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Improved outcomes associated with maximal extent of resection for butterfly glioblastoma: insights from institutional and national data

  • Original Article - Tumor - Glioma
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Abstract

Background

Butterfly glioblastomas (bGBMs) are grade IV gliomas that infiltrate the corpus callosum and spread to bilateral cerebral hemispheres. Due to the rarity of cases, there is a dearth of information in existing literature. Herein, we evaluate clinical and genetic characteristics, associated predictors, and survival outcomes in an institutional series and compare them to a national cohort.

Methods

We identified all adult patients with bGBM treated at Brigham & Women’s Hospital (2008–2018). The National Cancer Database (NCDB) was also queried for bGBM patients. Survival was analyzed with Kaplan–Meier methods, and Cox models were built to assess for predictive factors.

Results

Of 993 glioblastoma patients, 62 cases (6.2%) of bGBM were identified. Craniotomy for resection was attempted in 26 patients (41.9%), with a median volumetric extent of resection (vEOR) of 72.3% (95% confidence interval [95%CI] 58.3–82.1). The IDH1 R132H mutation was detected in two patients (3.2%), and MGMT promoter was methylated in 55.5% of the assessed cases. In multivariable regression, factors predictive of longer OS were increased vEOR, MGMT promoter methylation, and receipt of adjuvant therapy. Median OS for the resected cases was 11.5 months (95%CI 7.7–18.8) vs. 6.3 (95%CI 5.1–8.9) for the biopsied. Of 21,353 GBMs, 719 (3.37%) bGBM patients were identified in the NCDB. Resection was more likely to be pursued in recent years, and GTR was independently associated with prolonged OS (p < 0.01).

Conclusion

Surgical resection followed by adjuvant chemoradiation is associated with significant survival gains and should be pursued in carefully selected bGBM patients.

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Authors and Affiliations

  1. Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, 60 Fenwood Rd., Boston, MA, , 02115, USA

    Alessandro Boaro, Vasileios K. Kavouridis, Francesca Siddi, Elisabetta Mezzalira, Maya Harary, J. Bryan Iorgulescu & Timothy R. Smith

  2. Harvard Medical School, Boston, MA, USA

    Alessandro Boaro, Francesca Siddi, Elisabetta Mezzalira, Maya Harary, J. Bryan Iorgulescu, David A. Reardon & Timothy R. Smith

  3. Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway

    Vasileios K. Kavouridis

  4. Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA

    Maya Harary

  5. Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA

    J. Bryan Iorgulescu & David A. Reardon

  6. Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA

    J. Bryan Iorgulescu

Authors
  1. Alessandro Boaro
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  2. Vasileios K. Kavouridis
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  3. Francesca Siddi
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  5. Maya Harary
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  6. J. Bryan Iorgulescu
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Corresponding author

Correspondence to Vasileios K. Kavouridis.

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Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Brigham and Women’s Hospital) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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For this type of study (retrospective), formal consent is not required.

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The authors declare no competing interests.

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Comments

The authors present an analysis of 62 butterfly glioblastoma they identified in their institutional records and 719 such lesions identified in a national database. They found extent of resection to be associated with improved survival. Given the retrospective and registry-based nature of the data, laden with confounding by indication, caution should be used when interpreting these results. Nevertheless, one cannot fail to see that a lesion once considered "inoperable" or "not a surgical case" or "showing no benefit after surgery and adjuvant therapy" might still be amenable to surgery in selected cases. As expected, splenial glioblastomas were seldomly resected. The authors have been very strict in their radiological definition of butterfly glioblastoma. It is unclear whether patients in the national database also benefitted from the same strict definition, or whether patients were also included with some corpus callosum infiltration and shift, but no true crossing of the contrast-enhancing component to the contralateral side. Despite the limitations of the data, fact remains that in selected cases surgery for butterfly glioblastoma followed by adjuvant therapy appears to offer benefit in terms of survival, comparable to that of "regular" glioblastoma. Details about patient counselling and which patients to indicate for surgery are needed. These results should prompt in the very least a large-scale international prospective registry effort to gain more insight in the best treatment options for butterfly gliobastoma.

Victor Volovici

Rotterdam, Netherlands

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Alessandro Boaro and Vasileios K. Kavouridis shared first authorship.

This article is part of the Topical Collection on Tumor - Glioma

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Boaro, A., Kavouridis, V.K., Siddi, F. et al. Improved outcomes associated with maximal extent of resection for butterfly glioblastoma: insights from institutional and national data. Acta Neurochir 163, 1883–1894 (2021). https://doi.org/10.1007/s00701-021-04844-w

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