Left frontal high-grade glioma

Introduction

The primary modifiable risk factor for patients with high-grade gliomas is extent of resection. For patients with primary glioblastoma, the maximum residual volume threshold is 5 cm ³ , in which patients with higher residual volume had a median survival of 11.6 months as compared with 15.3 months for patients with lesser residual volume. In regard to percent resection, patients with less than 70% resection had a median survival of 10.5 months as compared with 14.4 months for patients with more than 70% resection. In patients in which gross total resection can be achieved, at least 95% resection needs to be achieved. These studies are based on resection of the contrast-enhancing regions. For tumors involving the frontal pole, these lesions are typically more amenable to extensive resection. In this chapter, we present a case of a left frontal pole high-grade glioma.

Example case

Chief complaint: headaches

History of present illness

A 28-year-old, right-handed man with no significant past medical history presented with headaches. He complained of progressive headaches not responsive to over-the-counter pain medications for 3 weeks, and most recently developed nausea and vomiting. He was taken to the emergency room where imaging revealed a brain lesion ( Fig. 16.1 ).

Medications : Aspirin, acetaminophen.
Allergies : No known drug allergies.
Past medical and surgical history : None.
Family history : No history of intracranial malignancies.
Social history : Waiter, no smoking or alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Cranial nerves II to XII intact; No drift, moves all extremities with full strength.
Imaging : Chest/abdomen/pelvis computed tomography negative for primary malignancy.

	Miguel A. Arraez, MD, PhD, Carlos Haya University Hospital, Malaga, Spain	Juan A. Barcia, MD, PhD, Hospital Clínico San Carlos, Complutense University, Madrid, Spain	Linda M. Liau, MD, PhD, University of California-Los Angeles, Los Angeles, CA, United States	Ian F. Parney, MD, PhD, Mayo Clinic, Rochester, MN, United States
Preoperative
Additional tests requested	Neuropsychological	DTI fMRI Neuropsychological assessment	DTI fMRI Neuropsychological assessment and language evaluation	None
Surgical approach selected	Left frontal craniotomy	Left frontal craniotomy with 5-ALA	Left frontal craniotomy with awake language and motor mapping	Left frontal craniotomy with possible fluorescence
Anatomic corridor	Left frontal	Left frontal	Left SFG and MFG and interhemispheric	Left frontal
Goal of surgery	Maximal resection of contrast enhancing lesion	Gross total removal of 5-ALA strong and weak fluorescent tissue	Maximal safe resection of contrast enhancing and FLAIR	Gross total resection of contrast enhancing (second look surgery for FLAIR if IDH mutant)
Perioperative
Positioning	Supine neutral	Supine neutral	Left supine with slight right rotation	Supine neutral
Surgical equipment	Surgical navigation Surgical microscope with 5-ALA Ultrasonic aspirator Intraoperative MRI if available	Surgical navigation Surgical microscope with 5-ALA Ultrasonic aspirator	Surgical navigation Surgical microscope IOM (MEP/SSEP/ECoG) Brain stimulator	Surgical navigation Ultrasonic aspirator Surgical microscope +/– fluorescence
Medications	Steroids Antiepileptics	Steroids Antiepileptics	Steroids Antiepileptics	Mannitol Steroids Antiepileptics
Anatomic considerations	Frontal lobe sulci and gyri	Sagittal suture, superior sagittal sinus, falx, ACA, frontopolar arteries, anterior parasagittal draining veins	Broca area inferolaterally, ACA medially, SMA and motor cortex/CST posteriorly	Frontal sinus, ACA medially, Broca area laterally
Complications feared with approach chosen	Motor deficit, aphasia	Left frontal lobe syndrome	Expressive aphasia, motor deficit	Expressive aphasia, motor deficit
Intraoperative
Anesthesia	General	General	Asleep-awake-asleep	General
Skin incision	Wide fronto-parietal-temporal	Pterional	Pterional	Pterional or bicoronal
Bone opening	Left frontal	Left frontal	Left frontal	Left frontal
Brain exposure	Left frontal	Left frontal	Left frontal	Left frontal
Method of resection	Left frontal craniotomy, dura opened and reflected toward midline, corticectomy at most superficial aspect of tumor to cortical surface, microsurgical resection with 5-ALA, inspection of cavity with fluorescence, intraoperative MRI to guide further resection if available, subgaleal drain to low suction pressure	Left frontal craniotomy, dural opening, subpial resection of tumor inside SFG and MFG based on 5-ALA fluorescence, resect until no strong or weak fluorescence remains	Left frontal craniotomy, peripheral tack up sutures, U-shaped dural opening with base along sagittal sinus observing for draining veins, motor strip mapping to identify primary motor cortex, awaken patient for language mapping with cortical stimulation to identify the Broca and other eloquent language areas, protect positive mapping sites, dissect around tumor with continuous cortical and subcortical mapping, remove tumor en bloc if possible, use microscope if necessary around ACA and eloquent white matter tracts, put back to sleep for remainder of case, watertight dural closure	Left frontal craniotomy ipsilateral to sagittal sinus based on navigation, dural opening, resection of tumor en bloc under microscopic visualization +/– fluorescence, further resection of any remaining lesion
Complication avoidance	Shortest trajectory	Subpial resection, resection of strong and weak fluorescence	Observe for cortical veins, language and motor mapping, en bloc resection	En bloc resection, possible use of fluorescence
Postoperative
Admission	ICU	ICU	Floor if no deficits	ICU
Postoperative complications feared	Cognitive dysfunction	CSF leak, left frontal lobe syndrome	SMA syndrome, expressive aphasia	Expressive aphasia, motor deficit
Follow-up testing	MRI within 72 hours after surgery	MRI within 48 hours after surgery	MRI within 24 hours after surgery	MRI within 24 hours after surgery
Follow-up visits	7 days after surgery	7 days after surgery 1 month after surgery	14 days after surgery	3 months after surgery 7 days after surgery with radiation and neurooncology
Adjuvant therapies recommended
IDH status	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–possible second look surgery of FLAIR Wild type–radiation/temozolomide +/– TTF
MGMT status	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide +/– TTF Unmethylated– radiation/temozolomide +/– TTF