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|Year : 2020 | Volume
| Issue : 4 | Page : 813-814
Early and Maximal Personalized Surgical Resection Improves Survival and Quality of Life in Low-grade Gliomas Patients
Department of Neurosurgery, Montpellier University Medical Center; Institute of Functional Genomics, INSERM U-1191, University of Montpellier, Montpellier, France
|Date of Web Publication||26-Aug-2020|
Prof. Hugues Duffau
Department of Neurosurgery, Gui de Chauliac Hospital, CHU Montpellier, 80 Avenue Augustin Fliche, 34295 Montpellier
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Duffau H. Early and Maximal Personalized Surgical Resection Improves Survival and Quality of Life in Low-grade Gliomas Patients. Neurol India 2020;68:813-4
Diffuse low-grade glioma (LGG), i.e., WHO grade II glioma, is a primary brain tumor which grows and migrates constantly within the central nervous system, and which ultimately progress to high-grade glioma, resulting in neurological worsening and death. However, because these neoplasms are very heterogeneous, it remains difficult to predict when the malignant transformation will occur at the individual level. Recently, Keshriet al. reported their preliminary experience with 130 LGG patients and observed that decreased overall survival (OS) was associated with age >50 years, tumor size >5cm, MIB index >5%, Karnofksy performance index (KPS) score <70 and gemistocytic pathology. Although this is a nice confirmation of the fact that older LGG patients, with a poor clinical status, a more voluminous and a more aggressive tumor have a worse prognosis, several results need nonetheless to be more extensively discussed.
From an oncological perspective, the OS in this series is 4.9 years, while OS in the modern literature is about 14 years (see for a recent review). Especially, it has been evidenced that the prognosis was significantly correlated with the extent of surgical resection, with a longer OS when a complete glioma removal (or even a supracomplete removal, that is, by resecting a margin beyond the signal abnormality visible on preoperative MRI) was achieved according to the objective evaluation on the postoperative FLAIR-weighted MRI. For example, these favorable results have been supported by a large experience from the French Glioma Network with over 1000 LGG patients who underwent early and maximal resection. Yet, Keshriet al. reported that “the type of surgery had no influence on the survival of LGG patients”. This could be due to the fact that they did not perform a volumetric calculation of the tumor before and after surgery since their proposal of risk stratification seems to be based on the size and not on the volume of the glioma. A better radiological characterization would have been helpful, including with regard to the tumor location. Indeed, it is surprising to see that this series does not comprise any insular glioma, whereas the insular/paralimbic localization is one of the most frequent (with the supplementary motor area) in the literature. In addition, regarding histomolecular considerations, only a few cases have been analyzed according to the WHO 2016 classification.
From a functional point of view, no detailed neurological and neurocognitive information has been provided in addition to the KPS score. However, LGG patients are usually young and enjoy a normal life at diagnosis. Therefore, because OS is now prolonged, their quality of life (QoL) should also be preserved, in order to give them the opportunity to resume an active familial, social and professional life. Interestingly, with the goal of optimizing the extent of resection while minimizing surgical morbidity, awake surgery with intraoperative electrical mapping of sensorimotor, visual, spatial, language, cognitive, emotional and behavioral functions became the gold standard for the management of LGG patients - with a risk to induce severe permanent impairment <2%, even in so-called “eloquent areas”. Unfortunately, Keshriet al. did not describe their surgical methodology, and did not provide neuropsychological assessments before and after each treatment (surgery, radiotherapy, chemotherapy), preventing to draw any reliable conclusion about the benefit-to-risk ratio of each therapy with a long-term follow-up.
In conclusion, currently, the first treatment to consider in LGG patient is maximal safe surgical resection(s), and then to adapt the personalized therapeutic management over years according to the evolution of individual clinical, neurocognitive, radiological and histomolecular parameters, allowing an optimization of the onco-functional balance. To this end, the risk stratification proposed by Keshriet al. could be of great interest.
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