Abstract
Grade II gliomas grow slowly and linearly (at rates about 4 mm/year) before undergoing anaplastic transformation. In order to analyze how surgery may affect radiological grade II glioma kinetics, we restrospectively reviewed our national database searching for patients operated on for a supratentorial grade II glioma between 1997 and 2007. We selected patients with at least two postoperative MRI with a minimal delay of 6 months. For each patient, postoperative residues were segmented on successive MRIs. Velocities of diameter expansion were estimated by linear regression of mean diameter evolution for each patient. Fifty-four patients fulfilled inclusion criteria. Median postoperative follow-up was 1.6 years with, on average, 3.4 MRI examinations per patient. Postoperative growth rates of mean diameter were normally distributed, around a mean value of 4.3 mm/year (SD = 3.2 mm/year). Statistical analysis showed no difference between this distribution and the distribution of preoperative growth rates in a previous series of 143 grade II gliomas. For a subset of 23 patients, delay between first MRI and surgery made it possible to estimate also preoperative growth rates. Intrapatient comparison revealed that growth rates were grossly unchanged for 80% of cases. In summary, inter- and intrapatient comparison of pre- and postoperative growth rates proves that surgery does not change grade II glioma dynamics, thus, acting as a cytoreduction.
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Marc Sindou, Lyon, France
This work is interesting as it deals with a subject only scarcely approached in the oncologic literature, namely the speed of tumor growth of gliomas grade II. In addition, it explains well the method of quantification: the velocity of diametric evolution (VDE); the main result of the study is that resective surgery is effective in delaying the volumetric—i.e., compressive—effects of the tumor. However, there no proof that resection delays anaplastic transformation. This has to be investigated through (randomized) prospective studies.
Benoit JM Pirotte, Brussels, Belgium
In this paper, Mandonnet and coauthors investigate whether surgical resection interferes or not on grade II glioma kinetics. The objective of that study might be surprising, and the conclusion that surgical resection should probably not act on tumor growth might appear as an evident statement to everyone. However, the idea deserved to be measured so far. Such study confirms once more the major role of surgery in the therapy of gliomas. The study design is very simple and accurate. The methodology used seems very appropriate and sustains the conclusion. Two limitations might, however, weaken the message of this very exciting work. First, the 54 cases studied by the authors represent less than 20% of all cases found in their initial database. We, therefore, need to extrapolate very carefully the current conclusion to the whole population. The selection bias, due to unavailability of Digital Imaging and Communications in Medicine images, should not alter significantly the data. Secondly, the FLAIR MRI signal used here for measuring tumor volumes might not exactly and accurately reflect the actual tumor boundaries in most cases. Indeed, in up to 80% of WHO grade II gliomas, FLAIR signal extent is found different (smaller in about two thirds of them or larger in about one third) than the volume of 18F-fluoroethyltyrosine or 11C-methionine uptake area on PET images (Pauleit D. et al., Brain 128:678–687, 2005; Pirotte B. et al., J Neurosurg 104:238–253, 2006). Different studies comparing MR and PET signals to local histology in stereotactic conditions have confirmed the higher specificity of methionine on MR signals as a marker of tumor tissue and as tool for tumor delineation. FLAIR MR signal, although being the best MRI signal to represent tumor boundaries, might, therefore, provide false-negative and false-positive signals for tumor tissue detection. In this paper, however, since the FLAIR imaging was used repeatedly for longitudinal comparison, its intrinsic limitations might not have consequence on the present results. We would strongly encourage the authors to keep on studying this issue in the future by using other detection tracers (metabolic or others) presenting higher specificity of tumor tissue.
Raimund Firsching, Magdeburg, Germany
Mandonnet and collaborators present an ambitious analysis of the biological activity of grade II gliomas. The data from preoperative MRI and postoperative repeat MRI indicate a mostly unchanged growth rate before and after partial surgical removal of the tumor. They concluded that the more tumor cells were removed, the less likely were an anaplastic malignant transformation. This appears reasonable, and as there is some uncertainty concerning the indication and extent of surgery of grade II gliomas in the neurosurgical community, this study is of great importance. The authors are to be congratulated on their work.
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Mandonnet, E., Pallud, J., Fontaine, D. et al. Inter- and intrapatients comparison of WHO grade II glioma kinetics before and after surgical resection. Neurosurg Rev 33, 91–96 (2010). https://doi.org/10.1007/s10143-009-0229-x
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DOI: https://doi.org/10.1007/s10143-009-0229-x