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Published on: October 27, 2014
Is FLAIRectomy Directly Correlated with Prolonged Survival in Glioblastoma? A Prospective National Multicenter Study
Francesco Certo1,2, Alessandro Pluchino3, Andrea Maugeri4
1Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico - San Marco'' University Hospital, University of Catania, Catania , Italy.
Background And Objectives:
Several articles have demonstrated a positive correlation between glioblastoma supramarginal resection, based on MRI fluid-attenuated inversion-recovery (FLAIR) sequences (ie, FLAIRectomy), and prolonged survival. This study analyses the efficacy, safety, and reliability of FLAIRectomy in a multicentric cohort of patients, correlating the extent of FLAIR resection (EOFR) with clinical outcome and survival.
Methods:
One hundred fifty glioblastoma or grade IV astrocytoma patients (82 men), with a mean age of 58.2 years (range 36-82 years), from 3 neurosurgical centers were included. In all cases, supramarginal resection was deemed feasible preoperatively; multicentric neoplasms or tumors with enhancing nodule involving eloquent areas were excluded. Analysis of EOFR was based on comparison between preoperative and postoperative 3-dimensional FLAIR images. EOFR was compared with extent of tumor resection (EOTR) based on gadolinium-enhanced T1 sequences; theses data were also statistically correlated with survival parameters as well as with clinical and biomolecular data.
Results:
EOFR rate was 78.8% in the entire cohort, whereas EOTR based on T1 sequences was 98.3%. Mean progression free survival (PFS) and overall survival (OS) were 16.33 and 28.4 months, respectively. Adjusted Cox-regression models showed that a higher EOTR based on T1 sequences and EOFR were both associated with improved OS in individuals with either isocytrate dehydrogenase-1 wild-type or isocytrate dehydrogenase-1 mutated tumors. After adjustment, only the EOFR retained a statistically significant association with OS. Specifically, the risk of mortality decreased by 6.8% and 12.1% with each one-unit increase in EOFR, respectively. Further analysis based on artificial intelligence demonstrated that the cluster of patients with higher values of PFS and OS received greater rate of FLAIRectomy.
Conclusion:
This multicenter study demonstrates that EOFR is a more reliable predictor of PFS and OS than extent of resection based on gadolinium-enhanced T1 sequences, if supramarginal resection is performed according to specific preoperative planning. 3-dimensional FLAIR navigation-guided resection may represent the optimal strategy to achieve a real FLAIRectomy.
Insights
FLAIRectomy, a specialized glioblastoma resection technique, significantly improves patient survival. This method, focusing on MRI FLAIR sequences, is a more reliable predictor of outcomes than standard T1-weighted imaging.
Area of Science:
- Neurosurgery
- Oncology
- Radiology
Background:
- Glioblastoma resection aims to maximize tumor removal for improved patient outcomes.
- MRI fluid-attenuated inversion-recovery (FLAIR) sequences offer detailed visualization of tumor infiltration.
- FLAIRectomy, or supramarginal resection guided by FLAIR, is hypothesized to enhance survival.
Purpose of the Study:
- To evaluate the efficacy, safety, and reliability of FLAIRectomy in a multicenter glioblastoma cohort.
- To correlate the extent of FLAIR resection (EOFR) with clinical outcomes and patient survival.
- To compare FLAIRectomy's predictive value against standard extent of tumor resection (EOTR) based on T1-weighted MRI.
Main Methods:
- A multicenter study included 150 glioblastoma patients undergoing supramarginal resection.
- Extent of FLAIR resection (EOFR) was assessed by comparing pre- and post-operative 3D FLAIR MRI.
- EOFR was statistically correlated with extent of tumor resection (EOTR) on T1-weighted MRI, progression-free survival (PFS), and overall survival (OS).
Main Results:
- The mean EOFR was 78.8%, while mean EOTR based on T1 sequences was 98.3%.
- Higher EOFR and EOTR were associated with improved OS, but only EOFR remained statistically significant after adjustment.
- Each unit increase in EOFR correlated with a significant decrease in mortality risk, with AI analysis supporting improved PFS and OS with higher FLAIRectomy rates.
Conclusions:
- Extent of FLAIR resection (EOFR) is a more reliable predictor of glioblastoma patient survival than extent of resection based on T1-weighted MRI.
- Meticulous preoperative planning and 3D FLAIR navigation-guided resection are crucial for achieving optimal FLAIRectomy.
- FLAIRectomy represents a promising strategy for improving glioblastoma patient outcomes.
