Acta Neurochirurgica

, Volume 155, Issue 1, pp 41–50

Cost-utility of maximal safe resection of WHO grade II gliomas within eloquent areas

  • Juan Martino
  • Elsa Gomez
  • José L. Bilbao
  • Juan C. Dueñas
  • Alfonso Vázquez-Barquero
Clinical Article - Brain Tumors

Abstract

Background

Despite the growing use of intraoperative electrical stimulation (IES) mapping for resection of WHO grade II gliomas (GIIG) located within eloquent areas, some authors claim that this is a complex, time-consuming and expensive approach, and not well tolerated by patients, so they rely on other mapping techniques. Here we analyze the health related quality of life, direct and indirect costs of surgeries with and without intraoperative electrical stimulation (IES) mapping for resection of GIIG within eloquent areas.

Methods

A cohort of 11 subjects with GIIG within eloquent areas who had IES while awake (group A) was matched by tumor side and location to a cohort of 11 subjects who had general anesthesia without IES (group B). Direct and indirect costs (measured as loss of labor productivity) and utility (measured in quality adjusted life years, QALYs), were compared between groups.

Results

Total mean direct costs per patient were $38,662.70 (range $19,950.70 to $61,626.40) in group A, and $32,116.10 (range $22,764.50 to $46,222.50) in group B (p = 0.279). Total mean indirect costs per patient were $10,640.10 (range $3,010.10 to $86,940.70) in group A, and $48,804.70 (range $3,340.10 to $98,400.60) in group B (p = 0.035). Mean costs per QALY were $12,222.30 (range $3,801.10 to $47,422.90) in group A, and $31,927.10 (range $6,642.90 to $64,196.50) in group B (p = 0.023).

Conclusions

Asleep-awake-asleep craniotomies with IES are associated with an increase in direct costs. However, these initial expenses are ultimately offset by medium and long-term costs averted from a decrease in morbidity and preservation of the patient’s professional life. The present study emphasizes the importance to switch to an aggressive and safer surgical strategy in GIIG within eloquent areas.

Keywords

Cost-utility Intraoperative electrical stimulation Surgery WHO grade II glioma 

Abbreviations

FLAIR

Fluid-attenuated inversion recovery

GIIG

WHO grade II glioma

GTR

Gross total resection

Hz

Hertz

ICER

Incremental Cost-effectiveness Ratio

IES

Intraoperative electrical stimulation

KPS

Karnofsky Performance Status

mA

Milliamper

ml

Milliliter

MRI

Magnetic resonance imaging

NTR

Near total resection

PET

Positron emission tomography

PFS

Progression free survival

STR

Subtotal resection

QALY

Quality adjusted life years

References

  1. 1.
    Cavaliere R, Lopes MB, Schiff D (2005) Low-grade gliomas: an update on pathology and therapy. Lancet Neurol 4:760–770PubMedCrossRefGoogle Scholar
  2. 2.
    Celli P, Nofrone I, Palma L, Cantore G, Fortuna A (1994) Cerebral oligodendroglioma: prognostic factors and life history. Neurosurgery 35:1018–1034, discussion 1034–1015PubMedCrossRefGoogle Scholar
  3. 3.
    De Witt Hamer PC, Gil Robles S, Zwinderman AH, Duffau H, Berger MS (2012) Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis. J Clin Oncol 30:2559–2565PubMedCrossRefGoogle Scholar
  4. 4.
    Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart GL (2005) Methods for the economic evaluation of health care programmes. Oxford Univeristy Press, New York, NYGoogle Scholar
  5. 5.
    Duffau H, Capelle L (2004) Preferential brain locations of low-grade gliomas. Cancer 100:2622–2626PubMedCrossRefGoogle Scholar
  6. 6.
    Duffau H, Capelle L, Denvil D, Sichez N, Gatignol P, Taillandier L, Lopes M, Mitchell MC, Roche S, Muller JC, Bitar A, Sichez JP, van Effenterre R (2003) Usefulness of intraoperative electrical subcortical mapping during surgery for low-grade gliomas located within eloquent brain regions: functional results in a consecutive series of 103 patients. J Neurosurg 98:764–778PubMedCrossRefGoogle Scholar
  7. 7.
    Duffau H, Gatignol P, Mandonnet E, Peruzzi P, Tzourio-Mazoyer N, Capelle L (2005) New insights into the anatomo-functional connectivity of the semantic system: a study using cortico-subcortical electrostimulations. Brain 128:797–810PubMedCrossRefGoogle Scholar
  8. 8.
    Duffau H, Lopes M, Arthuis F, Bitar A, Sichez JP, Van Effenterre R, Capelle L (2005) Contribution of intraoperative electrical stimulations in surgery of low grade gliomas: a comparative study between two series without (1985–96) and with (1996–2003) functional mapping in the same institution. J Neurol Neurosurg Psychiatry 76:845–851PubMedCrossRefGoogle Scholar
  9. 9.
    Duffau H, Peggy Gatignol ST, Mandonnet E, Capelle L, Taillandier L (2008) Intraoperative subcortical stimulation mapping of language pathways in a consecutive series of 115 patients with Grade II glioma in the left dominant hemisphere. J Neurosurg 109:461–471PubMedCrossRefGoogle Scholar
  10. 10.
    Engel JJ, Van Ness PC, Rasmussen TB, Ojemann LM (1993) Outcome with respect to epileptic seizures. In: Engel J (ed) Surgical Treatment of the Epilepsies. Raven Press, New YorkGoogle Scholar
  11. 11.
    Gisbert R, Brosa M (2005) Base de datos de costes sanitarios v. 1.4 [CD-ROM]. Centro de Estudios en Economía de la Salud y de Polıítica Social (SOIKOS), BarcelonaGoogle Scholar
  12. 12.
    Gupta DK, Chandra PS, Ojha BK, Sharma BS, Mahapatra AK, Mehta VS (2007) Awake craniotomy versus surgery under general anesthesia for resection of intrinsic lesions of eloquent cortex–a prospective randomised study. Clin Neurol Neurosurg 109:335–343PubMedCrossRefGoogle Scholar
  13. 13.
    Hodgson TA, Meiners MR (1982) Cost-of-illness methodology: a guide to current practices and procedures. Milbank Mem Fund Q Health Soc 60:429–462PubMedCrossRefGoogle Scholar
  14. 14.
    Karnofsky D, Burchenal J (1949) Evaluation of chemotherapeutic agents. Columbia University Press, New YorkGoogle Scholar
  15. 15.
    Kim S, Mortaz Hedjri S, Coyte PC, Rampersaud YR (2012) Cost-utility of lumbar decompression with or without fusion for patients with symptomatic degenerative lumbar spondylolisthesis. Spine J 12:44–54PubMedCrossRefGoogle Scholar
  16. 16.
    Kleihues P, Burger PC, Scheithauer BW (1993) The new WHO classification of brain tumours. Brain Pathol 3:255–268PubMedCrossRefGoogle Scholar
  17. 17.
    Kuhnt D, Bauer MH, Becker A, Merhof D, Zolal A, Richter M, Grummich P, Ganslandt O, Buchfelder M, Nimsky C (2012) Intraoperative visualization of fiber tracking based reconstruction of language pathways in glioma surgery. Neurosurgery 70:911–920PubMedCrossRefGoogle Scholar
  18. 18.
    Lopez-Bastida J, Oliva J, Antonanzas F, Garcia-Altes A, Gisbert R, Mar J, Puig-Junoy J (2010) Spanish recommendations on economic evaluation of health technologies. Eur J Health Econ 11:513–520PubMedCrossRefGoogle Scholar
  19. 19.
    Lopez-Bastida J, Serrano-Aguilar P, Perestelo-Perez L, Oliva-Moreno J (2006) Social-economic costs and quality of life of Alzheimer disease in the Canary Islands, Spain. Neurology 67:2186–2191PubMedCrossRefGoogle Scholar
  20. 20.
    Martino J, de Lucas EM, Ibanez-Plagaro FJ, Valle-Folgueral JM, Vazquez-Barquero A (2012) Foix-Chavany-Marie syndrome caused by a disconnection between the right pars opercularis of the inferior frontal gyrus and the supplementary motor area. J Neurosurg. doi:10.3171/2012.7.JNS12404
  21. 21.
    Martino J, Taillandier L, Moritz-Gasser S, Gatignol P, Duffau H (2009) Re-operation is a safe and effective therapeutic strategy in recurrent WHO grade II gliomas within eloquent areas. Acta Neurochir (Wien) 151:427–436, discussion 436CrossRefGoogle Scholar
  22. 22.
    McGirt MJ, Chaichana KL, Attenello FJ, Weingart JD, Than K, Burger PC, Olivi A, Brem H, Quinones-Hinojosa A (2008) Extent of surgical resection is independently associated with survival in patients with hemispheric infiltrating low-grade gliomas. Neurosurgery 63:700–707, author reply 707–708PubMedCrossRefGoogle Scholar
  23. 23.
    Oliva-Moreno J (2011) Loss of labour productivity caused by disease and health problems: what is the magnitude of its effect on Spain’s Economy? Eur J Health EconGoogle Scholar
  24. 24.
    Organization for Economic Co-operation and Development. Purchasing Power Parities. Available at: http//http://www.oecd.org. Accessed May 1, 2012
  25. 25.
    Parker SL, Adogwa O, Davis BJ, Fulchiero E, Aaronson O, Cheng J, Devin CJ, McGirt MJ (2011) Cost-utility analysis of minimally invasive versus open multilevel hemilaminectomy for lumbar stenosis. J Spinal Disord TechGoogle Scholar
  26. 26.
    Peruzzi P, Bergese SD, Viloria A, Puente EG, Abdel-Rasoul M, Chiocca EA (2011) A retrospective cohort-matched comparison of conscious sedation versus general anesthesia for supratentorial glioma resection. Clinical article. J Neurosurg 114:633–639PubMedCrossRefGoogle Scholar
  27. 27.
    Producer Price Index Industry Data. Available at: http://www.ine.es. Accessed on May 1st, 2012
  28. 28.
    Rodriguez Barrios JM, Perez Alcantara F, Crespo Palomo C, Gonzalez Garcia P, Anton De Las Heras E, Brosa Riestra M (2011) The use of cost per life year gained as a measurement of cost-effectiveness in Spain: a systematic review of recent publications. Eur J Health EconGoogle Scholar
  29. 29.
    Sanai N, Berger MS (2009) Operative techniques for gliomas and the value of extent of resection. Neurotherapeutics 6:478–486PubMedCrossRefGoogle Scholar
  30. 30.
    Sanai N, Chang S, Berger MS (2011) Low-grade gliomas in adults. J NeurosurgGoogle Scholar
  31. 31.
    Sanai N, Martino J, Berger MS (2012) Morbidity profile following aggressive resection of parietal lobe gliomas. J Neurosurg 116:1182–1186PubMedCrossRefGoogle Scholar
  32. 32.
    Sanai N, Mirzadeh Z, Berger MS (2008) Functional outcome after language mapping for glioma resection. N Engl J Med 358:18–27PubMedCrossRefGoogle Scholar
  33. 33.
    Sawaya R, Hammoud M, Schoppa D, Hess KR, Wu SZ, Shi WM, Wildrick DM (1998) Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 42:1044–1055, discussion 1055–1046PubMedCrossRefGoogle Scholar
  34. 34.
    Serletis D, Bernstein M (2007) Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors. J Neurosurg 107:1–6PubMedCrossRefGoogle Scholar
  35. 35.
    Smith JS, Chang EF, Lamborn KR, Chang SM, Prados MD, Cha S, Tihan T, Vandenberg S, McDermott MW, Berger MS (2008) Role of extent of resection in the long-term outcome of low-grade hemispheric gliomas. J Clin Oncol 26:1338–1345PubMedCrossRefGoogle Scholar
  36. 36.
    Suárez-Fernández D, Vázquez-Barquero A, Gómez E, Marco de Lucas E, López LA, Mato D, Martín-Láez R, Ocón R, Martino J (2012) Eficacia y seguridad del mapeo por estimulación eléctrica intraoperatoria para la extirpación de gliomas OMS grado II en áreas cerebrales elocuentes. (Efficacy and safety of intraoperative electrical stimulation mapping for resection of WHO grade II gliomas within eloquent areas). Med Clin (Barc) 139:331–340CrossRefGoogle Scholar
  37. 37.
    Taylor MD, Bernstein M (1999) Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases. J Neurosurg 90:35–41PubMedCrossRefGoogle Scholar
  38. 38.
    Vademecum Online: el localizador de medicamentos. Available at: http://www.vademecum.es/. Accessed May 1, 2012
  39. 39.
    Whittle IR, Borthwick S, Haq N (2003) Brain dysfunction following ‘awake’ craniotomy, brain mapping and resection of glioma. Br J Neurosurg 17:130–137PubMedCrossRefGoogle Scholar
  40. 40.
    Zhao Y, Chen X, Wang F, Sun G, Wang Y, Song Z, Xu B (2012) Integration of diffusion tensor-based arcuate fasciculus fibre navigation and intraoperative MRI into glioma surgery. J Clin Neurosci 19:255–261PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Wien 2012

Authors and Affiliations

  • Juan Martino
    • 1
    • 5
  • Elsa Gomez
    • 2
  • José L. Bilbao
    • 3
  • Juan C. Dueñas
    • 4
  • Alfonso Vázquez-Barquero
    • 1
  1. 1.Department of Neurological SurgeryHospital Universitario Marqués de Valdecilla and Instituto de Formación e Investigación Marqués de Valdecilla (IFIMAV)SantanderSpain
  2. 2.Department of PsychiatryHospital Universitario Marqués de ValdecillaSantanderSpain
  3. 3.Admission DepartmentHospital Universitario Marqués de ValdecillaSantanderSpain
  4. 4.Financial DepartmentHospital Universitario Marqués de ValdecillaSantanderSpain
  5. 5.Department of NeurosurgeryHospital Universitario Marqués de Valdecilla and Instituto de Formación e Investigación Marqués de Valdecilla (IFIMAV)SantanderSpain

Personalised recommendations