Postoperative Karnofsky Performance Status Research Articles

Predictors of early postoperative epileptic seizures after awake surgery in supratentorial diffuse gliomas.

Functional-based resection under awake conditions had been associated with a nonnegligible rate of intraoperative and postoperative epileptic seizures. The authors assessed the incidence of intraoperative and early postoperative epileptic seizures after functional-based resection under awake conditions. The authors prospectively assessed intraoperative and postoperative seizures (within 1 month) together with clinical, imaging, surgical, histopathological, and follow-up data for 202 consecutive diffuse glioma adult patients who underwent a functional-based resection under awake conditions. Intraoperative seizures occurred in 3.5% of patients during cortical stimulation; all resolved without any procedure being discontinued. No predictor of intraoperative seizures was identified. Early postoperative seizures occurred in 7.9% of patients at a mean of 5.1 ± 2.9 days. They increased the duration of hospital stay (p = 0.018), did not impact the 6-month (median 95 vs 100, p = 0.740) or the 2-year (median 100 vs 100, p = 0.243) postoperative Karnofsky Performance Status score and did not impact the 6-month (100% vs 91.4%, p = 0.252) or the 2-year (91.7 vs 89.4%, p = 0.857) postoperative seizure control. The time to treatment of at least 3 months (adjusted OR [aOR] 4.76 [95% CI 1.38-16.36], p = 0.013), frontal lobe involvement (aOR 4.88 [95% CI 1.25-19.03], p = 0.023), current intensity for intraoperative mapping of at least 3 mA (aOR 4.11 [95% CI 1.17-14.49], p = 0.028), and supratotal resection (aOR 6.24 [95% CI 1.43-27.29], p = 0.015) were independently associated with early postoperative seizures. Functional-based resection under awake conditions can be safely performed with a very low rate of intraoperative and early postoperative seizures and good 6-month and 2-year postoperative seizure outcomes. Intraoperatively, the use of the lowest current threshold producing reproducible responses is mandatory to reduce seizure occurrence intraoperatively and in the early postoperative period.

Mortality, Morbidity, and Prognostic Factors in the Surgical Resection of Brain Metastases: A Contemporary Cohort Study.

Despite advances in systemic therapy and radiotherapy (RT), neurosurgical resection (NSR) remains a mainstay of the treatment of brain metastases (BMs). Although it is unequivocal in instances of diagnostic doubt, radioresistance, and risk of death due to neurologic causes, NSR may be controversial in other situations. Many aspects related to NSR have not yet been well established, and the primary prognostic indices were proposed only in the last decade. This study evaluates the survival and the morbidity, causes of death, prognostic factors, and the impact of RT in patients with BMs treated by NSR in the current era. A total of 200 patients with BMs who were treated by NSR were evaluated sequentially and followed prospectively. We used logistic regression and Cox regression models to identify independent factors associated with mortality at 4 weeks and at 1 year, respectively. Clinical features, morbidity, recurrence, and causes of death were also studied. Lung cancer was the most prevalent cancer (36.5%); the median Karnofsky Performance Status (KPS) score was 60. Total resection was achieved in 89%, and adjuvant RT was applied in 63% of the cases. The rates of surgical mortality, morbidity, and mortality at 4 weeks were 1.5%, 17%, and 7.5%, respectively. Systemic infections were the leading cause of death in 62.5% of the cases. The median survival was 5 months, and 34.5% of patients lived > 1 year. The postoperative KPS (KPSpo) score remained unchanged or improved in 94.5% of the cases. In the multivariate analysis, a KPSpo score ≥ 80 and the application of adjuvant RT were associated with a lower risk of death at 12 weeks and at 1 year. Interestingly, the variables of primary tumor site, number of BMs, and presence of carcinomatous meningitis were not significant. Morbidity and mortality were high, a third of the patients lived > 1 year, and the KPS score improved or remained unchanged in most cases. Prognostic indices and health conditions were important predictive factors, but the KPSpo score and adjuvant RT were independent variables for survival at 12 weeks and at 1 year. Therefore, new studies are needed to assess the influence of new therapies and specific molecular profiles.

Retrospective and Randomized Analysis of Influence and Correlation of Clinical and Molecular Prognostic Factors in a Mono-Operative Series of 122 Patients with Glioblastoma Treated with STR or GTR.

Glioblastoma is a solid, infiltrating, and the most frequent highly malignant primary brain tumor. Our aim was to find the correlation between sex, age, preoperative Karnofsky performance status (KPS), presenting with seizures, and extent of resection (EOR) with overall survival (OS), progression-free survival (PFS), and postoperative KPS, along with the prognostic value of IDH1, MGMT, ATRX, EGFR, and TP53 genes mutations and of Ki67 through the analysis of a single-operator series in order to avoid the biases of a multi-operator series, such as the lack of homogeneity in surgical and adjuvant nonsurgical treatments. A randomized retrospective analysis of 122 patients treated by a single first operator at Sapienza University of Rome was carried out. After surgery, patients followed standard Stupp protocol treatment. Exclusion criteria were: (1) patients with primary brainstem and spinal cord gliomas and (2) patients who underwent partial resections (resection < 90%) or a biopsy exclusively for diagnostic purposes. Statistical analysis with a simultaneous regression model was carried out through the use of SPSS 25® (IBM). Results showed statistically significant survival increase in four groups: (1) patients treated with gross total resection (GTR) (p < 0.030); (2) patients with mutation of IDH1 (p < 0.0161); (3) patients with methylated MGMT promoter (p < 0.005); (4) patients without EGFR amplification or EGFRvIII mutation (p < 0.035). Higher but not statistically significant survival rates were also observed in: patients <75 years, patients presenting with seizures at diagnosis, patients affected by lesions in noneloquent areas, as well as in patients with ATRX gene mutation and Ki-67 < 10%.

Radical Laser Interstitial Thermal Therapy Ablation Volumes Increase Progression-Free Survival in Biopsy-Proven Radiation Necrosis

Treatment for surgically inaccessible medically refractory cerebral radiation necrosis (RN) has remained limited. Recently, laser interstitial thermal therapy (LITT) has gained traction as an effective means of treating these lesions but limited data are available regarding the effect of ablation size on patient outcome. Therefore, this study analyzed various outcome measures as a function of ablation volume/diameter for a series of 20 patients with surgically inaccessible biopsy-proven RN. Twenty patients with biopsy-proven RN treated with LITT from 2013 to 2018 at our institution were retrospectively reviewed. Local progression-free survival (PFS), overall survival, and steroid dependence were analyzed with Kaplan-Meier and Cox regression analysis for ablation volume/diameter. Comparison of preoperative and postoperative Karnofsky Performance Status was conducted with a matched paired t test. Patients with subtotal ablation (<100% increase in pre-LITT lesion volume or <0 mm increase in pre-LITT lesion diameter) had higher risk of local disease progression (hazard ratio, 12.4; P= 0.004) compared with patients with total ablations. Patients who received radical ablations (>200% increase in pre-LITT lesion volume or >2 mm increase in pre-LITT lesion diameter) showed the most favorable PFS (P < 0.0458 and P < 0.0378, respectively). There was no difference in post-LITT Karnofsky Performance Status and time to steroid freedom between ablation groups. Overall survival increased with radical diametric ablation (P= 0.0401). Although LITT has proved to be an effective salvage therapy for patients with RN, detailed volumetric studies have not been explored. Our results suggest that radical ablations have the potential to increase PFS.

Perioperative fatigue in patients with diffuse glioma

PurposeFew studies have assessed fatigue in relation to glioma surgery. The purpose of this study was to explore the prevalence of pre- and postoperative high fatigue, perioperative changes, and factors associated with pre- and postoperative high fatigue in patients undergoing primary surgery for diffuse glioma.MethodsA total of 112 adult patients were prospectively included. Patient-reported fatigue was assessed before and one month after surgery using the cancer-specific European Organization for Research and Treatment of Cancer questionnaire fatigue subscale. The scores were dichotomized as high fatigue (≥ 39) or low fatigue (< 39). A change in score of ≥ 10 was considered as a clinically significant change. Factors associated with pre- and postoperative high fatigue were explored in multivariable regression analyses.ResultsHigh fatigue was reported by 45% of the patients preoperatively and by 42% of the patients postoperatively. Female gender and low Karnofsky Performance Status (KPS) were associated with preoperative high fatigue, while postoperative complications, low KPS and low-grade histopathology were associated with postoperative high fatigue. In total 35/92 (38%) patients reported a clinically significant improvement of fatigue scores after surgery, 36/92 (39%) patients reported a clinically significant worsening of fatigue scores after surgery, and 21/92 (23%) patients reported no clinically significant change in fatigue scores after surgery. Patients with low-grade gliomas more often reported low fatigue before surgery and high fatigue after surgery, while patients with high-grade gliomas more often reported high fatigue before surgery and low fatigue after surgery.ConclusionsOur findings indicate that fatigue is a common symptom in patients with diffuse glioma, both pre- and postoperatively. Perioperative changes were frequently seen. This is important knowledge when informing patients before and after surgery.

Experience of Fully Awake Craniotomy for Supratentorial Lesions: A Single Institution Study.

To report and to discuss our experience of awake craniotomy for the treatment of supratentorial lesions. We included patients who underwent awake craniotomy for supratentorial tumors between 2007 and 2018. A bipolar stimulation probe was used for patients with eloquent area lesions. The demographic features, presenting symptoms, comorbidities, localization, histopathology, pre- and postoperative Karnofsky performance status, mean operation length, mean length of hospital stay, and intraoperative and postoperative complications were recorded. We included 250 patients (age, 53.5 ± 15.3 years; range, 15?90 years; 105 females and 145 males) mostly with metastasis (46%). The tumor resection rate was 90 ± 3.6%. Of 30 patients (12%) who experienced an increase in weakness, 26 experienced improvements within three days, and the remainder had permanent symptoms. Intraoperative and postoperative seizures occurred in three (1.2%) and seven (2.8%) patients, respectively, which were controlled by antiepileptic drugs. Dysphasia occurred intraoperatively in seven patients (2.8%) but improved in a month. The mean follow-up duration was 31.8 ± 11.9 months (range, 7?70 months). No mortality was seen during hospitalization. Awake procedures are a good option in supratentorial lesions to avoid the complications of general anesthesia for patients in poor medical condition. To obtain maximal tumor resection and to maintain better quality of life, neurosurgeons should opt for awake craniotomy when necessary.

Microsurgical resection of trigone ventricular meningiomas using the parieto-occipital approach: a retrospective analysis of 47 cases and literature review.

To investigate the risk factors of preoperative and postoperative treatment for trigone ventricular meningioma and the clinical efficacy of microsurgical resection of the neoplasm using the parieto-occipital approach. Forty-seven trigone ventricular meningiomas were resected using the parieto-occipital approach in one institute from January 2015 to January 2019. Patients were postoperative followed up for 3 months to 3 years. Karnofsky performance status (KPS) and Glasgow Coma Scale (GCS) were used to assess patient's performance status and consciousness. Clinical data including patients' characteristics, surgical procedure, and postoperative management were retrospectively analyzed. Microsurgery achieved total removal of the tumor in 46 cases with no obvious residue (97.9%), and subtotal removal in 1 case (2.1%). No deaths occurred. Preoperative symptoms of neurology were significantly improved. There was a significant difference in preoperative KPS and postoperative KPS (P<0.05). No difference was found in GCS. Compared to patients with peritumoral brain edema (PTBE), KPS of patients without PTBE was significantly increased (P<0.05). PTBE may be a risk factor for preoperative neurological symptoms. Furthermore, the parieto-occipital approach is a safe and effective surgical approach in resecting trigone ventricular meningioma.

Intraoperative MRI-assisted neuro-port surgery for the resection of cerebral intraparenchymal cavernous malformation

BackgroundIntraparenchymal cerebral cavernous malformation is difficult to localize intraoperatively with conventional frameless navigation due to the “brain shift” effect. We conducted this study to evaluate the efficacy and safety of intraoperative magnetic resonance image (iMRI)-assisted neuro-port surgery for the resection of cerebral intraparenchymal cavernous malformation.MethodsBetween April 2016 and December 2017, 54 consecutive patients with intraparenchymal cerebral cavernous malformation who get surgical treatment in our hospital were enrolled into this study. Twenty-one patients were treated using iMRI-assisted neuro-port surgery (experiment group), and 33 patients underwent treatment by conventional microsurgery (control group). The iMRI was used in all cases for the compensation of the “brain shift” effect and keeping the navigation system up-to-date. The surgical resection rate, the total operation time, and the preoperative and postoperative Karnofsky Performance Status (KPS) scores were determined to evaluate the operative procedures.ResultsThere were no significant differences between the two groups in mean age, gender ratio, and volume of lesions (P > 0.05). For the experiment group, the average duration of the procedure was 188.8 min with total resection of the lesions achieved in all 21 cases. For the control group, the average duration of the procedure was 238.2 min with total resection of the lesions achieved in 25 of 33 cases. The differences in the average duration of the procedure and the number of totally resected lesions between the two groups were statistically significant (P < 0.05). Regarding postoperative neurological function, postoperative KPS scores for the experiment group were significantly higher than those of the control group (P = 0.018).ConclusionOur results show that iMRI-assisted neuro-port surgery is helpful for intraparenchymal cerebral cavernous malformation surgery. The method provides high accuracy and efficiency for lesion targeting and permits excellent anatomic orientation. With the assistance of iMRI technology, we achieved a higher resection rate and a lower incidence of postoperative neurological deficits. Additionally, iMRI is helpful for the compensation of the “brain shift” effect, and it can update the navigation system.

P14.44 Survival benefit of lobectomy over gross-total resection without lobectomy in cases of glioblastoma in the noneloquent area: a retrospective study

Abstract BACKGROUND Following resection of glioblastoma (GBM), microscopic remnants of the GBM tumor remaining in nearby tissue cause tumor recurrence more often than for other tumors, even after gross-total resection (GTR). Although surgical oncologists traditionally resect some of the surrounding normal tissue, whether further removal of nearby tissue may improve survival in GBM patients is unknown. In this single-center retrospective study, the authors assessed whether lobectomy confers a survival benefit over GTR without lobectomy when treating GBMs in the noneloquent area. MATERIAL AND METHODS The authors selected 40 patients who had undergone GTR of a histopathologically diagnosed isocitrate dehydrogenase (IDH)-wild type GBM in the right frontal or temporal lobe and divided the patients into 2 groups according to whether GTR of the tumor involved lobectomy, defined as a supratotal resection (SupTR group, n = 20) or did not (GTR group, n = 20). Progression-free survival (PFS), overall survival (OS), and Karnofsky Performance Status (KPS) scores were compared between groups (p ≤ 0.05 for statistically significant differences). RESULTS The median postoperative PFS times for each group were as follows: GTR group, 11.5 months (95% CI 8.8–14.2) and SupTR group, 30.7 months (95% CI 4.3–57.1; p = 0.007). The median postoperative OS times for each group were as follows: GTR group, 18.7 months (95% CI 14.3–23.1) and SupTR group, 44.1 months (95% CI 25.1–63.1; p = 0.040). The mean postoperative KPS scores (GTR, 76.5; SupTR, 77.5; p = 0.904) were not significantly different. In multivariate analysis, survival for the SupTR group was significantly longer than that for the GTR group in terms of both PFS (HR 0.230; 95% CI 0.090–0.583; p = 0.002) and OS (HR 0.247; 95% CI 0.086–0.704; p = 0.009). CONCLUSION In cases of completely resectable, noneloquent area GBMs, SupTR provides superior PFS and OS without negatively impacting patient performance.

The application value of diffusion tensor imaging in surgical management of patients with brainstem gliomas

Objective To explore the role of diffusion tensor imaging (DTI) in brainstem glioma surgery. Methods A retrospective analysis was performed on 57 patients with brainstem gliomas who had undertaken surgery from January 2014 to December 2018 at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University. All patients underwent preoperative DTI and tumor resection with the assistance of neuronavigation and electrophysiological monitoring. Radiological and clinical data were collected, including conventional MRI and DTI, corticospinal tract (CST) score, tumor-to-CST distance (TCD), muscle strength and Karnofsky performance status (KPS) before and after surgery. Kruskal-Wallis H test was used to evaluate postoperative motor deficit and KPS of patients with different CST scores. Spearman's correlation was performed to assess the relationship of both CST score and TCD with postoperative motor deficits and KPS, respectively. Multiple linear regression was used to investigate the influence of CST score and TCD on postoperative muscle strength and KPS. Results Among the 57 patients, 51 patients had at least one CST compromised. The most common changes of the CST were deviation (30/114, 26.3%) and deformation (30/114, 26.3%). The surgical approaches were adjusted after evaluation of the DTI results in 21 (36.8%) cases. Postoperative muscle strength and KPS were significantly different between different CST score groups (χ2=16.011; χ2=9.576, all P<0.05). Preoperative CST scores were negatively correlated with postoperative muscle strength and KPS (r=-0.362; r=-0.354, both P<0.05) whereas TCD had positive correlation with both postoperative muscle strength and KPS (r=0.305, r=0.339, both P<0.05). CST score could independently influence postoperative muscle strength (t=-2.438, P=0.016). However, CST score could not independently influence postoperative KPS (t=-0.523, P=0.603). Conclusion DTI plays an important role in surgical management of brainstem gliomas and could help optimize the surgical strategy and predict postoperative motor deficits. Key words: Diffusion tensor imaging; Brainstem glioma; Neurosurgical procedures; Application value

High Expression of TGF-β1 Predicting Tumor Progression in Skull Base Chordomas

To investigate the expression characteristics and prognostic value of transforming growth factor β1 (TGF-β1) in primary skull base chordomas (SBCs). The mRNA expression levels of TGF-β1 were measured in 57 frozen samples from patients with primary SBCs. Clinical data collection, follow-up, correlations, and survival analyses were performed. In the series of 57 patients (29 men and 28 women) with primary SBCs, the mean value of TGF-β1 mRNA was 1.713 with a median of 0.904. Twenty-four SBCs were soft type and 33 were hard type. The Mann-Whitney U test revealed that the expression level of TGF-β1 mRNA in hard type SBCs was significantly higher than the expression level found in the soft type (P= 0.03). The independent-samples median test suggested that the expression level of TGF-β1 mRNA in female patients' SBCs was significantly higher than that in male patients' SBCs (P= 0.01). Expression differences of TGF-β1 were not seen among different pathological subtypes, tumor blood supply, or degree of resection. The Spearman rank correlation coefficient clarified that TGF-β1 mRNA levels were not correlated with tumor diameter, preoperative Karnofsky Performance Status (KPS), postoperative KPS, follow-up KPS, age, or intraoperative blood loss. The multivariate Cox analysis revealed that pathological subtype (P= 0.008), expression level of TGF-β1 mRNA (P= 0.01), and tumor texture (P= 0.03) were all independent prognostic factors for tumor progression. SBCs in female patients and SBCs with hard texture were prone to have high TGF-β1 mRNA expression. High expression of TGF-β1, hard tumor texture, and conventional subtype were all independent risk factors for tumor progression.

Awake surgery for glioblastoma can preserve independence level, but is dependent on age and the preoperative condition.

Lately, awake surgery has been frequently adapted for glioblastoma (GBM). However, even with awake surgery, the expected long-term independence levels may not be achieved. We studied the characteristics of independence levels in GBM patients, and investigated the usefulness and parameter thresholds of awake surgery from the standpoint of functional outcomes. Totally, 60 GBM patients (awake group, n = 30; general anesthesia group, n = 30) who underwent tumor resection surgery were included. We collected preoperative and 1- and 3-month postoperative Karnofsky Performance Status (KPS) scores, and analyzed causes of low KPS scores from the aspect of function, brain region, and clinical factors. Then, we focused on the operative method, and investigated the usefulness of awake surgery. Finally, we explored the parameter standards of awake surgery in GBM considering independence levels. Postoperative KPS were significantly lower than preoperative scores. Responsible lesions for low KPS scores were deep part of the left superior temporal gyrus and the right posterior temporal gyri that may be causes of aphasia and neuropsychological dysfunctions, respectively. Additionally, operative methods influenced on low independence level; long-term KPS scores in the awake group were significantly higher than those in the general anesthesia group, but they depended on age and preoperative KPS scores. Receiver operating characteristic curve analysis showed preoperative KPS = 90 and age = 62years as the cutoff values for preservation of long-term KPS scores in awake group. Awake surgery for GBM is useful for preserving long-term independence levels, but outcomes differ depending on age and preoperative KPS scores.

Lobectomy confers a survival benefit over gross-total resection without lobectomy in cases of primary glioblastoma in non-eloquent area: A retrospective study.

e13561 Background: Following resection, the microscopic remnants of glioblastomas in nearby tissue cause tumor recurrence more often than other tumors. Although surgical oncologists traditionally resect some of the surrounding normal tissue, whether further removal of nearby tissue may improve survival in cases of primary glioblastomas (pGBM) is unknown. In this single-center retrospective study, we assessed whether lobectomy confers a survival benefit over gross-total resection without lobectomy when treating pGBM in the non-eloquent area. Methods: We selected 28 patients who had complete resection of a histopathologically-diagnosed pGBM in the right frontal or temporal lobe, and divided them into two groups according to whether gross-total resection of the tumor involved lobectomy (SupTR group, n = 15) or did not (GTR group, n = 13). Progression-free survival (PFS), overall survival (OS), and Karnofsky Performance Status (KPS) scores were compared statistically between groups (p≤0.05 for significant differences). Results: Median post-operative PFS times (GTR, 9.7 months [95% CI 2.9-16.5]; SupTR, 35.0 months [95% CI 11.1–58.9]; p = 0.082) and mean KPS scores (GTR, 73.4; SupTR, 71.3; p = 0.586) were not significantly different; however, median post-operative OS times were (GTR, 14.4 months [95% CI 12.1–16.7]; SupTR, 35.0 months [95% CI 17.4–52.6]; p = 0.018). In multivariate analysis, the SupTR group was significantly better than the GTR group in terms of both OS (HR 0.249; 95% CI 0.085–0.730; p = 0.011) and PFS (HR 0.362; 95% CI 0.0134–0.982; p = 0.046). Conclusions: In cases of completely resectable, non-eloquent area pGBMs, including lobectomy improved overall survival without negatively impacting patient performance.

Association of Surgical Resection, Disability, and Survival in Patients with Glioblastoma.

Extent of resection (EOR) and Karnofsky Performance Status (KPS) are at odds in glioblastoma (GBM) surgery, that is, the anticipated postoperative disability limits the EOR. This study analyzes the correlation of different surgical modalities with the resulting physical status and survival of patients with GBM. A total of 565 patients with primary GBM were operated on in a single institution between 2006 and 2014. Possible surgical modalities comprised supratotal resection (SLR), gross total resection (GTR; ≥ 95% by volume), tumor debulking (TDB; ≤ 95% by volume), and stereotactic biopsy (SB). Pre- and postoperative KPS before and up to 4 weeks after surgery as well as overall survival (OS) rate were determined retrospectively. Hazard ratio (HR) and 95% confidence intervals were calculated using a Cox proportional hazards model. Median postoperative KPS was ≥ 70, irrespective of surgical modality. Mean OS was 12.5 months. Multivariate analysis revealed age ≥ 70 years (HR: 1.93), preoperative KPS < 70 (HR: 2.15), and unmethylation in MGMT promoter (HR: 1.27) as independent factors for worse OS. Regarding surgical modality, SB was associated with the worst survival (HR: 2.3) followed by TDB (HR: 1.36). SLR was inferior to GTR (HR: 1.27). Higher EOR in patients with GBM does not seem inevitably correlated with increasing functional impairment, but better survival, provided there is a balanced preoperative indication. Nevertheless, SLR does not seem to be superior to GTR. Whenever possible, maximal safe resection should be considered in patients with GBM, even if an EOR ≥ 95% is not possible.

Clinical Outcome of Operated Intracranial Meningiomas: An Ethiopian Experience

Intracranial meningioma is the most common brain tumor operated in the 2 teaching hospitals in Ethiopia. This study reviews the clinical outcome of intracranial meningiomas in a resource-limited setup. This is a retrospective study undertaken at 2 neurosurgical teaching hospitals: Black Lion Specialized Hospital and Myungsung Christian Medical Center. It includes all operated patients with intracranial meningioma during the time period January 2009 to December 2013. Patient data regarding sociodemographics, presenting complaint, focal neurologic deficit, preoperative imaging, postoperative neurologic findings, intraoperative findings, and histopathologic results were collected and analyzed. A total of 91 patients were enrolled in the study. Tumor size was estimated in 79 cases (86.8%). Fifty-one tumors (64.6%) were >5 cm in diameter, whereas 28 (35.4%) were ≤5 cm. Only 4 patients had tumors <3 cm (5.1%). Tumor size was shown to be related to postoperative functional outcome (P= 0.032). The surgical mortality rate, which was defined as death within 1 month, was 14.3%. Among 88 patients with a postoperative Karnofsky Performance Status Scale score, 43% achieved a postoperative score ≥70. Meningioma size determines the outcome of the patients. It was shown that the functional outcome of patients is encouraging even though further improvement on neurosurgical care is needed.

Evaluating the Association Between the Extent of Resection and Survival in Gliosarcoma.

Introduction: Gliosarcoma (GS) is a rare, malignant mixed tumor of the central nervous system with a median survival of approximately 13 months across multiple studies. Although the value of the extent of resection (EOR) has been confirmed as a prognostic survival factor in glioblastoma, no such association has been defined for GS. The goal of this study was to establish an association between EOR and survival and to determine if a threshold of resection exists for which a survival benefit is conferred in GS.Methods: The authors identified 11 patients with histologically confirmed GS between January 2005 and January 2015, treated at the Hospital of the University of Pennsylvania. Clinical, radiographic, and outcome data were retrospectively reviewed. Volumetric analysis was completed using semi-automated segmentation to measure the change in contrast-enhancing material based on preoperative T1-contrast (T1c) and postoperative T1 & T1c magnetic resonance imaging (MRI) scans. A log-rank test was completed to confirm an association between EOR and survival, and a series of Kaplan-Meier curves were constructed to determine an EOR threshold. Univariate Cox proportional hazards model (CPHM) followed by multivariate CPHM was also completed to evaluate associations between the prognostic clinical and immunohistochemistry variables under consideration.Results: Extent of resection categories were defined as gross total resection (GTR >95%), subtotal resection (STR 90%-95%), and partial resection (PR <90%). The median overall survival for the groups were as follows: GTR-17.3 months (n=4), STR-12.6 months (n=5), PR-4.3 months (n=2). A statistically significant association (p=05 level) was found between survival and the PR group with the GTR group as reference. Multivariate CPHM confirmed a statistically significant association between increased survival and age, preoperative Karnofsky Performance Status (KPS) scores, postoperative KPS scores, and KI-67 index. Serial Kaplan-Meier curves suggest a survival benefit with an EOR threshold of 94%.Conclusion: This study agrees with previous correlations in glioblastoma EOR and prolonged survival. For patients undergoing surgical resection for GS, maximal surgical removal, when safely possible, should be attempted as it appears to translate to longer survival times.

Survival benefit of lobectomy over gross-total resection without lobectomy in cases of glioblastoma in the noneloquent area: a retrospective study.

Following resection of glioblastoma (GBM), microscopic remnants of the GBM tumor remaining in nearby tissue cause tumor recurrence more often than for other types of tumors, even after gross-total resection (GTR). Although surgical oncologists traditionally resect some of the surrounding normal tissue, whether further removal of nearby tissue may improve survival in GBM patients is unknown. In this single-center retrospective study, the authors assessed whether lobectomy confers a survival benefit over GTR without lobectomy when treating GBMs in the noneloquent area. The authors selected 40 patients who had undergone GTR of a histopathologically diagnosed isocitrate dehydrogenase (IDH)-wild type GBM in the right frontal or temporal lobe and divided the patients into 2 groups according to whether GTR of the tumor involved lobectomy, defined as a supratotal resection (SupTR group, n = 20) or did not (GTR group, n = 20). Progression-free survival (PFS), overall survival (OS), and Karnofsky Performance Status (KPS) scores were compared between groups (p ≤ 0.05 for statistically significant differences). The median postoperative PFS times for each group were as follows: GTR group, 11.5 months (95% CI 8.8-14.2) and SupTR group, 30.7 months (95% CI 4.3-57.1; p = 0.007). The median postoperative OS times for each group were as follows: GTR group, 18.7 months (95% CI 14.3-23.1) and SupTR group, 44.1 months (95% CI 25.1-63.1; p = 0.040). The mean postoperative KPS scores (GTR, 76.5; SupTR, 77.5; p = 0.904) were not significantly different. In multivariate analysis, survival for the SupTR group was significantly longer than that for the GTR group in terms of both PFS (HR 0.230; 95% CI 0.090-0.583; p = 0.002) and OS (HR 0.247; 95% CI 0.086-0.704; p = 0.009). In cases of completely resectable, noneloquent-area GBMs, SupTR provides superior PFS and OS without negatively impacting patient performance.

Cranial Chordoma: A New Preoperative Grading System.

BACKGROUNDChordomas are rare but challenging neoplasms involving the skull base. A preoperative grading system will be useful to identify both areas for treatment and risk factors, and correlate to the degree of resection, complications, and recurrence.OBJECTIVETo propose a new grading system for cranial chordomas designed by the senior author. Its purpose is to enable comparison of different tumors with a similar pathology to clivus chordoma, and statistically correlate with postoperative outcomes.METHODSThe numerical grading system included tumor size, site of the tumor, vascular encasement, intradural extension, brainstem invasion, and recurrence of the tumor either after surgery or radiotherapy with a range of 2 to 25 points; it was used in 42 patients with cranial chordoma. The grading system was correlated with number of operations for resection, degree of resection, number and type of complications, recurrence, and survival.RESULTSWe found 3 groups: low-risk 0 to 7 points, intermediate-risk 8 to 12 points, and high-risk ≥13 points in the grading system. The 3 groups were correlated with the following: extent of resection (partial, subtotal, or complete; P < .002); number of operative stages to achieve removal (P < .014); tumor recurrence (P = .03); postoperative Karnofsky Performance Status (P < .001); and with successful outcome (P = .005). The grading system itself correlated with the outcome (P = .005).CONCLUSIONThe proposed chordoma grading system can help surgeons to predict the difficulty of the case and know which areas of the skull base will need attention to plan further therapy.

The influence of comorbidity on the postoperative survival in elderly (≥ 75years old) with lung cancer.

We conducted a multi-institutional prospective observational study of elderly patients (≥ 75years-old) with resected non-small cell lung cancer. In this report, we have followed the cohorts for 2years after surgery and examined both the influence of preoperative comorbidity [Adult Comorbidity Evaluation-27 (ACE-27) index] on the postoperative survival and the change in the Karnofsky Performance Status (KPS). From March 2014 to April 2015, 264 patients were prospectively registered from 22 hospitals affiliated with the National Hospital Organization. The mean age at the time of surgery was 79.3years (range 75-90years), and 41% of the patients were ≥ 80years of age. A total of 26% underwent sublobar resection. The study endpoints were the postoperative overall survival (OS), its prognostic factors, and the changes in the postoperative KPS. The 2-year OS was 85.3% (95% confidence interval 80.4-89.1%). Male gender, age ≥ 80, a smoking history, grade 2 of ACE-27, and an advanced disease stage were significantly poor prognostic factors for the OS in the univariate risk analysis. The multivariate analysis showed that male gender, age ≥ 80, an advanced disease stage and sublobar resection were significantly poor prognostic factors for the OS. In comparison with the preoperative KPS, no marked decline was observed in the postoperative chorological change of KPS. In the surgical treatment of elderly patients, the comorbidity as assessed by the ACE-27 index might affect the postoperative survival, and therefore should be taken into accounts in the preoperative evaluation of the surgical indications.

Validation of Grading Scores and Outcome Prognostic Factors in Intracranial Meningiomas in Elderly Patients.

Meningiomas are the most frequent benign intracranial tumors and they are becoming more frequent because of the aging population and advances in diagnostics and neurosurgical treatment. Therefore, there will be an increase of this disease in the coming years. We performed a retrospective analysis of patients older than 70 years who underwent surgery for intracranial meningiomas, and we established risk factors related to outcome, morbidity, and mortality. We compared 3 previously described scores (Geriatric Scoring System [GSS], Clinico-Radiological Grading System [CRGS], and Sex, Karnofsky, ASA, Location and Edema [SKALE] score). We identified 110 patients older than 70 years. In the univariate analysis, postoperative Karnofsky Performance Status (KPS) was related to the presence of edema (P= 0.036), tumor size (P= 0.043), previous neurologic impairment (P= 0.012), and preoperative American Society of Anesthesiologists (ASA) physical status classification (P= 0.029). In the multivariable logistic regression model, ASA classification (odds ratio, 0.324; P= 0.04) and preoperative KPS (odds ratio, 1.042; P= 0.05) were also statistically significant. In all cases, better survival curves in the Kaplan-Meier survival test appear in patients with lower scores (CRGS, P= 0.015; GSS, P= 0.014; SKALE, P < 0.001). Also, morbidity measured as postoperative KPS correlated with these scores (CRGS, P<0.001; SKALE, P < 0.001; GSS, P < 0.001). However, only SKALE correlated with perioperative morbidity, mortality, and 1-year mortality. Meningioma resection in patients older than 70 years is safe, with an acceptable rate of mortality and morbidity. Patients who should undergo surgery must be selected in relation to their comorbidities, such as ASA classification or preoperative KPS. However, SKALE could be a useful tool as an initial approach.