Feasibility, Safety and Impact on Overall Survival of Awake Resection for Newly Diagnosed Supratentorial IDH-Wildtype Glioblastomas in Adults

Background: Although awake resection using intraoperative cortico-subcortical functional brain mapping is the benchmark technique for diffuse gliomas within eloquent brain areas, it is still rarely proposed for IDH-wildtype glioblastomas. We have assessed the feasibility, safety, and efficacy of awake resection for IDH-wildtype glioblastomas. Methods: Observational single-institution cohort (2012–2018) of 453 adult patients harboring supratentorial IDH-wildtype glioblastomas who benefited from awake resection, from asleep resection, or from a biopsy. Case matching (1:1) criteria between the awake group and asleep group: gender, age, RTOG-RPA class, tumor side, location and volume and neurosurgeon experience. Results: In patients in the awake resection subgroup (n = 42), supratotal resections were more frequent (21.4% vs. 3.1%, p < 0.0001) while partial resections were less frequent (21.4% vs. 40.1%, p < 0.0001) compared to the asleep (n = 222) resection subgroup. In multivariable analyses, postoperative standard radiochemistry (aHR = 0.04, p < 0.0001), supratotal resection (aHR = 0.27, p = 0.0021), total resection (aHR = 0.43, p < 0.0001), KPS score > 70 (HR = 0.66, p = 0.0013), MGMT promoter methylation (HR = 0.55, p = 0.0031), and awake surgery (HR = 0.54, p = 0.0156) were independent predictors of overall survival. After case matching, a longer overall survival was found for awake resection (HR = 0.47, p = 0.0103). Conclusions: Awake resection is safe, allows larger resections than asleep surgery, and positively impacts overall survival of IDH-wildtype glioblastoma in selected adult patients.

P04.18 Management of diffuse gliomas using hypnosis-aided awake surgery: oncological and functional preliminary results in a series of 16 cases

BACKGROUND Awake resection of diffuse gliomas aims to find a tailored onco-functional balance for each patient. Hypnosis represents an innovative technique able to optimize the comfort and well-being of the patient during such procedures. The aim of the present study is to analyse the oncological and functional outcome in a cohort of patients operated on with hypnosis-aided awake surgery. MATERIAL AND METHODS All consecutive adult patients that underwent hypnosis-aided resection for a diffuse glioma between January 2018 and January 2019 were recorded. Neurological and cognitive status were assessed preoperatively and at 3 months postoperatively. Extent of tumor resection was quantified by a radiologist on magnetic resonance imaging. RESULTS Sixteen patients (6 males and 10 females), with a mean age of 39 years, were included. Gliomas were revealed by epileptic seizures (62.5%), motor deficit (6.25%) or incidentally discovered (31.25%) and were either located in the right hemisphere (50%) or in the left hemisphere (50%), with a mean initial volume of 42 mL. Histologically, there were six grade II-astrocytomas, three grade III-astrocytomas, five grade II-oligodendroglioma, one grade III-oligodendroglioma and one ganglioglioma. Under HAS, the awake-time after the anaesthesia drugs stop was short, because low doses of drugs were required thanks to the hypnotic state. All patients were able to reliably performed the different tests until functional subcortical limits were reached. Postoperative magnetic resonance imaging showed complete resection in 8 cases (50%), subtotal resection in 2 cases (12.5%) and partial resection in 6 cases (37.5%), with a mean resection rate of 84.6%. At 3 months after surgery, there was only a new motor deficit (6.25%). The language and neuropsychological assessments were improved in 7 patients (43.75%), stable in 7 patients (43.75%) and deteriorated in some tests in 2 patients (12.5%). After surgery, no patient reported negative emotion concerning the awake glioma resection and all patient declared being ready for a second awake resection in the future, if indicated. CONCLUSION According to these preliminary results, hypnosis-aided awake resection of diffuse gliomas appears to be safe and effective from an onco-functional viewpoint and parallelly contributes to decrease intra-operative pain, anxiety and major discomfort.

Awake resection of a left operculo-insular low-grade glioma guided by cortico-subcortical mapping

A 30-year-old right-handed female medical doctor experienced generalized seizures. MRI showed a left operculo-insular low-grade glioma. Awake resection was proposed. During the cortical mapping, counting and naming task combined with right upper limb movement enabled the identification of the ventral premotor cortex and negative motors areas. The so-called Broca’s area was not eloquent. Subpial dissection was performed by avoiding coagulation until the inferior fronto-occipital fasciculus and the junction between the output projection fibers and the anterior part of the superior longitudinal fasciculus III were reached. The patient resumed a normal familial and socio-professional life despite the resection of Broca’s area.The video can be found here: https://youtu.be/OALk0tvctQw.

Permanent anosmia and ageusia after resection of a left temporoinsular low-grade glioma: anatomofunctional considerations

Five percent of the general population has olfactory or gustatory disorders, although most do not complain about it. However, in some cases, these symptoms can be disabling and may affect quality of life. Anosmia was reported as a possible complication following head injury and neurosurgical procedures, particularly after the resection of tumors located in the anterior fossa and the treatment of aneurysms in the anterior circulation. Nonetheless, in all of these situations, olfactory dysfunction could be explained by damage to the peripheral olfactory system. Here, the authors report a case of complete anosmia associated with ageusia following awake resection of a low-grade glioma involving the left temporoinsular region, with no recovery during a follow-up of 3 years. The frontal lobe was not retracted, and the olfactory tract was not visualized during surgery; therefore, postoperative anosmia and ageusia are likely explained by damage to the cortex and central pathways responsible for these senses. The authors suggest that the patient might have had a subclinical right hemianosmia before surgery, which is a common condition. After resection of the central structures critical for smell and taste processing in the left hemisphere, the patient could have finally had bilateral and complete olfactory and gustatory loss. This is the first known report of permanent anosmia and ageusia following glioma surgery. Because these symptoms might have been underestimated, more attention should be devoted to olfaction and taste, especially with regard to possible subclinical preoperative deficit.