MALIGNANT GLIOMAS Clinical presentation & Surgical Management Wissam Asfahani AMG - Neurosurgery

Disclosures Nothing to disclose

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.

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. The patient was referred to see me in clinic. 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: The patient was admitted to the hospital He was started on High dose steroids (Decadron 10mg IVx1 and then 4mgQ6H IV). The patient was taken to surgery 2 days later. Pathology came back positive for Glioblastoma Multiforme (WHO-IV)

Epidemiology There are approximately 40,000 new primary brain tumor cases/year. 22,000 are High grade. Of these patients, approximately 12,500 will die. High grade gliomas are the most common malignant primary central nervous system (CNS) tumors in adults. The average age at which GBM is diagnosed is 53 years with a peak incidence between the ages of 65 and 74. GBM is more common in men, with a male-to-female ratio of 1.5:1 Without treatment, most patients die within 3 months of diagnosis. 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 Cognitive changes Personality changes 27 Changes in consciousness 18 Nausea and vomiting 15 Sensory deficit 12 Papilledema 5 Commonly, patients will have raised intracranial pressure, which may lead to headache, nausea and vomiting, blurred or double vision, and drowsiness. These signs and symptoms may be associated with extraocular palsies, objective papilledema, pupil abnormalities, or decreased level of consciousness. They are typically more prominent in the morning and improve over the course of the day. Relentless progressive headaches are a hallmark of the symptomatology of these tumors. Up to a third of patients with GBM have seizures. Neurological deficits are common and vary according to the location and extent of tumor infiltration Data from Glioma Outcome Project, Chang, SM, et al, JAMA 2005;299:557

Imaging Modalities CT is used in the acute environment as the first line of imaging to exclude hemorrhage or large areas of infarction in the brain. 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. 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. GBM normally appears as an irregular hypodense lesion on T1-weighted MRI with various degrees of contrast enhancement and edema. The presence of ring-like enhancement surrounding irregularly shaped areas of presumed necrosis suggests glioblastoma

MRI of the brain

Management of GBM Malignant astrocytoma is characterized by its invasive and infiltrative nature. This makes curative resection unlikely. Tumor recurrence in the surgical bed is the norm despite maximal resection. 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. Management: Surgery Chemotherapy Radiation therapy

Surgery in the Management of GBM The main goals of surgery for malignant glioma are: Obtain a tissue diagnosis Decrease the mass effect Reduce the tumor burden Extensive resection of GBM is difficult because these tumors are frequently invasive, widely infiltrative and often involve eloquent areas. Recent advances in operative techniques have improved the extent of resection while minimizing collateral damage to the brain.

Surgery in the Management of GBM Frameless stereotaxy has made surgery safer with better localization of surgical corridors and operative planning.

Surgery in the Management of GBM Awake craniotomies have made surgery for tumors in eloquent areas much safer and increased extent of resection.

Surgery in the Management of GBM Intra-op imaging modalities can guide resection in “real time”. These include intraop CT, MRI or US.

Surgery in the Management of GBM The role of extent of resection on survival has been heavily debated over the years. There are no Level-I studies to guide us. Some evidence that greater extent of resection leads to longer survival. Study N GTR(%) NTR(%) STR (%) GTR(mo) STR(mo) Schneider et al 2005 27 10 (37) 17 (63) 18 8 Bucci et al 2004 39 12 (31) 18 (46) 9 (23) 122 14 McGirt et al 2009 949 330 (35) 388 (41) 231 (24) 13

Conclusion GBM is a very malignant disease with a median survival of less than 2 years. Clinical picture can be diverse and related to location of the tumor with headache being the most common symptom. The main goals of surgery for malignant glioma are: Obtain a tissue diagnosis Decrease the mass effect Reduce the tumor burden Newer surgical adjunct help achieve better extent of resection. Greater extent of resection seems to improve median survival. Despite maximal resection, recurrence is the norm. GBM is not a surgical disease and requires a team approach for treatment including chemotherapy and radiation therapy.