1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
2Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Texas.
J Neurosurg. 2022 Apr 1;137(6):1618-1627. doi: 10.3171/2022.1.JNS211970. Print 2022 Dec 1.
The importance of extent of resection (EOR) in glioblastoma (GBM) has been thoroughly demonstrated. However, few studies have explored the practices and benefits of early repeat resection (ERR) when residual tumor deemed resectable is unintentionally left after an initial resection, and the survival benefit of ERR is still unknown. Herein, the authors aimed to internationally survey current practices regarding ERR and to analyze differences based on geographic location and practice setting.
The authors distributed a survey to the American Association of Neurological Surgeons and Congress of Neurological Surgeons Tumor Section, Society of British Neurological Surgeons, European Association of Neurosurgical Society, and Latin American Federation of Neurosurgical Societies. Neurosurgeons responded to questions about their training, practice setting, and current ERR practices. They also reported the EOR threshold below which they would pursue ERR and their likelihood of performing ERR using a Likert scale of 1-5 (5 being the most likely) in two sets of 5 cases, the first set for a patient's initial hospitalization and the second for a referred patient who had undergone resection elsewhere. The resection likelihood index for each respondent was calculated as the mean Likert score across all cases.
Overall, 180 neurosurgeons from 25 countries responded to the survey. Neurosurgeons performed ERRs very rarely in their practices (< 1% of all GBM cases), with an EOR threshold of 80.2% (75%-95%). When presented with 10 cases, the case context (initial hospitalization vs referred patient) did not significantly change the surgeon ERR likelihood, although ERR likelihood did vary significantly on the basis of tumor location (p < 0.0001). Latin American neurosurgeons were more likely to pursue ERR in the provided cases. Neurosurgeons were more likely to pursue ERR when the tumor was MGMT methylated versus unmethylated, with a resection likelihood index of 3.78 and 3.21, respectively (p = 0.004); however, there was no significant difference between IDH mutant and IDH wild-type tumors.
Results of this survey reveal current practices regarding ERR, but they also demonstrate the variability in how neurosurgeons approach ERR. Standardized guidelines based on future studies incorporating tumor molecular characteristics are needed to guide neurosurgeons in their decision-making on this complicated issue.
在胶质母细胞瘤（GBM）中，切除范围（EOR）的重要性已得到充分证明。然而，当最初切除后无意中残留可切除的肿瘤时，很少有研究探讨早期重复切除（ERR）的实践和益处，并且 ERR 的生存获益仍不清楚。在此，作者旨在对当前关于 ERR 的实践进行国际调查，并根据地理位置和实践环境进行差异分析。
作者向美国神经外科学会和神经外科学会肿瘤分会、英国神经外科学会、欧洲神经外科学会以及拉丁美洲神经外科学会联合会分发了一份调查。神经外科医生回答了有关他们的培训、实践环境以及当前 ERR 实践的问题。他们还报告了他们会追求 ERR 的 EOR 阈值，以及使用 1-5 级的李克特量表（5 表示最有可能）在两组 5 个病例中进行 ERR 的可能性，第一组是患者的初始住院治疗，第二组是在其他地方进行过切除的转诊患者。每位受访者的切除可能性指数是根据所有病例的平均李克特评分计算得出的。
共有来自 25 个国家的 180 名神经外科医生对调查做出了回应。神经外科医生在他们的实践中很少进行 ERR（不到所有 GBM 病例的 1%），EOR 阈值为 80.2%（75%-95%）。当提供 10 个病例时，手术上下文（初始住院治疗与转诊患者）并没有显著改变外科医生 ERR 的可能性，尽管 ERR 的可能性确实根据肿瘤位置而显著不同（p<0.0001）。拉丁美洲神经外科医生更有可能在提供的病例中进行 ERR。当肿瘤为 MGMT 甲基化与非甲基化时，神经外科医生更有可能进行 ERR，切除可能性指数分别为 3.78 和 3.21（p=0.004）；然而，IDH 突变型与野生型肿瘤之间没有显著差异。
这项调查的结果揭示了当前关于 ERR 的实践，但也表明了神经外科医生处理 ERR 的方式存在差异。需要基于未来纳入肿瘤分子特征的研究制定标准化指南，以指导神经外科医生在这一复杂问题上做出决策。
