[Molecular subtype-driven surgical concepts and clinical application in gliomas]

Objective: To compare the prognostic impact of different extents of resection among patients with molecularly defined glioma subtypes. Methods: This retrospective cohort study included 1 191 glioma patients who underwent surgical treatment at Beijing Tiantan Hospital, Capital Medical University, between January 2011 and January 2021. The cohort comprised 692 males and 499 females, with an age of (44.5±11.9) years (range: 18 to 75 years). Tumors were classified according to the 2021 WHO Classification of Tumors of the Central Nervous System (5th edition), and the extent of resection was assessed using postoperative MRI. Kaplan-Meier survival analyses and log-rank tests were used to evaluate the effects of resection extent on progression-free survival (PFS) and overall survival (OS) within each molecular subtype. Cox proportional hazards models were applied to identify independent prognostic factors for PFS and OS. Follow-up was completed in January 2024. Results: Among the 1 191 patients, 291 cases (24.43%) had isocitrate dehydrogenase(IDH)-mutant and 1p/19q-codeleted oligodendroglioma (OG), 338 cases (28.38%) had IDH-mutant astrocytoma, and 562 cases (47.19%) had IDH-wild-type glioblastoma (GBM). Patients with IDH-mutant and 1p/19q-codeleted OG had the best prognosis, with median PFS time and median OS time not reached. In IDH-wild type GBM, the median PFS time and median OS time were 12.0 and 24.0 months, respectively; in IDH-mutant astrocytoma, the median PFS time and median OS time were 61.0 and 102.0 months. Differences in PFS and OS among the three groups were statistically significant (both P<0.01). In patients with IDH-wild type GBM, supratotal resection yielded better PFS and OS than gross total resection (both P<0.05). In IDH-mutant astrocytoma, PFS and OS did not differ between supratotal and gross total resection (both P>0.05), while gross total resection was superior to subtotal resection (both P<0.05). In IDH-mutant, 1p/19q-codeleted OG, PFS and OS did not differ significantly across resection categories (both P>0.05). Multivariate analyses identified age, Karnofsky performance status, extent of resection, tumor grade, and O⁶-methylguanine-DNA methyltransferase promoter methylation status as independent predictors of both PFS and OS (both P<0.05). Conclusions: For IDH-wild type GBM, maximal efforts should be made to achieve supratotal resection. For IDH-mutant astrocytoma, maximal safe resection is recommended with preservation of neurological function. For IDH-mutant, 1p/19q-codeleted oligodendroglioma, a relatively conservative approach may be appropriate to protect neurological function.