SURG-07. ERAS IN NEURO-ONCOLOGY

BACKGROUND We performed a retrospective study assesses the efficacy and safety of a protocol for the enhanced clinical recovery of neuro-oncology patients undergoing surgery for supratentorial gliomas and metastasis. The protocol developed and applied to the Ca'Foncello Hospital in Treviso starts from the recommendations on the subject that the medical literature reported up to December 2018. Briefly, three main sections:1) preoperative functional status evaluation, preoperative oral carbohydrate loading; 2) minimally invasive surgery, scalp incision anesthesia, nonopioid analgesia; 3) early urinary-catheter removal, standing and feeding resumption within 3-4 hours from surgery. METHODS We collected and analyzed data on 28 patients operated on ERAS protocol and compared them to a control group (22 patients). The main clinical variables are: Charlson comorbidity index; times urinary-catether removal, adherence ambulation, taking food by mouth; hospital long of stay (LOS). We also collected studies from 2016 to 2020 describing data about ERAS and craniotomy and we pooled these into a meta-analysis. RESULTS Times urinary-catheter removal (3.1 vs 25 hours.), adherence to ambulation (4 vs 25 hours) and taking food by mouth (5.25 vs 23.72 hours) were significantly (p< 0.001) reduced in the ERAS group. Median hospital LOS was 2.85 days in the ERAS group and 4.77 days in the control group (p< 0.001). Our results overlapped those of the literature; the same trend was highlighted by our meta-analysis, with postoperative pain rates and hospital LOS significantly lower in ERAS patients (7.9 vs. 2.9 days, p < 0.001). A further important finding was that elderly patients (≥ 65 years) got the same outcomes as younger ones. CONCLUSIONS Our protocol for ERAS in neuro-oncology appears to have significant benefits over conventional management: it may improve patient outcomes, accelerate functional recovery, decrease length of stay, and enable patients to begin adjuvant chemotherapy and/or radiation in a more expeditious manner.

Simulation of surgery for supratentorial gliomas in virtual reality using a 3D volume rendering technique: a poor man's neuronavigation

OBJECTIVE Different techniques of performing image-guided neurosurgery exist, namely, neuronavigation systems, intraoperative ultrasound, and intraoperative MRI, each with its limitations. Except for ultrasound, other methods are expensive. Three-dimensional virtual reconstruction and surgical simulation using 3D volume rendering (VR) is an economical and excellent technique for preoperative surgical planning and image-guided neurosurgery. In this article, the authors discuss several nuances of the 3D VR technique that have not yet been described. METHODS The authors included 6 patients with supratentorial gliomas who underwent surgery between January 2019 and March 2021. Preoperative clinical data, including patient demographics, preoperative planning details (done using the VR technique), and intraoperative details, including relevant photos and videos, were collected. RadiAnt software was used for generating virtual 3D images using the VR technique on a computer running Microsoft Windows. RESULTS The 3D VR technique assists in glioma surgery with a preoperative simulation of the skin incision and craniotomy, virtual cortical surface marking and navigation for deep-seated gliomas, preoperative visualization of morbid cortical surface and venous anatomy in surfacing gliomas, identifying the intervenous surgical corridor in both surfacing and deep-seated gliomas, and pre- and postoperative virtual 3D images highlighting the exact spatial geometric residual tumor location and extent of resection for low-grade gliomas (LGGs). CONCLUSIONS Image-guided neurosurgery with the 3D VR technique using RadiAnt software is an economical, easy-to-learn, and user-friendly method of simulating glioma surgery, especially in resource-constrained countries where expensive neuronavigation systems are not readily available. Apart from cortical sulci/gyri anatomy, FLAIR sequences are ideal for the 3D visualization of nonenhancing diffuse LGGs using the VR technique. In addition to cortical vessels (especially veins), contrast MRI sequences are perfect for the 3D visualization of contrast-enhancing high-grade gliomas.

Assessment of neurological function using the National Institute of Health Stroke Scale in patients with gliomas

Background The evaluation of treatment response in patients with gliomas is performed using the Response Assessment in Neuro-Oncology (RANO) criteria. These criteria are based on cerebral magnetic resonance imaging (MRI), steroid use and neurological function. However, a standardized tool for evaluating neurological function was lacking. We compared changes in the National Institute of Health Stroke Scale (NIHSS) to changes in the RANO categories to determine the relationship between clinical and neuroradiological findings. Methods We reviewed data on all adult patients with supratentorial gliomas WHO grade II-IV who were treated at the Cantonal hospital St. Gallen from 2008 – 2015. The NIHSS was performed prospectively at baseline and at 3-months intervals simultaneously to MRI. Associations between changes in the NIHSS and RANO categories were assessed using the Stuart-Maxwell test. Results Our cohort consisted of 61 patients from which 471 observations were analyzed. The most common histological diagnosis was glioblastoma (49.2%). In total, 74% of RANO categories and 81% of the NIHSS scores remained stable on follow-up. Statistically, contemporaneous changes in the RANO category did not correlate with changes in the NIHSS (p < 0.0001). Conclusion The application of the NIHSS is easy and feasible in the heterogeneous population of glioma patients. In our cohort, the RANO categories did not reflect contemporaneous changes in the NIHSS. A validated clinical outcome measure with a well-defined minimal clinically important difference is warranted in neuro-oncological research and clinical practice.

Presurgical fMRI Affecting the Extent of Resection and Outcome of the Supratentorial Gliomas; a Single-center Experience From a Developing Country

BackgroundFunctional magnetic resonance imaging (fMRI) is one of the available non-invasive imaging to map the different brain areas, which has been used during the current years. In this study, we aimed to evaluate the effect of fMRI on decision-making, the extent of resection, and the outcome of the patients with supratentorial gliomas.MethodsThis prospective study conducted from 2014 through 2017 to investigate how presurgical fMRI can help the neurosurgeon during glioma surgery. Baseline demographic and clinical data were collected, and standard fMRI protocol was used for each patient.Results Forty-one patients with supratentorial gliomas met inclusion criteria, including 29 males and 12 females ranging in age from 21 to 72. Our results showed a significant association between eloquent areas tumor and the EOR. Eight out of 41 (19.5%) experienced higher EOR than what the neurosurgeon expected after adjusting the fMRI findings with the intraoperative situation. Among these patients, postoperative KPS and motor indices reflected dropped levels accompanied by an instant language index level in the short-term period, whereas all indices improved after long-term follow-up. There was a significant association between increasing EOR and all indices in the 1-year follow-up.ConclusionsIn conclusion, we postulate that preoperative fMRI should be considered preoperatively, especially in the eloquent areas gliomas disregarding tumor grade. Moreover, it can lead to a positive outcome in supratentorial gliomas via giving useful data about the relation of the tumor and vital centers of the brain, although it may result in an unfavorable short-term outcome.

Cerebral and tumoral blood flow in adult gliomas: a systematic review of results from magnetic resonance imaging

Objective: Blood flow is the rate of blood movement and relevant to numerous processes, though understudied in gliomas. The aim of this review was to pool blood flow metrics obtained from MRI modalities in adult supratentorial gliomas. Methods: MEDLINE, EMBASE and the Cochrane database were queried 01/01/2000–31/12/2019. Studies measuring blood flow in adult Grade II–IV supratentorial gliomas using dynamic susceptibility contrast (DSC) MRI, dynamic contrast enhanced MRI (DCE-MRI) or arterial spin labelling (ASL) were included. Absolute and relative cerebral blood flow (CBF), peritumoral blood flow and tumoral blood flow (TBF) were reported. Results: 34 studies were included with 1415 patients and 1460 scans. The mean age was 52.4 ± 7.3 years. Most patients had glioblastoma (n = 880, 64.6%). The most common imaging modality was ASL (n = 765, 52.4%) followed by DSC (n = 538, 36.8%). Most studies were performed pre-operatively (n = 1268, 86.8%). With increasing glioma grade (II vs IV), TBF increased (70.8 vs 145.5 ml/100 g/min, p < 0.001) and CBF decreased (85.3 vs 49.6 ml/100 g/min, p < 0.001). In Grade IV gliomas, following treatment, CBF increased in ipsilateral (24.9 ± 1.2 vs 26.1 ± 0.0 ml/100 g/min, p < 0.001) and contralateral white matter (25.6 ± 0.2 vs 26.0± 0.0 ml/100 g/min, p < 0.001). Conclusion: Our findings demonstrate that increased mass effect from high-grade gliomas impairs blood flow within the surrounding brain that can improve with surgery. Advances in knowledge: This systematic review demonstrates how mass effect from brain tumours impairs blood flow in the surrounding brain parenchyma that can improve with treatment.

ASL-Perfusion for Intrinsic Brain Tumor Diagnosis. Analysis of 253 Patients.

Purpose The aim of the study was to evaluate the role of pseudo-continuous ASL-perfusion (pCASL-perfusion) in preoperative assessing of cerebral glioma grades. Methods The study group consisted of 253 patients aged 7 to 78 years with supratentorial gliomas (65 had low-grade gliomas (LGG), 188 – high-grade gliomas (HGG)). Maximal tumor blood flow (maxTBF) in small ROIs (20 mm2 ± 10 mm2) were evaluated by subsequently normalized tumor blood flow (nTBF) calculation which was compared with normal appearing white matter of center semiovale of the contralateral hemisphere. Results TBF and nTBF values were significantly differed in HGG and LGG groups, as well as grade II and grade III gliomas; grade III and grade IV gliomas (p < 0.001). ASL-perfusion has demonstrated both high sensitivity and specificity in differentiating LGG and HGG, grade II and grade III gliomas, but low sensitivity and specificity in distinguishing grade III and grade IV gliomas. We did not observe a significant difference in TBF in astrocytomas and oligodendrogliomas. Conclusion Current results demonstrate that 3D pCASL-perfusion is an effective diagnostic tool for preoperative differentiation of low and high grade gliomas.

Association of preoperative seizures with tumor metabolites quantified by magnetic resonance spectroscopy in gliomas

Seizures are common in patients with gliomas; however, the mechanisms of epileptogenesis in gliomas have not been fully understood. This study hypothesized that analyzing quantified metabolites using magnetic resonance spectroscopy (MRS) might provide novel insights to better understand the epileptogenesis in gliomas, and specific metabolites might be indicators of preoperative seizures in gliomas. We retrospectively investigated patient information (gender, age at diagnosis of tumor, their survival time) and tumor information (location, histology, genetic features, and metabolites according to MRS) in patients with gliomas. The data were correlated with the incidence of seizure and analyzed statistically. Of 146 adult supratentorial gliomas, isocitrate dehydrogenase (IDH) mutant tumors significantly indicated higher incidence of preoperative seizures than IDH wild-type gliomas. However, MRS study indicated that glutamate concentration in IDH wild-type gliomas was higher than that in IDH mutant gliomas. Glutamate was not associated with high frequency of preoperative seizures in patients with gliomas. Instead, increased total N-acetyl-l-aspartate (tNAA) was significantly associated with them. Moreover, multivariable analysis indicated that increased level of tNAA was an independent predictor of preoperative seizures. According to MRS analysis, tNAA, rather than glutamate, might be a useful to detect preoperative seizures in patient with supratentorial gliomas.

Myoinositol to total choline ratio in IDH wild-type gliomas as a prognostic factor on preoperative magnetic resonance spectroscopy

Background: Isocitrate dehydrogenase (IDH) wild-type gliomas tend to be pathologically defined as glioblastomas. We previously reported that, unlike IDH-mutant gliomas, IDH wild-type gliomas showed significantly lower ratios of myoinositol to total choline (i.e., the Ins/Cho ratio) on magnetic resonance (MR) spectroscopy. Given that IDH-mutant gliomas also have much better prognoses than IDH wild-type gliomas, we hypothesized that this lower Ins/Cho ratio is associated with malignancy in adults with supratentorial gliomas. Therefore, we calculated the Ins/Cho ratios of patients with supratentorial IDH wild-type gliomas and investigated their progression free survival (PFS) and overall survival (OS) to determine its utility as a prognostic marker.Methods: We classified IDH wild-type gliomas (n = 30) into two groups based on the Ins/Cho ratios, and compared patient backgrounds, pathological findings, PFS, OS, and copy number aberrations.Results: Compared with the group with high Ins/Cho ratios, the group with low Ins/Cho ratios had shorter PFS (P = 0.020) and OS (P = 0.037) durations. Multivariate analysis demonstrated that the Ins/Cho ratio correlated significantly with PFS (hazard ratio 0.34, P = 0.027). Conclusion: We conclude that the preoperative Ins/Cho ratio can be used as a novel prognostic factor for IDH wild-type gliomas.

Myoinositol to total choline ratio in IDH wild-type gliomas as a prognostic factor on preoperative magnetic resonance spectroscopy

Background: Isocitrate dehydrogenase (IDH) wild-type gliomas tend to be pathologically defined as glioblastomas. We previously reported that, unlike IDH -mutant gliomas, IDH wild-type gliomas showed significantly lower ratios of myoinositol to total choline (i.e., the Ins/Cho ratio) on magnetic resonance (MR) spectroscopy. Given that IDH -mutant gliomas also have much better prognoses than IDH wild-type gliomas, we hypothesized that this lower Ins/Cho ratio is associated with malignancy in adults with supratentorial gliomas. Therefore, we calculated the Ins/Cho ratios of patients with supratentorial IDH wild-type gliomas and investigated their progression free survival (PFS) and overall survival (OS) to determine its utility as a prognostic marker. Methods: We classified IDH wild-type gliomas (n = 30) into two groups based on the Ins/Cho ratios, and compared patient backgrounds, pathological findings, PFS, OS, and copy number aberrations. Results: Compared with the group with high Ins/Cho ratios, the group with low Ins/Cho ratios had shorter PFS (P = 0.020) and OS (P = 0.037) durations. Multivariate analysis demonstrated that the Ins/Cho ratio corelated significantly with PFS (hazard ratio 0.34, P = 0.027). Conclusion: We conclude that the preoperative Ins/Cho ratio can be used as a novel prognostic factor for IDH wild-type gliomas.