Staged resection of multilobar lower-grade glioma: Case report and review of the literature

Abstract

Background and Importance:: Staged surgery has been used to treat large skull base tumors but is rarely used for intrinsic brain tumors, despite the fact that extent of resection (EOR) is associated with improved survival. A number of questions remain regarding specific indications for staged surgery including optimal time between stages and associated clinical outcomes. At present, there is a paucity of reports on staged surgery for large multilobar lower grade gliomas (LGGs) (>100 cm3) and no clear indications for staging. Clinical Presentation: A 34-year-old right handed female who presented with progressive headaches, nausea and dizziness underwent radical resection of a 130.5 cm 3 temporo-parietal-occipital anaplastic astrocytoma by a two-stage procedure. She initially underwent a superior parietal lobule approach followed by a frontotemporal approach 4 weeks later. Conclusion: Volumetric EOR for stage 1 was 76% based on postoperative MRI with near complete resection (96%) following stage 2. Pathology demonstrated WHO Grade 3 anaplastic astrocytoma, IDH1 R132H mutant. KPS on follow-up was 90%. The patient underwent treatment with concurrent temozolomide and radiation therapy, as well as a glutaminase inhibitor (CB-839) on Phase 1b clinical trial, which was followed by adjuvant temozolomide. She is 2 years post-surgery and continues on maintenance temozolomide without tumor progression. Potential indications for staged surgery for LGG include size > 100 cm3, multilobar extension, and intervening eloquent fasciculi and/or critical neurovascular structures that create an anatomic partition.

Keywords

• Staged
• Resection
• Glioma
• Lower-grade