gms | German Medical Science

Objective: Due to its infiltrating growth pattern, the typical recurrence pattern of a Glioblastoma multiforme(GBM) after open resection, occurs locally. With the introduction of the fluorescence-guided resection technique, the rate of complete resections of the contrast-enhancing part of the GBM increased significantly. We were interested in finding out whether this more aggressive local surgical treatment influenced the rate of local recurrences.

Method: Inclusion criteria for this single centre, retrospective study were a complete resection of the GBM at the time of the first diagnosis. Complete resection (CR) was defined as no residual contrast enhancement (CE) in the early postoperative MRI [<72h]), followed by standard adjuvant radio-chemotherapy. All patients included in the study presented at least one recurrence. At recurrence, patients were divided into two groups according to cerebral MRI imaging (T1 sequences plus CE): patients with a local recurrence (within 2 cm from the primary tumor's margins), patients with a distant recurrence (≥2 cm from the primary tumor's margins). For the latter group, the possible mechanisms of recurrence were analyzed and found to be either by CSF dissemination, meningeal invasion, along fibre tracts or de novo. In addition, survival data were determined.

Results: We identified 46 patients, who underwent CR for a primary GBM between January 2007 and December 2011, followed by Stupp protocol. At first recurrence, among these 46 patients, 39 patients (84.7%) presented a local recurrence, 7 patients (15.3%) with a distant recurrence. Among the patients with distant recurrence, we identified 1 patient (6.6%) with CSF disseminations, 2 patients (13.3%) with de novo manifestation, 3 patients (20.0%) with recurrence along fibre tracts and 1 patient (6.6%) with meningeal localization. Median survival for patients with local recurrence (39 cases) was 22.0 months (range 3.0–83.1) versus 32.4 months (range 16.6–89.3) for the patients with distant recurrence (7 cases).

Conclusions: Despite aggressive surgical treatment with no residual CE, the vast majority of recurrences still occur locally. If functionality is not compromised, even more aggressive “supramarginal” treatment might be considered, using extensive intraoperative monitoring to avoid permanent deficits. Our data suggest that local control might be associated with superior survival, potentially supporting the concept of “function preserving supramarginal resection”.