Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy.
Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Via S. Sofia, Catania, Italy.
Oper Neurosurg (Hagerstown). 2021 Jan 13;20(2):151-163. doi: 10.1093/ons/opaa293.
Extent of tumor resection (EOTR) in glioblastoma surgery plays an important role in improving survival.
To analyze the efficacy, safety and reliability of fluid-attenuated inversion-recovery (FLAIR) magnetic resonance (MR) images used to guide glioblastoma resection (FLAIRectomy) and to volumetrically measure postoperative EOTR, which was correlated with clinical outcome and survival.
A total of 68 glioblastoma patients (29 males, mean age 65.8) were prospectively enrolled. Hyperintense areas on FLAIR images, surrounding gadolinium-enhancing tissue on T1-weighted MR images, were screened for signal changes suggesting tumor infiltration and evaluated for supramaximal resection. The surgical protocol included 5-aminolevulinic acid (5-ALA) fluorescence, neuromonitoring, and intraoperative imaging tools. 5-ALA fluorescence intensity was analyzed and matched with the different sites on navigated MR, both on postcontrast T1-weighted and FLAIR images. Volumetric evaluation of EOTR on T1-weighted and FLAIR sequences was compared.
FLAIR MR volumetric evaluation documented larger tumor volume than that assessed on contrast-enhancing T1 MR (72.6 vs 54.9 cc); residual tumor was seen in 43 patients; postcontrast T1 MR volumetric analysis showed complete resection in 64 cases. O6-methylguanine-DNA methyltransferase promoter was methylated in 8/68 (11.7%) cases; wild type Isocytrate Dehydrogenase-1 (IDH-1) was found in 66/68 patients. Progression free survival and overall survival (PFS and OS) were 17.43 and 25.11 mo, respectively. Multiple regression analysis showed a significant correlation between EOTR based on FLAIR, PFS (R2 = 0.46), and OS (R2 = 0.68).
EOTR based on FLAIR and 5-ALA fluorescence is feasible. Safety of resection relies on the use of neuromonitoring and intraoperative multimodal imaging tools. FLAIR-based EOTR appears to be a stronger survival predictor compared to gadolinium-enhancing, T1-based resection.
脑胶母细胞瘤手术中的肿瘤切除程度（EOTR）对于提高生存率起着重要作用。
分析磁共振成像（MRI）中的液体衰减反转恢复（FLAIR）技术指导脑胶母细胞瘤切除术（FLAIRectomy）的疗效、安全性和可靠性，并对术后 EOTR 进行容积测量，与临床结果和生存情况相关联。
前瞻性纳入 68 例脑胶母细胞瘤患者（29 例男性，平均年龄 65.8 岁）。FLAIR 图像上的高信号区、T1 加权 MR 图像上的钆增强组织周围，筛选出提示肿瘤浸润的信号变化，并评估最大程度的切除。手术方案包括 5-氨基乙酰丙酸（5-ALA）荧光、神经监测和术中成像工具。分析 5-ALA 荧光强度并与导航性 MR 上的不同部位相匹配，包括增强后 T1 加权和 FLAIR 图像。比较 T1 加权和 FLAIR 序列上 EOTR 的容积评估。
FLAIR MR 容积评估记录的肿瘤体积大于增强后 T1 MR（72.6 比 54.9 cc）；43 例患者有残余肿瘤；增强后 T1 MR 容积分析显示 64 例患者完全切除。68 例患者中有 8 例（11.7%）O6-甲基鸟嘌呤-DNA 甲基转移酶启动子甲基化；66 例（66/68）为野生型异柠檬酸脱氢酶-1（IDH-1）。无进展生存期和总生存期（PFS 和 OS）分别为 17.43 和 25.11 个月。多因素回归分析显示，FLAIR 上的 EOTR 与 PFS（R2=0.46）和 OS（R2=0.68）显著相关。
基于 FLAIR 和 5-ALA 荧光的 EOTR 是可行的。切除的安全性依赖于神经监测和术中多模态成像工具的使用。与基于钆增强的 T1 切除相比，基于 FLAIR 的 EOTR 似乎是一个更强的生存预测因素。
