Abstract
BackgroundIntraoperative brain stimulation mapping reduces permanent postoperative deficits and extends tumor removal in resective surgery for glioma patients. Successful functional mapping is assumed to depend on the surgical team's expertise. In this study, glioma resection results are quantified and compared using a novel approach, so-called resection probability maps (RPM), exemplified by a surgical team comparison, here with long and short experience in mapping.MethodsAdult patients with glioma were included by two centers with two and fifteen years of mapping experience. Resective surgery was targeted at non-enhanced MRI extension and was limited by functional boundaries. Neurological outcome was compared. To compare resection results, we applied RPMs to quantify and compare the resection probability throughout the brain at 1 mm resolution. Considerations for spatial dependence and multiple comparisons were taken into account.ResultsThe senior surgical team contributed 56, and the junior team 52 patients. The patient cohorts were comparable in age, preoperative tumor volume, lateralization, and lobe localization. Neurological outcome was similar between teams. The resection probability on the RPMs was very similar, with none (0%) of 703,967 voxels in left-sided tumors being differentially resected, and 124 (0.02%) of 644,153 voxels in right-sided tumors.ConclusionRPMs provide a quantitative volumetric method to compare resection results, which we present as standard for quality assessment of resective glioma surgery because brain location bias is avoided. Stimulation mapping is a robust surgical technique, because the neurological outcome and functional-based resection results using stimulation mapping are independent of surgical experience, supporting wider implementation.
Highlights
A larger extent of resection (EOR) of diffusely infiltrative glioma is associated with increased survival [1,2]
We demonstrate the use of resection probability maps (RPMs), exemplified by a comparison of the quality of resective glioma surgery in two surgical centers with differential experience in stimulation mapping of 15 and 2 years, respectively
From each center patients over 17 years of age were consecutively included (1) with diffusely infiltrative glioma of WHO grade II or infiltrative glioma that consists largely of WHO grade II characteristics with an anaplastic focus of mitotic activity, resulting in WHO grade III diagnosis according to histopathological examination, (2) in whom the MRI fluid attenuated inversion recovery (FLAIR) hyperintense signal abnormality was the target for resection, (3) who had no prior radiotherapy to avoid misinterpretation of MRI FLAIR hyperintensity, and (4) had a 3 to 6 month postoperative MRI available
Summary
A larger extent of resection (EOR) of diffusely infiltrative glioma is associated with increased survival [1,2]. Resective surgery aims to maximize glioma removal while preserving functional integrity. These two aims require integration in quality assessment of glioma surgery. Standards for quality of glioma resections have not been determined. Several techniques are in use to improve glioma surgery. Some intend to preserve functional integrity, such as preoperative functional MRI and diffusion tensor imaging [3,4]. Others intend to maximize glioma removal, such as fluorescence light microscopy [5] and intraoperative MRI [6]. Intraoperative stimulation mapping, identifying functional brain regions, serves both aims [7]. Intraoperative brain stimulation mapping reduces permanent postoperative deficits and extends tumor removal in resective surgery for glioma patients. Glioma resection results are quantified and compared using a novel approach, so-called resection probability maps (RPM), exemplified by a surgical team comparison, here with long and short experience in mapping
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