Clinical analysis of the fatal cases of adult malignant gliomas after aggressive treatment
Takamura, Y.; Ibayashi, Y.; Morimoto, S.; Tanabe, S.; Hashi, K.
No Shinkei Geka. Neurological Surgery 22(3): 207-213
1994
ISSN/ISBN: 0301-2603 PMID: 8133960 Document Number: 431369
Six patients operated on for supratentorial malignant astrocytomas and seven patients operated on for glioblastoma multiforme were analyzed to evaluate the effect of aggressive surgical resection on the length of survival and causes of death. Early postoperative contrast enhanced CT scan was used to assess the extent of surgical resection. A gross total resection was considered to have been accomplished when there was no evidence of any residual enhanced mass. When 10% or less of the preoperative enhanced mass remained, the resection was classified as a subtotal resection. Subsequent follow-up CT scan showed that a gross total resection was accomplished in nine patients, and a subtotal resection was attained in four patients. The patients' ages ranged from 40 to 78 years (mean, 59 years). The median survival after the first aggressive surgical resection was 18.0 months in patients with malignant astrocytoma and 13.6 months in those with glioblastoma multiforme. The median duration between first operation and recurrence of tumor was 8.8 months in patients with malignant astrocytoma and 11.5 months in those with glioblastoma multiforme. A second aggressive surgical resection for recurrent malignant astrocytoma or glioblastoma multiforme was carried out in four patients (40%) of the evaluated ten patients. The median survival of these patients after reoperation was 8.25 months. Accordingly, aggressive surgical resection of malignant astrocytoma and glioblastoma multiforme is correlated with longer survival and is advocated in the treatment of recurrent tumors. Leptomeningeal dissemination was diagnosed in nine patients (90%) of evaluated ten patients. The median interval between the first aggressive surgical resection and leptomeningeal dissemination was 11.7 months in patients with malignant astrocytoma and 15.0 months in those with glioblastoma multiforme. The median survival after dissemination was 5.3 months. It was strongly suggested that clinical evidence of leptomeningeal dissemination is significantly related to prognosis after aggressive surgical resection. The causes of death were divided into the following three groups: Group I, leptomeningeal dissemination, 8 patients ; Group II, massive local recurrence, 2 patients ; Group III, postoperative complications, 3 patients. The patients with dissemination which was suspected to be the cause of death occupied 62% of this series. These findings suggest that aggressive surgical resection is a beneficial therapeutic procedure for malignant supratentorial gliomas, however the number of patients who died from leptomeningeal dissemination and diffuse parenchymal infiltration increased. We found two types of patients with leptomeningeal dissemination as follows: (a) CT scan revealed marked intraventricular dissemination or spinal seeding in contrast to slight invasion of the primary tumor. (b) CT scan revealed diffuse tumor invasion in subcortical white matter in contrast to slight subependymal dissemination. These results indicate that clinical manifestations of leptomeningeal dissemination or diffuse tumor invasion in subcortical white matter should be considered as grave prognostic factors after treatment with aggressive surgical therapy for malignant supratentorial gliomas.