Article
Clinical evaluation of intraoperative resection control by use of a vertically open configured 0.5 T-MR scanner during surgery of malignant astrocytomas
Klinische Evaluation der intraoperativen Resektionskontrolle mit Hilfe eines vertikal offenen 0,5-T-MRT in der Chirurgie maligner Astrozytome
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Authors
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Christoph Nagel
- Department of Neurosurgery, University of Leipzig, Leipzig
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C. Trantakis
- Department of Neurosurgery, University of Leipzig, Leipzig
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J. P. Schneider
- Department of Radiology, University of Leipzig, Leipzig
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J. Meixensberger
- Department of Neurosurgery, University of Leipzig, Leipzig
| Published: | April 23, 2004 |
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Outline
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Objective
Outcome and prognosis of malignant astrocytomas still remain poor. In several studies it could be shown, that the extent of tumor resection directly correlates with postoperative survival. The objective of this study was to evaluate the impact of performing microsurgical tumor exstirpation under intraoperative image guidance in a vertically open configured 0.5 T-MR scanner on clinical outcome and survival of patients suffering from a malignant astrocytoma.
Methods
Thirty-eight patients underwent surgery of a supratentorial malignant astrocytoma, 30 patients suffered from a glioblastoma multiforme (GBM), and 8 patients had an anaplastic astrocytoma (AA). Operations were performed under image guidance inside a 0.5 T-MR scanner "Signa SPi" ("double-doughnut") by General Electrics Medical Systems (GEMS, USA) under microsurgical conditions. Localization and removal of tumor remnants during operation was provided by navigation, based on intraoperatively updated 3D MRI datasets (Localite Brain Navigator, St. Augustin, Germany). Intraoperative T1w and T2w MR images with contrast medium were evaluated regarding the extent of resection both by the operating neurosurgeon and a neuroradiologist. All patients underwent clinical and MRI follow-up examinations in equidistant intervals. The cumulative survival between patients with complete and incomplete tumor resection was analysed by Kaplan Meier survival-curves.
Results
According to intraoperative MRI criteria gross total resection (GTR) could be achieved in 21 patients (55.3 %), in 17 (44.7 %) cases resection remained subtotal (STR). 28 patients (73.7 %) underwent first craniotomy, 10 patients (26.3 %) have had at least one craniotomy for tumor resection (both low-grade and high-grade primary tumor) before. One patient died the first postoperative day due to a non-treatable malignant brain edema, wheras no patient died due to performing craniotomy inside the scanner (mortality). Perioperative aggravation of neurological symptoms (morbidity) occured in 5 patients (13.2 %). Median time to clinical progression was 7.6 (GTR) vs. 4.7 (STR) months (p = 0.198), median time to tumor recurrence (GTR)/ time to tumor progression (STR) was 5.6 (GTR) vs. 6.8 (STR) months (p = 0.967), and median postoperative survival time was 14.4 (GTR) vs. 8.1 (STR) months (p = 0.172). None of these differences was statistically significant.
Conclusions
A noticeable trend toward a prolongated postoperative survival time and a prolongated time in favorable clinical condition and quality of life can be seen, if resection is complete according to intraoperative MRI criteria. The lack of statistical significance may be due to the small number of patients in this collective. The low overall perioperative morbidity indicates a reliable resection control by intraoperative MR image guidance regarding the identification and protection of functional brain areas. Intraoperative MR image guidance can be deemed to be a useful tool to achieve largest possible resection radicality with respect to protect functional brain areas in the surgery of malignant astrocytomas.
