OBJECTIVE
In this analysis, the authors sought to identify the variables of resection volume and quality of life in patients with brain tumors with the intraoperative use of neuronavigation system (NNS) and ultrasound in relation to the single use of NNS and without intraoperative neuroimaging.
METHODS
A retrospective analysis of 90 cases, divided into three groups: group A (N030) operated without intraoperative imaging (January 2009 – June 2014), group B (N030) with NNS and group C (N030) with NNS and ultrasound (July 2014 – March 2017). Includes glioma (WHO Grades I-IV), medulloblastoma and metastasis. The intraoperative neuroimaging systems were the curve dual system is a navigation platform used for Image Guided Surgery (IGS) and standard ultrasound device with a 7.5 MHz. The volumetric study was performed in MRI 1.5 –T / multiva 5.2 using the measures of the three main axis and this value was multiplied by a correction factor of 0.52. The aforementioned measures were performed on T1-weighted contrast for High – grade glioma (HGG) and metastases and T2-weighted flair for low-grade glioma (LGG). The anatomical location of the tumor was considered the most invasive cerebral lobe, eloquent or noneloquent area and dominant or nondominant hemisphere. Quality of life analysis is performed with the Karnofsky Performance Scale preoperative (Preq.KPS) and postoperative (Postq.KPS) up to three months, and immediate postoperative neurological deficit was evaluated.
RESULTS
The main types of tumors in the three groups were gliomas 68.9% (N062), metastasis 18.9% (N017) and medulloblastoma 11.1% (N011). The 73.3% (N066) were supratentorial, 32.2% (N029) in eloquent areas and 33.3% (N030) in the dominant hemisphere. In group C, 70% (N02) did not present any new deficits, with a difference between groups B and A, 46.7% (N014) and 33.3% (N010), respectively. Volumetric analysis showed that group C had the highest intended GTR ≥ 98% 40.87 ± 7.1cm3 (N024), group B 48.5 ± 8.9 cm3 (group N014) and group A 26.20 ± 5.7.cm3 (N08). In group C 12 cases with Preq.KPS <70 had a Postq.KPS recovery ≥70, lower in group A and B, 8 and 1 cases respectively. The trend in the three groups was higher tumor volume lower KPS, leading group B, Preq.KPS ≥70 (31.70 ± 6.1) and Preq.KPS <70 (106.80 ± 81). The highest resection volume was presented in the Postq.KPS group ≥70 (50.80 ± 6.9) and Postq.KPS <70 (32.05 ± 6.5).
| DEMOGRAPHIC CHARACTERISTICS OF THE THREE STUDY GROUPS | |||||||
| CHARACTERISTICS | TOTAL, N0= 90 | TOTAL, N0 – M/F | |||||
| GROUP A | GROUP B | GROUP C | |||||
| Age in yrs; mean±SEM | 34.9±3.1 | 34.2±3.2 | 43.2±3.2 | ||||
| Sex (N0 M/F) | 10/:20 | 16/14 | 13/17 | 39/51 | |||
| TUMOR ENTITY | GROUP A | GROUP B | GROUP C | TOTAL N0 | % | HISTOPATHOLOGICAL GROUPS | |
| WHO grade glioma (n0 %) | GLIOMA | % | |||||
| I | 1 | 5 | 1 | 7 | 7,78 | 11,29 | |
| II | |||||||
| Astrocytoma | 7 | 6 | 3 | 16 | 17,78 | 25,81 | |
| Oligodendroglioma | 1 | 1 | 1,11 | 1,61 | |||
| Oligoastrocytoma | 1 | 1 | 1,11 | 1,61 | |||
| III | |||||||
| Anaplastic astrocitoma | 5 | 2 | 8 | 15 | 16,67 | 62/68,9% | 24,19 |
| Anaplastic oligodendroglioma | 1 | 1 | 1,11 | 1,61 | |||
| Anaplastic Oligoastrocytoma | 1 | 1 | 1,11 | 1,61 | |||
| Anaplastic Ependymoma | 1 | 3 | 2 | 6 | 6,67 | 9,68 | |
| IV | |||||||
| Glioblastoma multiforme | 3 | 3 | 4 | 10 | 11,11 | 16,13 | |
| Gliosarcoma | 1 | 1 | 2 | 4 | 4,44 | 6,45 | |
| MEDULLOBLASTOMA (N0 %) | MEDULOB. | ||||||
| 4 | 4 | 2 | 10 | 11,11 | 10/11.1 | 10/11.1% | |
| METASTASIS(N0 %) | METASTASIS | ||||||
| Adenocarcinoma Breast | 5 | 4 | 4 | 13 | 14,44 | 76,47 | |
| Adenocarcinoma Lung | 1 | 1 | 2 | 2,22 | 17/18.9% | 11,76 | |
| Carcinoma Papillary Thyroid | 1 | 1 | 1,11 | 5,88 | |||
| Hepatoblastoma Epitelial | 1 | 1 | 1,11 | 5,88 | |||
| OTHERS | OTHERS | ||||||
| Primary Lymphoma | 1 | 1 | 1,11 | 1/1.1% | 1/1.1% | ||
that group B has the largest number of cases with KPS pre-operative ≥ 70(N018),group C (N015) and
group A (N0 12) respectively. KPS,Karnofsky Performance Scale.
that group C has the largest number of cases with KPS post-operative ≥70 (N0 26),group A (N020) and group B
(N0 19) respectively. KPS, Karnofsky Performance Scale
Note in the cases of KPS ≥ 70 (N020) red dots, presented a volume tumor of 28.81±5.6 and with KPS < 70 (N010)
white dots, was 49.66±8.1. KPS: Karnofsky Performance Scale mean ± SEM (cm3).
Note in the cases of KPS ≥ 70 (N019) red dots, presented a volume tumor of 25.00±3.4 and with KPS < 70 (N011)
white dots, was 89.70±8.9. KPS: Karnofsky Performance
Scale, mean ± SEM (cm3).
| NEUROANATOMIC LOCATION OF THREE GROUPS OF STUDY | |||||
| CHARACTERISTICS | TOTAL, N0= 90 | ||||
| Tumor Location | GROUP A | GROUP B | GROUP C | (N0 %) | |
| SUPRATENTORIAL | 66/73.3% | ||||
| Frontal Lobe | 6 | 5 | 7 | 18/20.0% | |
| Temporal lobe | 7 | 4 | 7 | 18/20.0% | |
| Parietal Lobe | 7 | 7 | 7 | 21/23.3% | |
| Occipital Lobe | 1 | 2 | 4 | 7/7.8% | |
| Insular Lobe | 1 | 1 | 2/2.2% | ||
| INFRATENTORIAL | 24/26.7% | ||||
| Cerebelo | 9 | 11 | 4 | 24/26.7% | |
| Funcional location (N0 %) | |||||
| Noneloquent | 24 | 19 | 18 | 61/67.8% | |
| Eloquent | 6 | 11 | 12 | 29/32,2% | |
| Hemispherie (N0 %) | |||||
| Dominant | 8 | 11 | 11 | 30/33.3% | |
| Nondominant | 22 | 19 | 19 | 60/66.7% |
|
| POSTOPERATIVE MORBILITY IN THREE GROUPS STUDY | ||||
| CARACTERISTICAS | TOTAL, n= 90 | TOTAL,% | ||
| GRUPO A | GRUPO B | GRUPO C | ||
| NEUROLOGICAL DEFICITS (N0 %) | ||||
| No new déficits | 10 (33.3%) | 14(46.7%) | 21(70.0%) | 45(50.0%) |
| Transient déficits | 7(23.3%) | 8(26.7%) | 5(16.7%) | 20(22.3%) |
| Mild persistent déficits | 8(26.7%) | 4(13.3%) | 3(10.0%) | 15(16.7%) |
| Severe persistent deficits | 5(16.7%) | 4(13.3%) | 1(3.3%) | 10 (11.0%) |
| VOLUMETRIC ANALISIS IN THREE GROUPS STUDY | |||
| VOLUME TUMOR: N0 cases ( %) / mean±SEM (cm3 ) | GROUP A | GROUP B | GROUP C |
| Intended GTR (98 % ≥ ) | 8(26.7%)/28.37±5.5 | 14(46.7%)/48.6±9 | 24(80.0%)/41.03±7 |
| Intended STR (90 % ≥ ) | 5(16.7%)/76.65±9.0 | 2(6.6%)/56.7±9.1 | 4(13.3%)/60.69±4.5 |
| Intended PR (70 % ≥ ) | 17(56.6%)/50.25±5 | 14(46.7%)/75.6±9 | 2 (6.7%)/198.81±2.0 |
| RESECTION VOLUME:N0 cases (%) / mean±SEM (cm3 ) | |||
| Intended GTR (98 % ≥ ) | 8(26.7%)/26.20±5.7 | 14(46.7%)/48.5±9 | 24(80.0%) /40.87±7 |
| Intended STR (90 % ≥ ) | 5(16.7%)/72.94±8.9 | 2(6.6%)/3.7±9.8 | 4 (13.3%)/58.53±4.4 |
| Intended PR (70 % ≥ ) | 17((56.6%)/29.33±5 | 14(46.7%)/48.0±9. | 2 (6.7%) /117.0±5.3 |
| RESIDUAL VOLUME:N0 cases
( %) / mean±SEM (cm3 ) |
|||
| Intended GTR: (98 % ≥ ) | 8(26.7%) / 2.17±1.8 | 14(46.7%) / 0.1±0.3 | 24(80.0%)/0.17±1.2 |
| Intended STR (90 % ≥ ) | 5(16.7%) / 3.71±2.1 | 2(6.6%) / 3.7±9.8 | 4(13.3%) / 2.17±0.8 |
| Intended PR (70 % ≥ ) | 17(56.6%)/20.92±5 | 14(46.7%)/27.6±5 | 2(6.7%) / 81.73±9.5 |
CONCLUSIONS
This study demonstrates that the routine use of NNS and Ultrasound in brain tumor surgery is safe and reliable for resection orientation allowing greater intended GTR ≥ 98%, no new neurological deficit immediately after surgery and better quality of life a clear benefit in relation to the other two study groups.
Key words: neuronavigation; ultrasound; glioma; metastasis; resection; karnofsky performance scale, resection tumor, residual tumor.
REFERENCES
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- Jin-Song Wu, Xiu Gong, Yan Yan Song, Dong Wiao Zhuang, Et al, 3.0 – T Intraoperative Magnetic Resonance imaging-guided resection in cerebral glioma surgery: Interim analysis of a prospective, randomized, triple-blind, parallel-controlled trial. Clinical Neurosurgery.2014; 61 N0 1, 145-154.