Abstract
Object:Glioblastoma is a highly malignant brain tumor, for which standard treatment consists of surgery, radiotherapy, and chemotherapy. Increasing extent of tumor resection (EOTR) is associated with prolonged survival. Intraoperative magnetic resonance imaging (iMRI) is used to increase EOTR, based on contrast enhanced MR images. The correlation between intraoperative contrast enhancement and tumor has not been studied systematically.Methods:For this prospective cohort study, we recruited 10 patients with a supratentorial brain tumor suspect for a glioblastoma. After initial resection, a 0.15 Tesla iMRI scan was made and neuronavigation-guided biopsies were taken from the border of the resection cavity. Scores for gadolinium-based contrast enhancement on iMRI and for tissue characteristics in histological slides of the biopsies were used to calculate correlations (expressed in Kendall's tau).Results:A total of 39 biopsy samples was available for further analysis. Contrast enhancement was significantly correlated with World Health Organization (WHO) grade (tau 0.50), vascular changes (tau 0.53), necrosis (tau 0.49), and increased cellularity (tau 0.26). Specificity of enhancement patterns scored as “thick linear” and “tumor-like” for detection of (high grade) tumor was 1, but decreased to circa 0.75 if “thin linear” enhancement was included. Sensitivity for both enhancement patterns varied around 0.39-0.48 and 0.61-0.70, respectively.Conclusions:Presence of intraoperative contrast enhancement is a good predictor for presence of tumor, but absence of contrast enhancement is a bad predictor for absence of tumor. The use of gadolinium-based contrast enhancement on iMRI to maximize glioblastoma resection should be evaluated against other methods to increase resection, like new contrast agents, other imaging modalities, and “functional neurooncology” – an approach to achieve surgical resection guided by functional rather than oncological-anatomical boundaries.
Highlights
Glioblastoma is a highly malignant brain tumor that often shows extensive infiltrative growth in the surrounding brain parenchyma
Contrast enhancement was significantly correlated with World Health Organization (WHO) grade, vascular changes, necrosis, and increased cellularity
Presence of intraoperative contrast enhancement is a good predictor for presence of tumor, but absence of contrast enhancement is a bad predictor for absence of tumor
Summary
Glioblastoma is a highly malignant brain tumor that often shows extensive infiltrative growth in the surrounding brain parenchyma. The added value of iMRI in increasing EOTR for glioblastoma is based on visualizing remaining contrast enhancement on T1‐weighted scans at the border of the resection cavity. This contrast enhancement is supposed to indicate residual tumor, which can be resected in the same procedure. In a few studies the resected tissue was sent separately for histological analysis, leading to varying reports on tumor presence.[25,20,16] due to the infiltrative nature of a glioblastoma, tumor cells are often present outside the contrast enhancing area.[5,1] If contrast enhancement on T1‐weighted iMRI is to be used as a marker for high grade glioma, contrast enhancing tissue should exhibit more high grade tumor characteristics than non (contrast) enhancing tissue. Histologic results correlated to preoperative imaging might not correlate to iMRI
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