Transcript MALIGNANT GLIOMAS Clinical presentation & Surgical Management Wissam Asfahani AMG - Neurosurgery Disclosures • Nothing to disclose.

MALIGNANT GLIOMAS
Clinical presentation
&
Surgical Management
Wissam Asfahani
AMG - Neurosurgery
Disclosures
•
Nothing to disclose
Case Presentation:
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The patient is a 55 year old male previous healthy has been
complaining of headaches for about 2 weeks.
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He developed a syncopal episode.
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He was transferred to an outside hospital ER where he underwent a
CT scan of the head.
CT of the head
Case Presentation:
•
The patient is a 55 year old male previous healthy has been
complaining of headaches for about 2 weeks.
•
He developed a syncopal episode.
•
He was transferred to an outside hospital ER where he underwent a
CT scan of the head.
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The patient was referred to see me in clinic.
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The night before his scheduled appointment he developed another
syncopal episode and he was transferred to Avera McKennan for
further workup and management.
MRI of the brain
MRI of the brain
Case Presentation:
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The patient was admitted to the hospital
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He was started on High dose steroids (Decadron 10mg IVx1 and then
4mgQ6H IV).
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The patient was taken to surgery 2 days later.
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Pathology came back positive for Glioblastoma Multiforme (WHO-IV)
Epidemiology
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There are approximately 40,000 new primary brain tumor cases/year.
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22,000 are High grade.
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Of these patients, approximately 12,500 will die.
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High grade gliomas are the most common malignant primary central nervous
system (CNS) tumors in adults.
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The average age at which GBM is diagnosed is 53 years with a peak incidence
between the ages of 65 and 74.
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GBM is more common in men, with a male-to-female ratio of 1.5:1
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Without treatment, most patients die within 3 months of diagnosis.
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Even with optimal treatment, median survival is less than 16 months for patients
with GBM with fewer than 25% surviving up to 2 years
Clinical Presentation
Symptom
Percentage
Headache
57
Seizure
23
Memory Loss
39
Motor weakness
36
Visual symptoms
21
Language deficits
36
Cognitive changes
39
Personality changes
27
Changes in consciousness
18
Nausea and vomiting
15
Sensory deficit
12
Papilledema
5
Data from Glioma Outcome Project, Chang, SM, et al, JAMA 2005;299:557
Imaging Modalities
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CT is used in the acute environment as the first line of imaging to exclude
hemorrhage or large areas of infarction in the brain.
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Once a mass lesion is suspected on non–contrast-enhanced CT, MRI is used to
better characterize the mass because of its multiplanar capability and superior
soft tissue contrast.
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Standard T1- and T2-weighted MRI studies are able to detect brain tumors with
high sensitivity with regard to size and localization. They are also able to detect
mass effect, edema, hemorrhage, and necrosis.
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GBM normally appears as an irregular hypodense lesion on T1-weighted MRI
with various degrees of contrast enhancement and edema.
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The presence of ring-like enhancement surrounding irregularly shaped areas of
presumed necrosis suggests glioblastoma
MRI of the brain
Management of GBM
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Malignant astrocytoma is characterized by its invasive and infiltrative nature.
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This makes curative resection unlikely.
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Tumor recurrence in the surgical bed is the norm despite maximal resection.
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In the 1930s, Walter Dandy reported recurrence of contralateral gliomas even
after hemispherectomy of the tumor-bearing hemisphere, thus illustrating how
infiltrative these tumors are.
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Management:
 Surgery
 Chemotherapy
 Radiation therapy
Surgery in the Management of
GBM
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The main goals of surgery for malignant glioma are:
 Obtain a tissue diagnosis
 Decrease the mass effect
 Reduce the tumor burden
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Extensive resection of GBM is difficult because these tumors are frequently
invasive, widely infiltrative and often involve eloquent areas.
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Recent advances in operative techniques have improved the extent of
resection while minimizing collateral damage to the brain.
Surgery in the Management of
GBM
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Frameless stereotaxy has made surgery safer with better localization
of surgical corridors and operative planning.
Surgery in the Management of
GBM
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Awake craniotomies have made surgery for tumors in eloquent areas
much safer and increased extent of resection.
Surgery in the Management of
GBM
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Intra-op imaging modalities can guide resection in “real time”.
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These include intraop CT, MRI or US.
Surgery in the Management of
GBM
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The role of extent of resection on survival has been heavily debated over the
years.
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There are no Level-I studies to guide us.
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Some evidence that greater extent of resection leads to longer survival.
Study
N
GTR(%)
Schneider et al 2005
27
10 (37)
Bucci et al 2004
39
12 (31)
McGirt et al 2009
949
330 (35)
NTR(%)
STR (%)
GTR(mo)
STR(mo
)
17 (63)
18
8
18 (46)
9 (23)
122
14
388 (41)
231 (24)
13
8
Conclusion
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GBM is a very malignant disease with a median survival of less than 2 years.
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Clinical picture can be diverse and related to location of the tumor with
headache being the most common symptom.
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The main goals of surgery for malignant glioma are:
 Obtain a tissue diagnosis
 Decrease the mass effect
 Reduce the tumor burden
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Newer surgical adjunct help achieve better extent of resection.
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Greater extent of resection seems to improve median survival.
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Despite maximal resection, recurrence is the norm.
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GBM is not a surgical disease and requires a team approach for treatment
including chemotherapy and radiation therapy.