Multiple resections may extend life of patients with aggressive brain cancer

Issue: December 25, 2012

Patients who undergo multiple surgeries to remove glioblastomas may survive longer than those who have just one operation, according to results of a retrospective study.

Perspective from Roger J. Packer, MD

Glioblastomas are the most common and deadly form of primary brain tumor in adults. The aggressive brain tumor recurs regardless of intervention. Because of this, clinicians may be skeptical about the survival chances of patients who undergo repeated resections.

Alfredo Quinones-Hinojosa

“We are reluctant to operate on patients with brain cancer multiple times, as we are afraid to incur new neurological deficits or poor wound healing,” Alfredo Quinones-Hinojosa, MD, professor of neurosurgery at the Johns Hopkins School of Medicine, said in a press release.

In the study, researchers evaluated whether patients who underwent repeated resections experienced improved survival compared with patients who underwent only one resection. The researchers also determined whether the number of surgeries was an independent predictor of prolonged survival.

Kaisorn L. Chaichana, MD, a neurosurgery resident in the departments of neurosurgery and neuro-oncology for the Neuro-Oncology Outcomes Laboratory at Johns Hopkins University, and colleagues examined the records of 578 adult patients who underwent surgery to remove a glioblastoma between 1997 and 2007.

Researchers used multivariate proportional hazards regression analysis to identify an association between the number of glioblastoma resections and survival after controlling for age, functional status, periventricular location, extent of resection and adjuvant therapy.

By the last follow-up, 354 patients underwent one resection, 168 underwent two resections, 41 underwent three resections and 15 underwent four resections.

Patients who underwent only one resection experienced shortened survival (6.8 months; RR=3.4; 95% CI, 2.423-4.774) compared with patients who underwent two resections (15.5 months; RR=0.688; 95% CI, 0.525-0.898), three resections (22.4 months; RR=0.614; 95% CI, 0.388-0.929) and four resections (26.6 months; RR=0.6; 95% CI, 0.238-0.853).

The risk for infections or iatrogenic deficits did not increase with repeated surgeries (P>.05), according to the  results.

“The present study shows that patients with recurrent glioblastoma can have improved survival with repeated resections,” Chaichana and colleagues wrote.

The data findings may have been limited by an intrinsic bias associated with patient selection, Chaichana and colleagues said. The researchers attempted to minimize those biases by using strict inclusion criteria, multivariate analysis and case-control evaluation.

Reference:

Chaichana KL. J Neurosurg. 2012;doi:10.3171/2012.9.JNS1277.

Perspective

Roger J. Packer, MD

The article by Chaichana et al reviewing the experience at Johns Hopkins University on 578 adult patients with glioblastoma suggests that in certain circumstances patients with glioblastoma multiforme may benefit from re-resections after tumor recurrence. It is reassuring that the majority of patients who underwent re-resection did not have a higher risk of infection and, by and large, did not suffer new neurologic deficits. As the authors appropriately point out, the decision in this retrospective on who should undergo re-resection is often arbitrary, and patients who are older and likely sicker are less likely to undergo re-resection. I am sure tumor location and size also played a role in the decision-making process, and these factors are very difficult to assess in a retrospective analysis. In some ways, it is not surprising that patients who are well enough to undergo multiple resections live longer.

One obvious question not answered by the study is how did re-resection impact the individual’s ability to live independently and function, even if it did not result in new neurologic deficits? The bottom line is that the vast majority of patients succumb to this terrible disease and novel treatment approaches are required. In the meantime, as these more effective therapies are sought, the article by Chaichana and colleagues suggest that multiple re-resections are reasonable in a select subset of patients.

Roger J. Packer, MD

HemOnc Today Editorial Board member

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