Search

BACKGROUND: The aim of glioblastoma surgery is to maximize the extent of resection, while preserving functional integrity. Standards are lacking for surgical decision-making and consequently surgical strategies may differ between neurosurgical teams. In this study we quantitated and compared surgical decision-making throughout the brain between neurosurgical teams for patients with a glioblastoma using probability maps. MATERIAL AND METHODS: All adults with first-time glioblastoma surgery in 2012–2013 from twelve tertiary referral centers for neuro-oncological care were included in this study. For each patient, pre- and postoperative tumor were manually segmented on MRI and aligned to standard brain space. Resection probability maps and biopsy probability maps were constructed in 1 mm resolution for each team’s cohort. Brain regions with differential biopsy and resection results between teams were identified. RESULTS: The study cohort consisted of 1085 patients of whom 305 received a biopsy and 780 a resection. Biopsy probability maps demonstrated differences between teams in biopsy rate per brain location, such as for the right caudate nucleus, indicating variation in biopsy decisions. Resection probability maps demonstrated differences between teams in residual tumor rate per brain location, such as for the left sagittal striatum and neighboring posterior corpus callosum, indicating variation in resection decisions. CONCLUSION: Biopsy and resection probability maps indicate treatment variation between teams for patients with a glioblastoma. This conveys useful objective arguments for quality of care discussions between surgical teams for these patients.

PURPOSE: To measure between-hospital variation in risk-standardized survival outcome after glioblastoma surgery and to explore the association between survival and hospital characteristics in conjunction with patient-related risk factors. METHODS: Data of 2,409 adults with first-time glioblastoma surgery at 14 hospitals were obtained from a comprehensive, prospective population-based Quality Registry for Neurological Surgery in the Netherlands between 2011 and 2014. We compared the observed survival with patient-specific risk-standardized expected early (30-day) mortality and expected late (2-year) survival, based on patient age, performance status, and year of treatment. Summarized outcomes per hospital were analyzed in funnel plots. Hospital characteristics were analyzed in logistic regression and Cox proportional hazards models. RESULTS: Overall 30-day mortality was 5.2% and overall 2-year survival was 13.5%. Median overall survival varied between 4.8 and 14.9 months among hospitals, and biopsy percentages ranged between 16% and 73%. One hospital had lower than expected early mortality, and four hospitals had lower than expected late survival. Higher hospital volume was related with lower early mortality (P=0.031). A 10% increase in volume was associated with 3.9% relative decrease in early mortality, but not with overall survival. Patient-related risk factors (lower age; better performance; more recent years of treatment) were significantly associated with longer overall survival. Of the hospital characteristics, longer overall survival was associated with lower biopsy percentage (HR: 2.09, 1.34–3.26, P=0.001), and not with academic setting (HR: 0.951, 0.858–1.05), nor with hospital volume (HR: 0.954, 0.866–1.05). CONCLUSION: Hospitals vary more in late survival than early mortality after glioblastoma surgery. Widely varying biopsy percentages indicate treatment variation. Patient-related factors have a stronger association with overall survival than hospital-related factors.

Early resection is standard of care for presumed low-grade gliomas. This is based on studies including only tumors that were post-surgically confirmed as low-grade glioma. Unfortunately this does not represent the clinicians’ situation wherein he/she has to deal with a lesion on MRI that is suspect for low-grade glioma (i.e. without prior knowledge on the histological diagnosis). We therefore aimed to determine the optimal initial strategy for patients with a lesion suspect for low-grade glioma, but not histologically proven yet. We retrospectively identified 150 patients with a resectable presumed low-grade-glioma and who were otherwise in good clinical condition. In this cohort we compared overall survival between three types of initital treatment strategy: a wait-and-scan approach (n = 38), early resection (n = 83), or biopsy for histopathological verification (n = 29). In multivariate analysis, no difference was observed in overall survival for early resection compared to wait-and-scan: hazard ratio of 0.92 (95% CI 0.43–2.01; p = 0.85). However, biopsy strategy showed a shorter overall survival compared to wait-and-scan: hazard ratio of 2.69 (95% CI 1.19–6.06; p = 0.02). In this cohort we failed to confirm superiority of early resection over a wait-and-scan approach in terms of overall survival, though longer follow-up is required for final conclusion. Biopsy was associated with shorter overall survival.

INTRODUCTION The aim of glioblastoma surgery is to maximize the extent of resection, while preserving functional integrity. Standards are lacking for surgical decision-making and consequently surgical strategies may differ between neurosurgical teams. In this study, we quantitated and compared surgical decision-making throughout the brain between neurosurgical teams for patients with a glioblastoma using probability maps. METHODS All adults with first-time glioblastoma surgery in 2012-2013 from 10 tertiary referral centers for neurooncological care were included in this study. For each patient, pre- and postoperative tumor were manually segmented on MRI and aligned to standard brain space. Resection probability maps and biopsy probability maps were constructed in 1 mm resolution for each team's cohort. Brain regions with differential biopsy and resection results between teams were identified. RESULTS The study cohort consisted of 931 patients of whom 293 received a biopsy and 638 a resection. Biopsy probability maps demonstrated differences between teams in biopsy rate per brain location, such as for the left precuneus and superior parietal lobule, indicating variation in biopsy decisions. Resection probability maps demonstrated differences between teams in residual tumor rate per brain location, such as for the left saggital striatum and neighboring posterior corpus callosum, indicating variation in resection decisions. CONCLUSION Biopsy and resection probability maps indicate treatment variation between teams for patients with a glioblastoma. This conveys useful objective arguments for quality of care discussions between surgical teams for these patients.

The occurrence of pregnancy in women with brain tumors confronts both patients and physicians with difficult decision making at each stage of pregnancy. We studied the course of events of nine pregnancies in seven women with low-grade glioma in our hospital over a 10 year period. Five patients had a surgical resection, one a biopsy and one woman was followed by wait-and-see policy before pregnancy. In two women, a therapeutic abortion was carried out in the first trimester because of signs of progression, necessitating surgical removal of the tumor. In the other five women pregnancy had an uncomplicated course. Based on a literature review, we found 28 women diagnosed with a known glioma before becoming pregnant. All pregnancies but one, were uneventful and all women had a normal delivery, including the seven cases with exposure to chemotherapy and in whom healthy babies were born. A total of 75 pregnant women were identified in whom new onset glioma developed, which was high-grade in 56 %, and becoming symptomatic in 51 % during the third trimester, usually by focal neurological deficits. We conclude that in relation to pregnancy, low-grade gliomas are more often seen in women already known with a brain tumor, while high-grade gliomas represent more frequently a new onset phenomenon. Based on these observations, guidelines are given on initiation of antitumor therapy during pregnancy, seizure management, counseling on therapeutic abortion, and on the timing and choice of obstetrical interventions.