Recurrent high-grade glioma

Introduction

Despite advances in medical and surgical therapy, the median survival for patients with high-grade gliomas remains approximately 1 year. These tumors frequently invade and infiltrate the surrounding parenchyma, and therefore make curative resection unlikely. Despite extensive resection, these tumors will also still recur. For patients with recurrence, the management is controversial and includes repeat resection, radiation therapy, salvage chemotherapy, and/or clinical trials. ^, In this chapter, we present a case of a recurrent high-grade glioma.

Example case

Chief complaint: headaches with potential recurrent tumor

History of present illness

A 50-year-old, right-handed man with type 2 diabetes who underwent gross total resection of a left temporal IDH wild-type, O6-methylguanine-DNA methyl-transferase nonmethylated glioblastoma 6 months prior, followed by 6 weeks of radiation and temozolomide, followed by three adjuvant cycles with worsening headaches and possible recurrence ( Fig. 27.1 ). He was given steroids without improvement.

Medications : Metformin, dexamethasone.
Allergies : No known drug allergies.
Past medical and surgical history : Gross total resection of a left temporal glioblastoma resection 6 months prior.
Family history : No history of intracranial malignancies.
Social history : Professional speaker. No smoking and social alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Language : intact naming and repetition; Cranial nerves II to XII intact; No drift, moves all extremities with full strength.

	Orin Bloch, MD, University of California-Davis, Sacramento, CA, United States	Javier Avendano Mendez-Padilla, MD, National Institute of Neurology and Neurosurgery, Tlalpan, Mexico	Maryam Rahman, MD, University of Florida, Gainesville, FL, United States	Walter Stummer, MD, PhD, University of Munster, Munster, NRW, Germany
Preoperative
Additional tests requested	MR perfusion fMRI DTI MRS	PETMRSfMRI DTI Neuropsychological assessment	fMRI DTI Neuropsychological assessment	FET PET to evaluate for pseudoprogression with biopsy fMRI DTI MRS Language evaluation
Surgical approach selected	Left fronto-temporal craniotomy with awake language, motor, and sensory mapping pending MRS	Left temporal awake craniotomy with language mapping	Left temporal craniotomy with awake mapping and 5-ALA resection and intraoperative MRI	Left temporal craniotomy with awake language mapping and 5-ALA
Anatomic corridor	Left fronto-temporal	Left temporal	Left temporal	Left temporal
Goal of surgery	Biopsy to determine recurrent tumor; then if positive, safe maximal resection of enhancing portion	GTR of enhancing portion and maximal FLAIR with brain mapping	Resection of contrast and FLAIR based on mapping	Resection of fluorescence
Perioperative
Positioning	Left semi-lateral	Left supine with 90-degree right rotation	Left lateral	Left supine with right rotation
Surgical equipment	Stereotactic navigation IOM (EEG) Brain stimulator Ultrasonic aspirator	Stereotactic navigation Ultrasound Brain stimulator Fluorescein	Stereotactic navigation Surgical microscope Brain stimulator IOM (EEG) Intraoperative MRI	Stereotactic navigation Surgical microscope with 5-ALA Ultrasound Brain stimulator Ultrasonic aspirator
Medications	Steroids Antiepileptics Mannitol	Steroids Antiepileptics Fluorescein	Steroids Antiepileptics Mannitol Fluorescein	Steroids
Anatomic considerations	AF, temporal stem, MCA and lenticulostriates	AF, uncinate fasciculus, Sylvian fissure and vessels	Sylvian fissure, language cortical and subcortical regions	Wernicke, Ludders temporobasal language, IFOF, AF, internal capsule
Complications feared with approach chosen	Language deficit, stroke	Language deficit, venous injury, arterial injury, cerebral edema	Language deficit	Language deficit, dysphagia, visual field deficit
Intraoperative
Anesthesia	Asleep-awake-asleep	Asleep-awake-asleep	Asleep-awake-asleep	Awake-awake-awake
Skin incision	Pterional (previous incision)	Pterional (previous incision)	Question mark	Pterional
Bone opening	Left fronto-temporal	Left fronto-temporal	Left temporal	Left fronto-temporal
Brain exposure	Left fronto-temporal	Left fronto-temporal	Left temporal	Left fronto-temporal
Method of resection	Circumferential scalp block, craniotomy to include complete left temporal and inferior frontal region, expand prior craniotomy if necessary, open dura, biopsy through old corticectomy, awaken patient, motor and speech mapping and identify positive sites in temporal lobe, internal debulking while mapping if biopsy positive for recurrent tumor, maximal safe resection, insertion of subgaleal drain	Patient asleep with laryngeal mask, scalp block, craniotomy that extends 2–4 cm outside lesion boundary, dura opened largely to encompass mapping sites, patient awakened, simulation with brain stimulator at 2 mA up to 8 mA with language mapping by neuropsych, positive sites marked with tags, resection based on negative areas, subcortical mapping using semantics for AF, after resection patient is put under general anesthesia	Monitored anesthesia care, scalp block, myocutaneous flap, temporal craniotomy, awaken patient, ECoG and bipolar stimulation for brain mapping with language tasks (naming, repetition) by neuropsych, fluorescence-guided resection, intraoperative MRI to guide further resection	Monitored scalp block, position while patient responsive with no laryngeal mask, deepen sedation for craniotomy, left temporal craniotomy, reduce sedation, language mapping over exposed area with identification of the Broca, resect upper and medial and posterior margins of fluorescence while mapping, spare mesial temporal structures, remove temporobasal remnants
Complication avoidance	Awake language and motor mapping, internal debulking until margins met or positive mapping site encountered	Awake language mapping in cortical and subcortical space	Cortical and subcortical mapping, fluorescence, intraoperative MRI	Cortical and subcortical language mapping, fluorescence, spare mesial temporal structures
Postoperative
Admission	ICU	ICU	ICU	ICU or intermediate care
Postoperative complications feared	Language deficit, seizure	Language deficit, motor deficit, seizures, cerebral edema	Language deficit	Language or visual field deficit
Follow-up testing	MRI within 48 hours after surgery	MRI within 72 hours after surgery	MRI within 48 hours after surgery	MRI within 48 hours after surgery
Follow-up visits	14 days after surgery with neurosurgery and neurooncology	2 weeks after surgery with neurosurgery and neurooncology	2 weeks after surgery with neurooncology 6 weeks after surgery with neurosurgery	3 months after surgery
Adjuvant therapies recommended
IDH status	Mutant–clinical trial, CCNU or bevacizumab Wild type–clinical trial, CCNU or bevacizumab	Mutant–bevacizumab and/or irinotecan Wild type–bevacizumab and/or irinotecan	Mutant–radiation/temozolomide Wild type–radiation/temozolomide, TTF, consideration of clinical trials	Mutant–CCNU +/– TTF Wild type–CCNU +/– TTF, experimental therapy
MGMT status	Methylated–clinical trial, CCNU or bevacizumab Unmethylated–clinical trial, CCNU or bevacizumab	Methylated–bevacizumab and/or irinotecan Unmethylated–bevacizumab and/or irinotecan	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide, TTF, consideration of clinical trials	Methylated–CCNU +/– TTF Unmethylated–CCNU +/– TTF, experimental therapy