Conf. Dr.

Mircea Gorgan
Copyright 2006

NEUROSURGICAL
MANAGEMENT OF
RECURRENCES IN LOW
GRADE GLIOMA
Ass Prof. Gorgan Mircea MD, PhD, Neacsu Angela MD,
Bucur Narcisa MD,PhD,
Diaconu Nicoleta MD, Pruna Viorel MD, Craciunas Sorin MD,
Luca Ionut MD
First Neurosurgical Clinic
Clinic Emergency Hospital "Bagdasar
"Bagdasar-- Arseni" Bucharest
RSN Conference
Sinaia, September 2006

Conf. Dr. Mircea Gorgan

Copyright 2006
Low-grade gliomas (LGG) are a heterogeneous group of
relatively slow-growing primary tumors of astrocytic and/or
oligodendroglial
g
g
origin.
g
An important feature of astrocytomas is their inherent tendency
t recur after
to
ft surgical
i l resection.
ti
Many WHO grade II (low grade diffuse) astrocytomas and nearly
all high
g ggrade anaplastic
p
astrocytomas
y
and glioblastoma
g
(WHO
(
grades III and IV respectively) recur at some points.
Another interesting feature is that upon recurrence,
recurrence some tumors
retain the same histological grade, whereas a significant
proportion undergo malignant progression and regrow into a
more anaplastic form so that the grade of the recurrent tumor is
higher than the original tumor.

Conf. Dr. Mircea Gorgan

LOW GRADE GLIOMA
Copyright
2006
NO

YES
PALEATIV
TREATMENT

YES

NO
BIOPSY

CRANIOTOMY

HISTOLOGICAL
DIAGNOSTIC
HIGH GRADE

LOW GRADE
PREVIOUS
RADIOTHERAPY

NO
RX

YES

NO

YES

SMALL FOCAR
TUMOR

SMALL FOCAR
TUMOR

SMALL FOCAR
TUMOR

NO

YES
CH

OP+RX

NO

YES
RX +CH OP + RX+CH

NO
CH

YES
OP+ RX + CH

Conf. Dr. Mircea Gorgan

Copyright 2006

REOPERATION CRITERIA
1) The length of time of recurrence;
2) The morphological characteristics of the
recurrence, location of the recurrence in close
proximity off the original tumor
3) The patients age, performance statusstatusKarnofski score,
score and associated diseases;
4) Radiological recurrence prior to the clinical
symptoms;
5) Radiological appearance of tumor necrosis or
abcess;
abcess;
6) The written option of the family and patient to
accept surgery.

Conf. Dr. Mircea Gorgan

Copyright
2006
39 years old woman operated
in January
1995
for left sided frontal fibrillary
astrocytoma,
t
t
with
ith decompressive
d
i craniotomy,followed
i t
f ll
d by
b chemo
h
and
d
radiotherapy..

Conf. Dr. Mircea Gorgan

Copyright 2006
F b
February
19971997 free
f
off ttumor

Conf. Dr. Mircea Gorgan

Copyright 2006

March 1997-giant
g
tumoral regrowth
g
operated
p
reveals malignancy
g
y
progression to secondary glioblastoma.

Conf. Dr. Mircea Gorgan

Copyright 2006
1998 last postoperative CT scan > 3 years of evolution
1998-last

Conf. Dr. Mircea Gorgan

Copyright 2006

38 case series of recurrent astrocytic tumors in

patients with low grade gliomas operated
between 1995-2005 by the same team in the
Fourth Neurosurgical Department of the Clinic
Emergency Hospital "Bagdasar - Arseni"
B h
Bucharest.
ece ved adjuva
adjuvant therapy
e apy aafter
e thee first
s
All cases received
operation.

Conf. Dr. Mircea Gorgan

Copyright 2006

OPERATED GLIOMA CASE SERIES

1995-2005
Year

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Total

Glioma

34

34

33

37

35

33

33

35

33

36

35

378

Low
grade
((I/II)
/ )

11

12

10

10

95
25,13
%

Anapla
stic
(III)

11

10

84
22,22
%

Gliobla
stoma
(IV)

21

14

22

20

18

23

17

16

15

17

16

199
52,64
%

Conf. Dr. Mircea Gorgan

Copyright 2006

Histological
g
type
yp of operated
p
LGG
95 case series
Fibrillary astrocytoma
39-41,05%
Gemistocytic astrocytoma
9-9,47%
Subependimar astrcytoma
3-3 15%
3-3,15%
Protoplasmatic astrocytoma
6-6,31%
Pilocytic
Pil
i astrocytoma 55-5,26%
5 26%
Oligoastrocytoma grade II
10-10,05%
Oligodendroglioma grade II
7-7,36%

Mixed glioma grade II 3-3

3 3,15%
15%
Ganglioglioma grade II 6-6,31%
Gangliocytoma 1-1,01%
Infundibuloma 1-1,01%
Pleomorphic xantho-astrocytoma
(PXA) 2-2,10%
Neurocytoma 3-3,15%
Dysembryoblastic neuro-epithelial
tumours (DNET) 0

Conf. Dr. Mircea Gorgan

Copyright 2006
Fibrillary
Protoplasmatic
Oligoastrocytoma
g
y
Ganglioglioma
Xantoastrocytoma

Gemistocytic
Pilocytic
Oligodendroglioma
g
g
Gangliocytoma
Neurocytoma

Subependimar
Protoplasmatic
Mixed g
glioma
Infundibuloma

Conf. Dr. Mircea Gorgan

Copyright 2006
39 years old man operated in 1998 for a frontal oligoastrocytoma

Conf. Dr. Mircea Gorgan

Copyright 2006
C t l CT scan after
Control
ft oncologic
l i treatment
t t
t

Conf. Dr. Mircea Gorgan

Copyright 2006

Reoperated
p
in 2005 for a huge
g recidive and malignancy
g
y
progression in grade III ->7 years of evolution

Conf. Dr. Mircea Gorgan

38 cases
of recidives
Copyright
2006

The most frequent location was frontal -20

20
cases

Frontal

Temporal

Parietal

Occipital

Other

Conf. Dr. Mircea Gorgan

Copyright
2006
38 cases
of recidives

Peak of age was between 21-40 years (29 cases)

21 40
21-40

41 50
41-50

51 60
51-60

>61

Conf. Dr. Mircea Gorgan

Copyright 2006

38 cases of recidives
The most frequent encountered tumor was
fibrillary astrocytoma (17 cases).
The mean reccurence time of this very
heterogeneous
g
ggroup
p of tumors was 4,2
, years
y
(1,7 years for gemistocytic astrocytoma grade II,
and 9 years for fibrillary astrocytoma grade II).
II)

Conf. Dr. Mircea Gorgan

Copyright 2006

The authors precise :

The time of follow-up -median 6,8 years,

Surviving time -median 5,3 years,
Morbidity -13,15%-5
13,15% 5 cases
Standard mortality 5,26% (2 cases).

Conf. Dr. Mircea Gorgan

Copyright 2006

21 cases (55,26%) remained in the same tumoral grade

17 cases (44,73%) presents malignancy progression.
All gemistocytic astrocytomas presented malingnant
progression at recurrence.
recurrence
12 recurrences supported total resection at initial
surgery
7 cases remained in the same grade, and 5 progressed to
a higher grade.

THE

Conf. Dr. Mircea Gorgan

PROFILE
OFREOPERATED
Copyright
2006

PATIENTS

FEMALES

16

42,10%

MALES

22

57,90%

RECURRENCE <12 MONTHS

1-2 YEARS

10,52%

2-4 YEARS

21,05%

>4 YEARS

26

68 42%
68,42%

TUMOR GRADE
SAME GRADE

21

55,26%

HIGH GRADE

17

44,73%

NUMBER OF OPERATIONS FOR RECURRENCE PER PATIENT

ONE OPERATION

16

42,10%

TWO OPERATIONS

15

39,47%

THREE OPERATIONS

10 52%
10,52%

FOUR OPERATIONS

7,89%

Conf. Dr. Mircea Gorgan

Copyright 2006

23 cases of recidive benefit from subtotal

resection at initial operation
p
13 of them remained in the same grade
10 progressed to a more aggressive tumor
From 3 cases with biopsy followed by chemo
and radiotherapy,
py, 1 remained in the same
tumoral grade and 2 progressed to a more
aggressive
gg
ggrade.

Conf. Dr. Mircea Gorgan

Histological
profile of recidives/regrowth.
Copyright
2006
All gemistocytic astrocytoma presented malignancy progression.
Number
of initial
cases

Number of
recurrences

Higher
grade

Higher
grade

Grade
III

Grade
IV

Fibrillary
astrocytoma

39

17

12

70 58%
70,58%

29 41%
29,41%

Gemistocytic
astrocytoma

100%

Subependimar
astrcytoma

100%

Protoplasmatic
astrocytoma

Oligoastrocytoma
grade II

10

60%

40%

Oligodendroglioma
Oli
d d li
grade II

66 66%
66,66%

33 33%
33,33%

Mixed glioma grade

II

100%

Ganglioglioma
grade II

100%

Tumor type

Same
grade

% from # = the percentage from the same anatomopathological category.

% from
#

%from
#

Conf. Dr. Mircea Gorgan

Copyright 2006

Degree of resection at initial surgery, the

recurrence and malignancy
g
y progression.
p g
Degree of resectioninitial surgery
Total resection
cases

65

Recurrence Same tumoral grade

High tumoral
grade

12 cases
18,46%

7 cases
10,76%

5 cases
7,69%

Subtotal resection
27 cases

23 cases
85,18%

13 cases
48,14%

10 cases
37,03%

Biopsies
3 cases

3 cases
100%

1 case
33,33%

2 cases
66,66%

Conf. Dr. Mircea Gorgan

Copyright 2006

28 yyears old woman operated

p
in 1998 for a temporal
p
fibrillary
y
astrocytoma with postoperative radio and chemotherapy

Conf. Dr. Mircea Gorgan

Copyright 2006

In 2001 she was operated

p
for a recidive with the same tumoral
grade adding a decompressive craniotomy

Conf. Dr. Mircea Gorgan

Copyright 2006

In Januaryy 2005 she was operated

p
again
g
for another recidive,,
who remained in the same histological grade

Conf. Dr. Mircea Gorgan

Copyright 2006
IRM September
p
2006
>8 years of evolution

Conf. Dr. Mircea Gorgan

Copyright 2006

None of the Grade I tumors showed evidence of

malignant progression.
Gangliocytoma grade I-IRM 5 years after operation

Conf. Dr. Mircea Gorgan

Copyright 2006
59 years old
ld man, with
ith seizures
i
started
t t d iin M
May 2005

Conf. Dr. Mircea Gorgan

Copyright
2006
Biopsy,-fibrillary
astrocytoma
in November 2005
( post-biopsy
t bi
IRM)
The patient refused oncologic treatement.

Conf. Dr. Mircea Gorgan

Copyright 2006

The tumor evolved after 10 months to a gglioblastoma,, and was

operated in august 2006

Conf. Dr. Mircea Gorgan

Copyright 2006

CONCLUSIONS
Our results indicate that both tumor progression and
histopathological dedifferentiation were less commonly
seen when
h a totall resection
i could
ld be
b achieved.
hi d
Data from this study demonstrate that tumor
progression occurs in 44,73% of a heterogenic group of
i fil i LGG
infiltrative
LGGs subjected
bj
d to next surgeries.
i
Gross- total resection with postoperative adjuvant
therapy was associated with increased time to second
surgery, andd low
l incidence
i id
off progression
i off
malignancy.