Multifocal high-grade glioma

Introduction

Patients with high-grade gliomas have poor prognoses, with median survival approximately 12 months. A subset of patients with glioblastoma (GBM) have multifocal disease, whereby their lesions are separated by space. ^, These patients are considered to have poorer prognoses among patients with GBM. ^, These tumors are known to possess mutations in all three common GBM pathways, including RTK/PI3K, p53, and RB regulatory pathways with aberrations of epidermal growth factor receptor and CDKN2A/B. The management of these lesions is therefore controversial and ranges from needle biopsies and resection of the most accessible lesion to resection of all lesions. ^, ^, In this chapter, we present a case of a multifocal high-grade glioma.

Example case

Chief complaint: right arm and leg weakness

History of present illness

A 51-year-old, right-handed man with no significant past medical history presented with progressive right arm and leg weakness. Over the past 3 weeks, he has noted decreased dexterity in his right hand and now with an inability to walk ( Fig. 28.1 ).

Medications None.
Allergies No known drug allergies.
Past medical and surgical history None.
Family history No history of intracranial malignancies.
Social history Accountant. No smoking and no alcohol.
Physical examination Awake, alert, oriented to person, place, and time; Language intact naming and repetition; Cranial nerves II to XII intact; Right drift, right upper extremity 4/5, left upper extremity 5/5, right lower extremity 4/5, left lower extremity 5/5.
Imaging Chest/abdomen/pelvis with no evidence of primary disease.

	Juan A. Barcia, MD, PhD, Hospital Clínico San Carlos, Complutense University, Madrid, Spain	Mohamed El-Fiki, MBBCh, MS, MD, University of Alexandria, Alexandria, Egypt	Michael Lim, MD, Stanford University School of Medicine, Stanford, CA, United States	Michael E. Sughrue, MD, Prince of Wales Hospital, Sydney, Australia
Preoperative
Additional tests requested	DTI Neuropsychological assessment for language dominanceCT chest/abdomen/pelvis	DTI MRS Whole-body PET CT chest, abdominal ultrasound	DTI fMRI	DTI
Surgical approach selected	Right temporal stereotactic biopsy with local anesthetics followed by adjuvant therapy or left awake craniotomy if hemiparesis persists despite steroids pending patient’s preference	Right temporal excisional biopsy with 5-ALA	Right temporal craniotomy	Right awake transcallosal contralateral transventricular approach for left basal lesion, LITT for remaining lesions
Anatomic corridor	Right temporal	Right temporal	Right temporal	Interhemispheric transventricular
Goal of surgery	Diagnosis if biopsy pursued, diagnosis and motor recovery if left basal ganglia lesion pursued	Diagnosis to guide adjuvant therapy	Gross total resection of right temporal lesion	Extensive resection of contrast-enhancing portion of left basal ganglia lesion to reduce mass effect
Perioperative
Positioning	Right lateral	Right supine with left rotation	Right supine	Left lateral (surgical side down)
Surgical equipment	Surgical navigation Biopsy set	Surgical navigation Surgical microscope with 5-ALA Ultrasonic aspirator	Surgical navigation IOM (SSEP)	Surgical navigation Brain stimulator Surgical microscope
Medications	Antiepileptics	Steroids Mannitol/furosemide Antiepileptics	Steroids Mannitol Antiepileptics	Steroids Mannitol
Anatomic considerations	Right temporal lobe, Sylvian fissure, temporal horn of lateral ventricle	STA, zygomatic arch, MTG/ITG	Right anterior temporal lobe	ACA, cingulate gyrus, caudate nucleus, CST, basal ganglia, lenticulostriate artery
Complications feared with approach chosen	Hemorrhage, brain shifts	Increasing neurologic deficit	Motor and language deficit from left lesion	Avoiding laterally placed critical white matter tracts
Intraoperative
Anesthesia	General	General	General	Asleep-awake-asleep
Skin incision	Linear	Reverse question mark	Reverse question mark	Linear bicoronal
Bone opening	Right temporal	Right temporal	Right temporal	Right frontal
Brain exposure	Right temporal	Right temporal	Right temporal	Right frontal
Method of resection	Linear incision, right temporal burr hole, open dura, stereotactic needle biopsy of right temporal lesion, obtain various samples at the periphery and core of the enhancing region, intraoperative pathology to confirm lesional tissue	Craniotomy guided by navigation, low temporal opening and removal of bone to reach temporal floor, suture holes for fixation, dural tack up sutures, U-shaped dural opening based on temporal floor, identify Sylvian fissure/STS/ITS, transsulcal approach, excisional biopsy with 5-ALA, dissect lesion from surrounding brain if possible and remove en bloc, avoid ventricular entry, watertight dural closure, insertion of subgaleal drain	Myocutaneous flap, craniotomy guided by navigation, large corticectomy in MTG over lesion, dissect capsule from surrounding brain, attempted en bloc resection	Patient sedated, scalp block, right frontal craniotomy under navigation guidance up to sagittal sinus, interhemispheric approach, left callosotomy, entry into the left lateral ventricle, enter tumor above caudate head, awake patient and perform language and motor mapping, resection of tumor preserving lenticulostriates at inferior aspect of the tumor, awareness that tumor can appear like basal ganglia, placement of EVD
Complication avoidance	Stereotactic needle biopsy, avoid left basal ganglia lesion, biopsy from different locations	Preserve STA, transsulcal, avoid left basal ganglia lesion, en bloc resection, avoid ventricular entry	Avoid left basal ganglia lesion, IOM	Awake cortical and subcortical language and motor mapping, contralateral approach, EVD
Postoperative
Admission	ICU	ICU	ICU	ICU
Postoperative complications feared	Hemorrhage, seizures	Hematoma, seizures	Visual field deficit, memory loss	Hydrocephalus, injury to lenticulostriate arteries
Follow-up testing	CT immediately after surgery	Depends on pathology of lesion	MRI within 48 hours after surgery Visual field testing	MRI within 48 hours after surgery LITT therapy of remaining lesions if GBM in 1–2 weeks
Follow-up visits	When pathological diagnosis available	7 days, 1 month, and every three months after surgery	14 days after surgery	7–14 days after surgery
Adjuvant therapies recommended
IDH status	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide +/– TTF Wild type–radiation/temozolomide +/– TTF	Mutant–radiation/temozolomide Wild type–radiation/temozolomide
MGMT status	Methylated–temozolomide, followed by radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide +/– TTF Unmethylated–radiation/temozolomide +/– TTF	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide