Abstract
The objective of the present study is to assess the influence of extent of resection (EoR), use of intraoperative imaging, and awake surgery on health-related quality of life (HRQoL) in high-grade glioma (HGG) patients in a prospective multicenter study. We analyzed 170 surgeries of patients suffering from a HGG. During the first year after resection, HRQoL was evaluated using the European Organization of Research and Treatment of Cancer Core Questionnaire C30 and Brain Neoplasm 20 questionnaires. We assessed the influence of EoR; awake surgery; and use of 5-aminolevulinic acid (5-ALA), intraoperative MRI (iMRI), and their combination on sum scores for function and symptoms as well as several neurological single items. In mixed-model analyses, adjustments for age, Karnofsky performance status (KPS), and eloquent location were performed. In the mixed model, EoR generally did not significantly influence HRQoL (p = 0.10). Yet, patients receiving subtotal resection (STR) vs. patients with biopsy showed significantly better QoL and role and cognitive functions (p = 0.04, p = 0.02, and p < 0.01, respectively). The combination of iMRI and 5-ALA reached the highest EoR (95%) followed by iMRI alone (94%), 5-ALA alone (74%), and no imaging (73%). Thereby, neurological symptoms were lowest and functioning score highest after combined use of iMRI and 5-ALA, without reaching significance (p = 0.59). Despite lower scores in emotional function (59 vs. 46, p = 0.24), no significant impact of awake surgery on HRQoL was found (p = 0.70). In HGG patients, STR compared to biopsy was significantly associated with better HRQoL and fewer neurological symptoms in this series. An escalated use of intraoperative imaging increased EoR with stable or slightly better HRQoL and fewer neurological symptoms. Based on HRQoL, awake surgery was a well-tolerated and safe method in our series.
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References
DeAngelis LM (2001) Brain tumors. N Engl J Med 344:114–123. doi:10.1056/NEJM200101113440207
Marko NF, Weil RJ, Schroeder JL, Lang FF, Suki D, Sawaya RE (2014) Extent of resection of glioblastoma revisited: personalized survival modeling facilitates more accurate survival prediction and supports a maximum-safe-resection approach to surgery. J Clin Oncol Off J Am Soc Clin Oncol 32:774–782. doi:10.1200/jco.2013.51.8886
Ostrom QT, Bauchet L, Davis FG, Deltour I, Fisher JL, Langer CE, Pekmezci M, Schwartzbaum JA, Turner MC, Walsh KM, Wrensch MR, Barnholtz-Sloan JS (2014) The epidemiology of glioma in adults: a “state of the science” review. Neuro-Oncology 16:896–913. doi:10.1093/neuonc/nou087
Calvert M, Brundage M, Jacobsen PB, Schünemann HJ, Efficace F (2013) The CONSORT patient-reported outcome (PRO) extension: implications for clinical trials and practice. Health Qual Life Outcomes 11:184. doi:10.1186/1477-7525-11-184
Sanders C, Egger M, Donovan J, Tallon D, Frankel S (1998) Reporting on quality of life in randomised controlled trials: bibliographic study. BMJ (Clinical research ed) 317:1191–1194
Senft C, Bink A, Franz K, Vatter H, Gasser T, Seifert V (2011) Intraoperative MRI guidance and extent of resection in glioma surgery: a randomised, controlled trial. The Lancet Oncology 12:997–1003. doi:10.1016/s1470-2045(11)70196-6
Stummer W, Pichlmeier U, Meinel T, Wiestler OD, Zanella F, Reulen H-J (2006) Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. The Lancet Oncology 7:392–401. doi:10.1016/s1470-2045(06)70665-9
Stummer W, Tonn J-C, Mehdorn HM, Nestler U, Franz K, Goetz C, Bink A, Pichlmeier U (2011) Counterbalancing risks and gains from extended resections in malignant glioma surgery: a supplemental analysis from the randomized 5-aminolevulinic acid glioma resection study. J Neurosurg 114:613–623. doi:10.3171/2010.3.JNS097
Hoffermann M, Bruckmann L, Mahdy Ali K, Zaar K, Avian A, von Campe G (2017) Pre- and postoperative neurocognitive deficits in brain tumor patients assessed by a computer based screening test. J Clin Neurosci 36:31–36. doi:10.1016/j.jocn.2016.10.030
Wolf J, Campos B, Bruckner T, Vogt L, Unterberg A, Ahmadi R (2016) Evaluation of neuropsychological outcome and “quality of life” after glioma surgery. Langenbeck’s Arch Surg 401:541–549. doi:10.1007/s00423-016-1403-6
Milian M, Luerding R, Ploppa A, Decker K, Psaras T, Tatagiba M, Gharabaghi A, Feigl GC (2013) “Imagine your neighbor mows the lawn”: a pilot study of psychological sequelae due to awake craniotomy: clinical article. J Neurosurg 118:1288–1295. doi:10.3171/2013.2.JNS121254
Milian M, Tatagiba M, Feigl GC (2014) Patient response to awake craniotomy—a summary overview. Acta Neurochir 156:1063–1070. doi:10.1007/s00701-014-2038-4
Coburger J, Hagel V, Wirtz CR, Konig R (2015) Surgery for glioblastoma: impact of the combined use of 5-aminolevulinic acid and intraoperative MRI on extent of resection and survival. PLoS One 10:e0131872. doi:10.1371/journal.pone.0131872
Taphoorn MJ, Claassens L, Aaronson NK, Coens C, Mauer M, Osoba D, Stupp R, Mirimanoff RO, van den Bent MJ, Bottomley A, Group EQoL, and Brain Cancer N, Radiotherapy G (2010) An international validation study of the EORTC brain cancer module (EORTC QLQ-BN20) for assessing health-related quality of life and symptoms in brain cancer patients. Eur J Cancer 46(6):1033–1040
Hinz A, Einenkel J, Briest S, Stolzenburg JU, Papsdorf K, Singer S (2012) Is it useful to calculate sum scores of the quality of life questionnaire EORTC QLQ-C30? European Journal of Cancer Care 21:677–683. doi:10.1111/j.1365-2354.2012.01367.x
Hinz A, Mehnert A, Degi C, Reissmann DR, Schotte D, Schulte T (2015) The relationship between global and specific components of quality of life, assessed with the EORTC QLQ-C30 in a sample of 2019 cancer patients. European Journal of Cancer Care. doi:10.1111/ecc.12416
Schwarz R, Hinz A (2001) Reference data for the quality of life questionnaire EORTC QLQ-C30 in the general German population. European Journal of Cancer (Oxford, England: 1990) 37:1345–1351 doi: S0959804900004470
Mauer M, Stupp R, Taphoorn MJ, Coens C, Osoba D, Marosi C, Wong R, de Witte O, Cairncross JG, Efficace F, Mirimanoff RO, Forsyth P, van den Bent MJ, Weller M, Bottomley A (2007) The prognostic value of health-related quality-of-life data in predicting survival in glioblastoma cancer patients: results from an international randomised phase III EORTC Brain Tumour and Radiation Oncology Groups, and NCIC Clinical Trials Group study. Br J Cancer 97:302–307
Hickmann AK, Hechtner M, Nadji-Ohl M, Janko M, Reuter AK, Kohlmann K, Haug M, Gruninger S, Deininger M, Ganslandt O, Konig J, Wirtz CR, Coburger J, Renovanz M (2016) Evaluating patients for psychosocial distress and supportive care needs based on health-related quality of life in primary brain tumors: a prospective multicenter analysis of patients with gliomas in an outpatient setting. J Neuro-Oncol. doi:10.1007/s11060-016-2280-0
Maratia S, Cedillo S, Rejas J (2016) Assessing health-related quality of life in patients with breast cancer: a systematic and standardized comparison of available instruments using the EMPRO tool. Qual Life Res Int J Qual Life Asp Treat Care Rehab 25:2467–2480. doi:10.1007/s11136-016-1284-8
Kreth FW, Thon N, Simon M, Westphal M, Schackert G, Nikkhah G, Hentschel B, Reifenberger G, Pietsch T, Weller M, Tonn JC, German Glioma N (2013) Gross total but not incomplete resection of glioblastoma prolongs survival in the era of radiochemotherapy. Annals of Oncology: Official Journal of the European Society for Medical Oncology 24:3117–3123. doi:10.1093/annonc/mdt388
Osoba D, Aaronson NK, Muller M, Sneeuw K, Hsu MA, Yung WK, Brada M, Newlands E (1996) The development and psychometric validation of a brain cancer quality-of-life questionnaire for use in combination with general cancer-specific questionnaires. Qual Life Res Int J Qual Life Asp Treat Care Rehab 5:139–150
Quinten C, Coens C, Ghislain I, Zikos E, Sprangers MA, Ringash J, Martinelli F, Ediebah DE, Maringwa J, Reeve BB, Greimel E, King MT, Bjordal K, Flechtner HH, Schmucker-Von Koch J, Taphoorn MJ, Weis J, Wildiers H, Velikova G, Bottomley A, Probe GEC (2015) The effects of age on health-related quality of life in cancer populations: a pooled analysis of randomized controlled trials using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 involving 6024 cancer patients. European Journal of Cancer (Oxford, England: 1990) 51:2808–2819. doi:10.1016/j.ejca.2015.08.027
Drewes CSL, Jakola AS, Solheim O (2016) Quality of life in patients with intracranial tumors: does tumor laterality matter? J Neurosurg 125:1400–1407. doi:10.3171/2015.12.JNS152252
Jakola AS, Unsgård G, Solheim O (2011) Quality of life in patients with intracranial gliomas: the impact of modern image-guided surgery. J Neurosurg 114:1622–1630. doi:10.3171/2011.1.JNS101657
Schucht P, Beck J, Abu-Isa J, Andereggen L, Murek M, Seidel K, Stieglitz L, Raabe A (2012) Gross total resection rates in contemporary glioblastoma surgery: results of an institutional protocol combining 5-aminolevulinic acid intraoperative fluorescence imaging and brain mapping. Neurosurgery 71:927–936
Li YM, Suki D, Hess K, Sawaya R (2016) The influence of maximum safe resection of glioblastoma on survival in 1229 patients: can we do better than gross-total resection? J Neurosurg 124:977–988. doi:10.3171/2015.5.jns142087
Goebel S, Nabavi A, Schubert S, Mehdorn HM (2010) Patient perception of combined awake brain tumor surgery and intraoperative 1.5-T magnetic resonance imaging: the Kiel experience. Neurosurgery 67:594–600 . doi:10.1227/01.NEU.0000374870.46963.BBdiscussion 600
Singer S, Danker H, Guntinas-Lichius O, Oeken J, Pabst F, Schock J, Vogel HJ, Meister EF, Wulke C, Dietz A (2014) Quality of life before and after total laryngectomy: results of a multicenter prospective cohort study. Head & neck 36:359–368. doi:10.1002/hed.23305
Maringwa J, Quinten C, King M, Ringash J, Osoba D, Coens C, Martinelli F, Reeve BB, Gotay C, Greimel E, Flechtner H, Cleeland CS, Schmucker-Von Koch J, Weis J, Van Den Bent MJ, Stupp R, Taphoorn MJ, Bottomley A (2011) Minimal clinically meaningful differences for the EORTC QLQ-C30 and EORTC QLQ-BN20 scales in brain cancer patients. Annals of Oncology: Official Journal of the European Society for Medical Oncology / ESMO 22:2107–2112. doi:10.1093/annonc/mdq726
Osoba D, Rodrigues G, Myles J, Zee B, Pater J (1998) Interpreting the significance of changes in health-related quality-of-life scores. J Clin Oncol Off J Am Soc Clin Oncol 16:139–144. doi:10.1200/jco.1998.16.1.139
Schwartz CE, Andresen EM, Nosek MA, Krahn GL (2007) Response shift theory: important implications for measuring quality of life in people with disability. Arch Phys Med Rehabil 88:529–536. doi:10.1016/j.apmr.2006.12.032
Ousmen A, Conroy T, Guillemin F, Velten M, Jolly D, Mercier M, Causeret S, Cuisenier J, Graesslin O, Hamidou Z, Bonnetain F, Anota A (2016) Impact of the occurrence of a response shift on the determination of the minimal important difference in a health-related quality of life score over time. Health Qual Life Outcomes 14:167. doi:10.1186/s12955-016-0569-5
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The authors thank Sonja Grüninger, Monika Deininger, Güler Savas, Christa Topp, Heike Lahr, Doro Maurer, Linda Messing, and Larissa Reitzug for their reliable cooperation.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
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Nickel, K., Renovanz, M., König, J. et al. The patients’ view: impact of the extent of resection, intraoperative imaging, and awake surgery on health-related quality of life in high-grade glioma patients—results of a multicenter cross-sectional study. Neurosurg Rev 41, 207–219 (2018). https://doi.org/10.1007/s10143-017-0836-x
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DOI: https://doi.org/10.1007/s10143-017-0836-x