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Multiple Craniotomies in the Management of Multifocal and Multicentric Glioblastoma. Raymond Sawaya, M.D. Multiple GBM Lesions are not Rare. Glioblastoma Multiple Synchronous Gliomas ~ 0.5 – 20% . Pathogenesis. Not Clearly Understood Zülch, 1957 Metastasis ? Willis, 1967

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multiple craniotomies in the management of multifocal and multicentric glioblastoma

Multiple Craniotomies in the Management of Multifocal and Multicentric Glioblastoma

Raymond Sawaya, M.D.

multiple gbm lesions are not rare

Multiple GBM Lesions are not Rare

Glioblastoma

Multiple Synchronous Gliomas

~ 0.5 – 20%

pathogenesis
Pathogenesis
  • Not Clearly Understood
    • Zülch, 1957
        • Metastasis ?
    • Willis, 1967
        • multi-focal growth
    • Kyritsis et al.,1994
        •  p53 gene mutation (? Genetic Background)
literature
Literature
  • Questions more than answers
    • Case Reports and 3 Series
literature7
Literature

Case Reports

Ampil et al., 2007

slide8

Int. J. Radiation Oncology Biol. Phys., Vol. 69, No. 3, pp. 820–824, 2007

  • 50 patients with MF GBM (1995-2005)
  • The Policy:
    • Remove one tumor focus
    • WBRT or 3D Conformal RT
    • Concurrent Chemotherapy 42%

Median Survival 8.1 months

slide9

40 patients with Multiple CNS Tumors (1988-1993)

    • 10 Multicentric
    • 30 Multifocal
  • The Policy:
    • Removal of all tumor(s) [no description]
    • Radiotherapy
    • 30 patients received Chemotherapy
slide11

51 patients with MF Gliomas (1988-1992)

  • Describes the Radiological Characteristics with No Comments on the Management
  • The Median Survival Time was 6 months

European Journal of Radiology, 16 (1993) 163-170

illustrative case
Illustrative Case
  • 47 y/o M; Anesthesiologist
  • H/A, Focal seizure in the Lt Leg
  • Neurological Exam: Normal
slide14

Multiple craniotomies in the management of multifocal and multicentric glioblastoma

Wael Hassaneen, MD, Nicholas B. Levine, MD, Dima Suki, PhD, Abbhijit Salaskar, MBBS, Alessandra de Moura Lima, Ian McCutcheon, MD, Sujit Prabhu, MD, Frederick F. Lang, MD, Franco DeMonte, MD, Ganesh Rao, MD, Jeffrey S. Weinberg, MD, David Wildrick PhD, Ken Aldape, MD, and Raymond Sawaya, MD

Under review

objectives
Objectives
  • Complications
    • Do multiple craniotomies increase the risks to the patients?
  • Survival
    • Is the overall survival with multiple lesions who undergo extensive resections, similar to that of patients with a single lesion?
multicentric vs multifocal
Multicentric vs. Multifocal

T1 + C

Flair

Multicentric

Multifocal

study design
Study Design

Study period: 1993-2008

matching factors 1 1 ratio
Matching Factors (1:1 Ratio)

6000 surgically treated GBM

        • 20 controls
  • Preop KPS score
  • Extent of resection
  • Age at surgery
  • Year of surgery
  • Tumor Functional Grade
clinical characteristics tumor status
Clinical CharacteristicsTumor Status

The Study included New and Recurrent Lesions

clinical characteristics symptoms
Clinical CharacteristicsSymptoms

Patient may have > 1 symptom

clinical characteristics management cont
Clinical CharacteristicsManagement Cont.

* Except for 3 patients who lost to follow up in each group

overall survival
Overall Survival
  • 2 Patients still alive in each Group

(P= 0.34)

overall survival group
Overall Survival (Group)

KPS > 80

Solitary

MF/MC

overall survival31
Overall Survival
  • Multicentric
      • 12.9 mos
  • Multifocal
      • 9.6 mos
overall survival new lesions
Overall Survival (New Lesions)

En Bloc Resection

Solitary

MF

MC

limitations of the study
Limitations of the Study
  • Retrospective Case Series
  • Small sample size
  • Highly selected cases
  • Patients treated by other modalities (biopsy, resection of one lesion….) were not included in the study.
conclusions
Conclusions
  • Morbidity:

Multiple Craniotomies appear similar to Single Craniotomies

  • Survival:

MF and MC GBM may benefit from complete resection of all the lesions

  • Future Studies:

Prospective Assessment of the role of Multiple Craniotomies in the management of MF MC glioblastomas