course induces some physicians to resort to all the therapeutic options available and, at recurrence, to reevaluate the patient for a second intervention. Others consider reoperation to be an overtreatment. The debate is ongoing, and an answer likely will be found only through better identification of the prognostic factors that will identify patients who will benefit from reoperation.