CAMPUS GROSSHADERN
NEUROCHIRURGISCHE KLINIK UND POLIKLINIK INTERNET: NEUROCHIRURGIE.KLINIKUM.UNI-MUENCHEN.DE
2nd surgery in recurrent glioblastoma: when and why?
Jörg-Christian Tonn
Dept Neurosurgery
University Munich LMU Campus
Grosshadern
Germany
Disclosures
Consultant
MerckSerono, Roche, medac, BrainLab
Grants
Deutsche Forschungsgemeinschaft (DFG)
German Cancer Research Foundation
(Deutsche Krebshilfe)
Surgery at Relapse of GBM
– complete resection of relapse associated with better
prognosis in retrospective study
– improves situation for further chemotherapy?
– indicated for 20-30%
– for patients „in good clinical status“ and with
„resectable tumors“
McGirt et al. J Neurosurg 110:156–162 (2009)
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
Reoperation for recurrent high-grade glioma:
a current perspective of the literature Hervey-Jumper SL et al: Neurosurgery. 2014;75(5):491-9
• Review 1980 - 2013: 31 studies glioma WHO III und IV
• 29/31 studies advantage of re-resection (OS /clinical status)
• Age, KPS (> 70), time intervall from first surgery (> 6 months),
EOR
• patient selection reg KPS and risk factors ( Avastin< 4
weeks!)
• Limitations: all retrospective, non-controlled, selection-bias
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
An extent of resection threshold for recurrent
glioblastoma and its risk for neurological morbidity Oppenlander ME et al, J Neurosurg. 2014;120(4):846-53
• 170 consecutive pts (2001-2011), supratentorial GB , after surgery
plus EORTC/NCIC
• mean clinical follow-up 22.6 months - no patient lost to follow-up
• median preoperative tumor volume: 26.1 cm3 (1.7 cm diameter!)
• after Re-OP: median tumor volume 3.1 cm3 (87.4% EOR)
• median overall survival: 19.0 months, median PRS 5.2 months
• Cox proportional hazards analysis and RPA:
age, KPS, EOR (p = 0.0001)
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
An extent of resection threshold for recurrent
glioblastoma and its risk for neurological morbidity Oppenlander ME et al, J Neurosurg. 2014;120(4):846-53
• 7 days post re-resection:
deterioration > 1 on NIH stroke scale in 39.1% of pts with EOR ≥ 80%
vs 16.7% with EOR < 80% (p = 0.0049)
- disparity did not endure beyond 30 days postoperatively (p = 0.1279)
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
MGMT promoter methylation is a strong prognostic biomarker for
benefit from dose-intensified temozolomide rechallenge in progressive
glioblastoma: the DIRECTOR trial Weller M et al: Clin Cancer Res. 2015 Feb 5. [Epub ahead of print]
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
MGMT promoter methylation is a strong prognostic biomarker for
benefit from dose-intensified temozolomide rechallenge in progressive
glioblastoma: the DIRECTOR trial Weller M et al: Clin Cancer Res. 2015 Feb 5. [Epub ahead of print]
Reoperation: 61
No re-OP: 44
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
Gross total but not incomplete resection of glioblastoma
prolongs survival in the era of radiochemotherapy Kreth, F.-W. et al.: Ann Oncol. 2013; 24(12):3117-23
n= 222, all pts with EORTC/NCIC protocol
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
What should we know about the „recurrent GBM“?
• Progression or „pseudoprogression“ ?
• Recurrent tumor or progression of a previous
remnant?
• If remnant: why was it left behind?
• ? „true“ extension of the lesion (T2, FLAIR, PET)
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
Extent of the Tumor ?
LMU
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
What is important ?
• Early diagnosis of recurrent GBM to maintain the
prognostically good score
– size
– KPS
– surgical risk
• regular follow-up (3 months , MRI & clinical)
• Decide, whom not to operate
• Prospective studies!
Klinikum der Universität München • Großhadern • Neurochirurgische Klinik und Poliklinik
http://neurochirurgie.klinikum.uni-muenchen.de
What is next ?
• Tissue of re-OP informative for therapy of recurrent
tumor
– IDH 1 & LOH 1p/19q remain
– MGMT remains (Felsberg et al 2011)
– Other targets (EGFRVIII) , others ….
• Tissue of re-OP informative for biology of tumor
progression
• Material precious !
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