Fluorescence guided versus conventional surgical resection of high grade glioma : a single centre 7 year comparative effectiveness study
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Date
2016
Authors
Ping, Ng Wei
Journal Title
Journal ISSN
Volume Title
Publisher
Pusat Pengajian Sains Perubatan, Universiti Sains Malaysia
Abstract
Background
High grade gliomas (HGGs) are locally invasive and aggressive brain tumors that carry dismal prognosis. Despite the rapidly evolving therapeutic strategies to treat HGGs, Malaysia still failed to demonstrate the expected standard HGGs management. According to National Comprehensive Cancer Network (NCCN) Guideline, the current standard management of HGGs includes maximum safe microsurgery resection followed by chemotherapy and radiotherapy. Complete resection, though increases median survival, is often hindered by the challenge of demonstrating the tumor border reliably. Department of Neurosurgery Hospital Sungai Buloh therefore has adopted fluorescence guided (FG) surgery using 5-aminolevulinic acid (5-ALA) as the first public hospital in Malaysia to overcome this shortcoming since 2010.
Objectives
The aim of this research was to evaluate the effects of fluorescence guided (FG) surgery on overall survival and functional outcome as compared to conventional surgery. Besides, the study also aimed to find out the independent predictors that are associated with survival in
high grade gliomas (HGGs) patients. Lastly, the effect of the extent of surgical resection on overall survival and functional outcome in FG patients was also evaluated.
Methodology
This study was a retrospective observational study. 74 patients with histologically proven high grade gliomas (HGGs) were recruited between January 2008 and December 2014. 37 HGG patients that underwent FG surgery from January 2010 until 31st December 2014 and fulfilled the inclusion criteria were recruited. Another 37 patients from conventional group was recruited consecutively from January 2008 until 31st December 2014 as the comparison group. The follow-up periods were done according to the scheduled appointment date (mostly at 6 weeks and 6 months) from the date of operation, which ended on 30rd June 2015. Patients, who were below 18 years old and above 65 years old, preoperative KPS <70, recurrent multicentric, midline deep seated tumor, history of malignant tumor at other body site, known and suspected pregnancy were excluded in the study. Data entry and analysis was done using Statistical Package for Social Sciences (SPSS) version 22.0. Mean and standard deviation were calculated for continuous variables, and frequency and percentage for categorical variables. Pearson Chi-square were identified, however if expected frequency of less than five were more than twenty percent of cells, Fischer’s Exact Test was applied. Patient’s cumulative life span following the date of surgery at our institution were analyzed using Kaplan Meier method and the evaluation of difference survival existence between groups through log rank test The prognostic factors for predictor of survival in high grade glioma patients were determine using Cox Proportional Hazards Regression Model. The significant value was set at p value less than 0.05.
Results
Seventy four High grade glioma patients treated in Hospital Sungai Buloh between January 2008 and 31st December 2014 were studied. Significant survival advantage was observed in fluorescence guided group compared with conventional group (12 versus 8 months), p<0.02.
Even without adjuvant therapy, HGG patients from FG group survived longer than those from conventional group with a documented median survival of 8.0 months versus 3 months (p = 0.006). No significant differences of postoperative Karnofsky performance scale (KPS) between groups. At 6 week and 6 months postoperative, FG patients in the study did not succumb into worsening of functional outcome as compared to conventional group. Patient in both group also showed better KPS scores in the short term and long term follow up period. Multivariate analysis identified four independent predictors of survival: KPS>80 (p=0.01), histology (p<0.001), surgical method (p<0.001) and adjuvant therapy (p<0.001). Multiple logistic regression analysis showed only three predictors of survival: tumor located in non-eloquent or near eloquent area (p=0.092), surgical method (0.087) and adjuvant therapy (0.094). Although FG patients did not demonstrate significant influence of extent of surgical resection on patients’ survival and functional outcome, patients with GTR/ NTR appeared to survive longer than STR (10.0 months vs 8.0 months).
Conclusions
This study showed a significant clinical benefit for HGG patients in terms of overall survival using FG surgery without resulting in worsening of postoperative function outcome when compared with conventional surgical method. Besides, four independent predictors of survival were also identified using multivariate analysis in the present study:
Description
Keywords
Glioma , Surgery