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Observational Study
. 2020 Jan 1;86(1):112-121.
doi: 10.1093/neuros/nyz008.

Perilesional Resection of Glioblastoma Is Independently Associated With Improved Outcomes

Wajd N Al-Holou  1 , Tiffany R Hodges  2 , Richard G Everson  2 , Jacob Freeman  2 , Shouhao Zhou  3 , Dima Suki  2 , Ganesh Rao  2 , Sherise D Ferguson  2 , Amy B Heimberger  2 , Ian E McCutcheon  2 , Sujit S Prabhu  2 , Frederick F Lang  2 , Jeffrey S Weinberg  2 , David M Wildrick  2 , Raymond Sawaya  2
Affiliations
Observational Study

Perilesional Resection of Glioblastoma Is Independently Associated With Improved Outcomes

Wajd N Al-Holou et al. Neurosurgery. .

Abstract

Background: Resection is a critical component in the initial treatment of glioblastoma (GBM). Often GBMs are resected using an intralesional method. Circumferential perilesional resection of GBMs has been described, but with limited data.

Objective: To conduct an observational retrospective analysis to test whether perilesional resection produced a greater extent of resection.

Methods: We identified all patients with newly diagnosed GBM who underwent resection at our institution from June 1, 1993 to December 31, 2015. Demographics, presenting symptoms, intraoperative data, method of resection (perilesional or intralesional), volumetric imaging data, and postoperative outcomes were obtained. Complete resection (CR) was defined as 100% resection of all contrast-enhancing disease. Univariate analyses employed analysis of variance (ANOVA) and Fisher's exact test. Multivariate analyses used propensity score-weighted multivariate logistic regression.

Results: Newly diagnosed GBMs were resected in 1204 patients, 436 tumors (36%) perilesionally and 766 (64%) intralesionally. Radiographic CR was achieved in 69% of cases. Multivariate analysis demonstrated that perilesional tumor resection was associated with a significantly higher rate of CR than intralesional resection (81% vs 62%, multivariate odds ratio = 2.5, 95% confidence interval: 1.8-3.4, P < .001). Among tumors in eloquent cortex, multivariate analysis showed that patients who underwent perilesional resection had a higher rate of CR (79% vs 58%, respectively, P < .001) and a lower rate of neurological complications (11% vs 20%, respectively, P = .018) than those who underwent intralesional resection.

Conclusion: Circumferential perilesional resection of GBM is associated with significantly higher rates of CR and lower rates of neurological complications than intralesional resection, even for tumors arising in eloquent locations. Perilesional resection, when feasible, should be considered as a preferred option.

Keywords: Circumferential dissection; Extent of resection; Glioblastoma; Intralesional resection; Neurological complications; Perilesional.

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Figures

FIGURE 1.
FIGURE 1.
Perilesional technique of GBM resection. A, A GBM in the left frontal lobe abutting Broca's area is shown. The expanded gyrus is identified, and its surrounding sulci are dissected. A perpendicular section at the level of the green plane in A is shown in B: the sulci are split to identify the large arteries, and the feeding vessels are coagulated and cut. After reaching the base of the sulcus, the inferior portion of the tumor is resected along the plane between the solid mass and the infiltrated brain. Reproduced with permission from Hentschel, S. J. and F. F. Lang, Current surgical management of glioblastoma. Cancer J, 2003. 9 (2): 113-125. (http://ovidsp.tx.ovid.com/sp-3.26.1a/ovidweb.cgi?&S = HKKPFPPKLKDDIGCKNCGKPBIBCBPPAA00&Link + Set = S.sh.22.23.26.29%7c7%7csl_10).
FIGURE 2.
FIGURE 2.
A, Perilesional resection of a right temporo-occipital GBM. (Left) Preoperative axial T1-weighted postcontrast MR image. (Right) Postoperative axial T1-weighted postcontrast MR image. B, Intraoperative image of perilesional resection of the right temporo-occiptal GBM shown in Figure 2, depicting craniotomy with inferiorly based dural flap exposing the temporo-occipital region overlying the tumor. The outline of the planned corticectomy can be seen. The Penfield #4 dissector is seen in the lower left (anterior superior) corner of the craniotomy. A large vein of Labbé is seen along the inferior edge of the planned resection (*). C, Depicts the resection cavity. The Penfield #4 dissector is within the cavity at the edge of a ventricular opening (*). The tentorium is seen in the depths of the cavity (**). D, Image of the GBM tumor specimen that was resected in a perilesional manner, as described above.
FIGURE 3.
FIGURE 3.
Bar graph depicting the percentage of complete resection for each variable. Tumor volume is dichotomized for the purpose of visualization. *Statistically significant based on univariate analysis. ‡Statistically significant based on multivariate analysis.
FIGURE 4.
FIGURE 4.
The percentages of all neurological complications and specific subtypes are shown for the 2 resection techniques (perilesional and intralesional). *Statistically significant based on univariate analysis. ‡Statistically significant based on multivariate analysis. P < .05 was considered significant.
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