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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 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 • multi-focal growth • Kyritsis et al.,1994 • p53 gene mutation (? Genetic Background)
Literature • Questions more than answers • Case Reports and 3 Series
Literature Case Reports Ampil et al., 2007
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
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
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 • 47 y/o M; Anesthesiologist • H/A, Focal seizure in the Lt Leg • Neurological Exam: Normal
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 • 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 T1 + C Flair Multicentric Multifocal
Study Design Study period: 1993-2008
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 CharacteristicsTumor Status The Study included New and Recurrent Lesions
Clinical CharacteristicsSymptoms Patient may have > 1 symptom
Clinical CharacteristicsManagement Cont. * Except for 3 patients who lost to follow up in each group
Overall Survival • 2 Patients still alive in each Group (P= 0.34)
Overall Survival (Group) KPS > 80 Solitary MF/MC
Overall Survival • Multicentric • 12.9 mos • Multifocal • 9.6 mos
Overall Survival for New Lesions (P= 0. 014)
Overall Survival (New Lesions) En Bloc Resection Solitary MF MC
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 • 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