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The preoperative use of navigated transcranial magnetic stimulation facilitates early resection of suspected low-grade gliomas in the motor cortex

  • Clinical Article - Brain Tumors
  • Published:
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Abstract

Background

Resection is recommended for low-grade gliomas, but often it is not performed if the tumor is suspected of invading the primary motor cortex. The study aim is to assess what influence preoperative navigated transcranial magnetic stimulation (nTMS) has on the treatment strategy and clinical outcome for suspected low-grade gliomas in presumed motor eloquent location.

Methods

This paper reports on all our patients with gliomas in the primary motor cortex that were non-enhancing on MRI, since we began using nTMS (n = 11). For the comparison group, we identified the 11 most recent such patients just before we started using nTMS.

Results

Exact delineation of motor functional versus non-functional cortical tissue was provided by nTMS in all cases, also within the area of altered FLAIR signal. In 6 out of 11 cases, the nTMS mapping result changed the treatment plan towards early and more extensive resection. Only one nTMS patient had another seizure within the follow-up period, whereas four patients in the comparison group had further seizures. In the nTMS group, 1 of 4 patients with pre-op neurological deficits improved by one year; whereas the comparison group had increased neurological deficits in 3 of the 8 patients not having surgery. The median (range) change of tumor volume from baseline to 1 year was −83 % (−67 % to −100 %) in the nTMS group, but +12 % (+40 % to −56 %) in the comparison group (p < 0.001).

Conclusions

nTMS provides accurate motor mapping results also in infiltrative gliomas and enables more frequent and more extensive surgical resection of non-enhancing gliomas in or near the primary motor cortex. The substantial differences observed here in neurological and oncological outcomes suggest that further comparative research is warranted.

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Acknowledgments

We would like to thank Michael Hanna, PhD, (Mercury Medical Research & Writing) for providing publication consulting, statistical analysis, and medical writing services. We would also like to thank Adela Castelló, MSc, DPH, (Mercury Medical Research & Writing) for some recommendations on statistics and publishing.

Conflicts of interest

The research reported in this article was supported in part by a grant from the Berlin Cancer Society. Dr. Picht has served as a speaker for Nexstim OY, the manufacturer of the device used in this study. Dr Picht and Dr. Schulz had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Authors and Affiliations

  1. Department of Neurosurgery, Charité University Hospital, Berlin, Germany

    Thomas Picht & Peter Vajkoczy

  2. Department of Neurosurgery, Helios Kliniken Schwerin, Schwerin, Germany

    Juliane Schulz

  3. Neurochirurgische Klinik, Charité – Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany

    Thomas Picht

Authors
  1. Thomas Picht
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  2. Juliane Schulz
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  3. Peter Vajkoczy
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Corresponding author

Correspondence to Thomas Picht.

Additional information

Comment

Picht et al. present a study were they assessed the usefulness of preoperative navigated transcranial magnetic stimulation for the surgery of presumed low grade astrocytomas. This topic is interesting as nTMS is a relatively new tool, is not part of the standard armamentarium of most neurosurgical centers and therefore its use is limited and its usefulness still uncertain.

The goal of the study is to define the impact of this technology on the surgical results and on the overall clinical course of patients with presumed WHOII gliomas in or invading the motor cortex. The authors describe their experience with 11 patients and show convincingly good results in terms of extent of resection and low postoperative deficits. Every neurosurgeon knows from experience that lesions in the primary motor cortex are challenging and prone to postoperative motor deficits. Therefore we can appreciate the good results shown by the authors and reasonably deduct that nTMS probably provided an advantage, be it solely the confidence to offer surgery and attempt an extensive resection.

The comparison with an historical group can be useful for the assessment of new technology that is not easily subjected to randomized control trials and the number of patients is low. However, this requires homogenous groups which is not the case here and this is the main flaw of this study. Scientifically, the historical groups are not comparable. The study assesses what the availability of TMS changes in the overall management of these patients. However, this study does not compare surgery with or without TMS nor does it provide comparative data on observation vs Surgery (with or without TMS). Therefore any conclusion about the safety of surgery or the specific contribution of TMS to surgical outcomes cannot be drawn. Furthermore heterogeneity between groups is introduced by the fact that there were grade II and III tumors in both groups but some historical cases do not have a definitive diagnosis.

After all it could well be that surgery with DES alone is equal to nTMS and that the number of patients undergoing surgery in the nTMS group are the result of a change in the surgical philosophy for these lesions overtime.

Ivan Radovanovic

Toronto, Canada

Thomas Picht and Juliane Schulz contributed equally to this paper.

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Picht, T., Schulz, J. & Vajkoczy, P. The preoperative use of navigated transcranial magnetic stimulation facilitates early resection of suspected low-grade gliomas in the motor cortex. Acta Neurochir 155, 1813–1821 (2013). https://doi.org/10.1007/s00701-013-1839-1

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  • DOI: https://doi.org/10.1007/s00701-013-1839-1

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