Progression-free survival versus post-progression survival and overall survival in WHO grade 2 gliomas.

BACKGROUND AND PURPOSE: Progression-free survival (PFS) remains to be validated as an outcome measure for diffuse WHO grade 2 gliomas, and knowledge about the relationships between PFS, post-progression survival (PPS), and overall survival (OS) in this subset of tumors is limited. We sought to assess correlations between PFS and OS, and identify factors associated with PFS, PPS, and OS in patients treated for diffuse supratentorial WHO grade 2 gliomas. MATERIAL AND METHODS: We included 319 patients from three independent observational cohorts. The correlation between PFS and OS was analyzed using independent exponential distributions for PFS and time from progression to death. Cox proportional hazards models were used to determine the effects of covariates on PFS, PPS, and OS. RESULTS: The overall correlation between PFS and OS was rs0.31. The correlation was rs 0.37 for astrocytomas and rs 0.19 for oligodendrogliomas. Longer PFS did not predict longer PPS. Patients with astrocytomas had shorter PFS, PPS, and OS. Larger preoperative tumor volume was a risk factor for shorter PFS, while older age was a risk factor for shorter PPS and OS. Patients who received early radio- and chemotherapy had longer PFS, but shorter PPS and OS. INTERPRETATION: We found a weak correlation between PFS and OS in WHO grade 2 gliomas, with the weakest correlation observed in oligodendrogliomas. Our analyses did not demonstrate any association between PFS and PPS. Critically, predictors of PFS are not necessarily predictors of OS. There is a need for validation of PFS as an endpoint in diffuse WHO grade 2 gliomas.

Passive or active drainage system for chronic subdural haematoma-a single-center retrospective follow-up study.

BACKGROUND: Postoperative drainage systems have become a standard treatment for chronic subdural hematoma (CSDH). We previously compared treatment results from three Scandinavian centers using three different postoperative drainage systems and concluded that the active subgaleal drainage was associated with lower recurrence and complication rates than the passive subdural drainage. We consequently changed clinical practice from using the passive subdural drainage to the active subgaleal drainage. OBJECTIVE: The aim of the present study was to assess a potential change in reoperation rates for CSDH after conversion to the active subgaleal drainage. METHODS: This single-center cohort study compared the reoperation rates for recurrent same-sided CSDH and postoperative complication rates between patients treated during two study periods (passive subdural drainage cohort versus active subgaleal drainage cohort). RESULTS: In total, 594 patients were included in the study. We found no significant difference in reoperation rates between the passive subdural drain group and the active subgaleal drain group (21.6%, 95% CI 17.5-26.4% vs. 18.0%, 95% CI 13.8-23.2%; p = 0.275). There was no statistical difference in the rate of serious complications between the groups. The operating time was significantly shorter for patients operated with the active subgaleal drain than patients with the passive subdural drain (32.8 min, 95% CI 31.2-34.5 min vs. 47.6 min, 95% CI 44.7-50.4 min; p < 0.001). CONCLUSIONS: Conversion from the passive subdural to the active subgaleal drainage did not result in a clear reduction of reoperation rates for CSDH in our center.

Association between patient-reported cognitive function and location of glioblastoma.

Objective cognitive function in patients with glioblastoma may depend on tumor location. Less is known about the potential impact of tumor location on cognitive function from the patients' perspective. This study aimed to investigate the association between patient-reported cognitive function and the location of glioblastoma using voxel-based lesion-symptom mapping. Patient-reported cognitive function was assessed with the European Organisation for Research and Treatment (EORTC) QLQ-C30 cognitive function subscale preoperatively and 1 month postoperatively. Semi-automatic tumor segmentations from preoperative MRI images with the corresponding EORTC QLQ-C30 cognitive function score were registered to a standardized brain template. Student's pooled-variance t-test was used to compare mean patient-reported cognitive function scores between those with and without tumors in each voxel. Both preoperative brain maps (n = 162) and postoperative maps of changes (n = 99) were developed. Glioblastomas around the superior part of the left lateral ventricle, the left lateral part of the thalamus, the left caudate nucleus, and a portion of the left internal capsule were significantly associated with reduced preoperative patient-reported cognitive function. However, no voxels were significantly associated with postoperative change in patient-reported cognitive function assessed 1 month postoperatively. There seems to be an anatomical relation between tumor location and patient-reported cognitive function before surgery, with the left hemisphere being the dominant from the patients' perspective.

Is intracranial volume a risk factor for IDH-mutant low-grade glioma? A case-control study.

PURPOSE: Risk of cancer has been associated with body or organ size in several studies. We sought to investigate the relationship between intracranial volume (ICV) (as a proxy for lifetime maximum brain size) and risk of IDH-mutant low-grade glioma. METHODS: In a multicenter case-control study based on population-based data, we included 154 patients with IDH-mutant WHO grade 2 glioma and 995 healthy controls. ICV in both groups was calculated from 3D MRI brain scans using an automated reverse brain mask method, and then compared using a binomial logistic regression model. RESULTS: We found a non-linear association between ICV and risk of glioma with increasing risk above and below a threshold of 1394 ml (p < 0.001). After adjusting for ICV, sex was not a risk factor for glioma. CONCLUSION: Intracranial volume may be a risk factor for IDH-mutant low-grade glioma, but the relationship seems to be non-linear with increased risk both above and below a threshold in intracranial volume.

How well do neurosurgeons predict survival in patients with high-grade glioma?

Due to the lack of reliable prognostic tools, prognostication and surgical decisions largely rely on the neurosurgeons' clinical prediction skills. The aim of this study was to assess the accuracy of neurosurgeons' prediction of survival in patients with high-grade glioma and explore factors possibly associated with accurate predictions. In a prospective single-center study, 199 patients who underwent surgery for high-grade glioma were included. After surgery, the operating surgeon predicted the patient's survival using an ordinal prediction scale. A survival curve was used to visualize actual survival in groups based on this scale, and the accuracy of clinical prediction was assessed by comparing predicted and actual survival. To investigate factors possibly associated with accurate estimation, a binary logistic regression analysis was performed. The surgeons were able to differentiate between patients with different lengths of survival, and median survival fell within the predicted range in all groups with predicted survival < 24 months. In the group with predicted survival > 24 months, median survival was shorter than predicted. The overall accuracy of surgeons' survival estimates was 41%, and over- and underestimations were done in 34% and 26%, respectively. Consultants were 3.4 times more likely to accurately predict survival compared to residents (p = 0.006). Our findings demonstrate that although especially experienced neurosurgeons have rather good predictive abilities when estimating survival in patients with high-grade glioma on the group level, they often miss on the individual level. Future prognostic tools should aim to beat the presented clinical prediction skills.

Are there predilection sites for intracranial meningioma? A population-based atlas.

Meningioma is the most common benign intracranial tumor and is believed to arise from arachnoid cap cells of arachnoid granulations. We sought to develop a population-based atlas from pre-treatment MRIs to explore the distribution of intracranial meningiomas and to explore risk factors for development of intracranial meningiomas in different locations. All adults (≥ 18 years old) diagnosed with intracranial meningiomas and referred to the department of neurosurgery from a defined catchment region between 2006 and 2015 were eligible for inclusion. Pre-treatment T1 contrast-enhanced MRI-weighted brain scans were used for semi-automated tumor segmentation to develop the meningioma atlas. Patient variables used in the statistical analyses included age, gender, tumor locations, WHO grade and tumor volume. A total of 602 patients with intracranial meningiomas were identified for the development of the brain tumor atlas from a wide and defined catchment region. The spatial distribution of meningioma within the brain is not uniform, and there were more tumors in the frontal region, especially parasagittally, along the anterior part of the falx, and on the skull base of the frontal and middle cranial fossa. More than 2/3 meningioma patients were females (p < 0.001) who also were more likely to have multiple meningiomas (p < 0.01), while men more often have supratentorial meningiomas (p < 0.01). Tumor location was not associated with age or WHO grade. The distribution of meningioma exhibits an anterior to posterior gradient in the brain. Distribution of meningiomas in the general population is not dependent on histopathological WHO grade, but may be gender-related.

Patient-reported cognitive function before and after glioma surgery.

BACKGROUND: Little is known about the extent to which glioma patients experience subjective changes in cognitive function following surgery. We sought to assess patient-reported cognitive function before and after glioma surgery and explore potential factors associated with cognitive change. METHODS: In a prospective population-based study, patient-reported cognitive function was measured in 182 patients undergoing primary surgery for diffuse glioma (141 high-grade gliomas (HGG) and 41 low-grade gliomas (LGG)) by using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 cognitive function subscale preoperatively and at 1 and 6 months postoperatively. Binomial logistic regression models were used to assess factors possibly associated with patient-reported cognitive changes. RESULTS: In the HGG group, the mean cognitive function score increased from 70.9 (95% 66.6, 75.2) preoperatively to 85.1 (95% CI 81.2, 89.0) (p < 0.001) and 83.3 (95% CI 79.1, 87.6) (p < 0.001) at 1 and 6 months postoperatively, respectively. In the LGG group, the mean score was 80.9 (95% CI 74.4, 87.4) preoperatively and remained stable at postoperative follow-ups. Females reported lower scores than males. At an individual level, both improvement and deterioration in cognitive scores were frequently seen in LGG and HGG patients after surgery. Preoperative use of corticosteroids and large tumor volume were predictors for cognitive improvement at 1 month postoperatively. No predictors were identified for cognitive improvement at 6 months and worsening at 1 and 6 months. CONCLUSION: Many glioma patients experience perioperative subjective changes in cognitive function after surgery. At group level, HGG patients reported improved cognitive function after surgery, while LGG patients reported stable cognitive function. Preoperative use of corticosteroids and large tumor volume were independently associated with postoperative improvement.

Primary versus recurrent surgery for glioblastoma-a prospective cohort study.

BACKGROUND: There is currently limited evidence for surgery in recurrent glioblastoma (GBM). Our aim was to compare primary and recurrent surgeries, regarding changes in perioperative, generic health-related quality of life (HRQoL), complications, extents of resection and survival. METHODS: Between 2007 and 2018, 65 recurrent and 160 primary GBM resections were prospectively enrolled. HRQoL was recorded with EQ-5D 3L preoperatively and at 1 month postoperatively. Median perioperative change in HRQoL and change greater than the minimal clinically important difference (MCID) were assessed. Tumour volume and extent of resection were obtained from pre- and postoperative MRI scans. Survival was assessed from date of surgery. RESULTS: Comparing recurrent surgeries and primary resections, most variables were balanced at baseline, but median age (59 vs. 62, p = 0.005) and median preoperative tumour volume (14.9 vs. 25.3 ml, p = 0.001) were lower in recurrent surgeries. There were no statistically significant differences regarding complication rates, neurological deficits, extents of resection or EQ-5D 3L index values at baseline and at follow-up. Twenty (36.4%) recurrent resections vs. 39 (27.5%) primary resections reported clinically significant deterioration in HRQoL at follow-up. Stratified by clinically significant change in EQ-5D 3L, the survival distributions were not statistically significantly different in either group. Survival was associated with extent of resection (p = 0.015) in recurrent surgeries only. CONCLUSIONS: Outcomes after primary and recurrent surgeries were quite similar in our practice. As surgery may prolong life in patients where gross total resection is obtainable with reasonable risk, the indication for surgery in GBM should perhaps not differ that much in primary and recurrent resections.

Pretreatment patient-reported cognitive function in patients with diffuse glioma.

PURPOSE: Cognitive function is frequently assessed with objective neuropsychological tests, but patient-reported cognitive function is less explored. We aimed to investigate the preoperative prevalence of patient-reported cognitive impairment in patients with diffuse glioma compared to a matched reference group and explore associated factors. METHODS: We included 237 patients with diffuse glioma and 474 age- and gender-matched controls from the general population. Patient-reported cognitive function was measured using the cognitive function subscale in the European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire. The transformed scale score (0-100) was dichotomized, with a score of ≤ 75 indicating clinically important patient-reported cognitive impairment. Factors associated with preoperative patient-reported cognitive impairment were explored in a multivariable regression analysis. RESULTS: Cognitive impairment was reported by 49.8% of the diffuse glioma patients and by 23.4% in the age- and gender-matched reference group (p < 0.001). Patients with diffuse glioma had 3.2 times higher odds (95% CI 2.29, 4.58, p < 0.001) for patient-reported cognitive impairment compared to the matched reference group. In the multivariable analysis, large tumor volume, left tumor lateralization, and low Karnofsky Performance Status score were found to be independent predictors for preoperative patient-reported cognitive impairment. CONCLUSIONS: Our findings demonstrate that patient-reported cognitive impairment is a common symptom in patients with diffuse glioma pretreatment, especially in patients with large tumor volumes, left tumor lateralization, and low functional levels. Patient-reported cognitive function may provide important information about patients' subjective cognitive health and disease status and may serve as a complement to or as a screening variable for subsequent objective testing.

What is the current clinico-radiological diagnostic accuracy for intracranial tumours?

OBJECTIVE: To determine the diagnostic accuracy of routine clinico-radiological workup for a population-based selection of intracranial tumours. METHODS: In this prospective cohort study, we included consecutive adult patients who underwent a primary surgical intervention for a suspected intracranial tumour between 2015 and 2019 at a single-neurosurgical centre. The treating team estimated the expected diagnosis prior to surgery using predefined groups. The expected diagnosis was compared to final histopathology and the accuracy of preoperative clinico-radiological diagnosis (sensitivity, specificity, positive and negative predictive values) was calculated. RESULTS: 392 patients were included in the data analysis, of whom 319 underwent a primary surgical resection and 73 were operated with a diagnostic biopsy only. The diagnostic accuracy varied between different tumour types. The overall sensitivity, specificity and diagnostic mismatch rate of clinico-radiological diagnosis was 85.8%, 97.7% and 4.0%, respectively. For gliomas (including differentiation between low-grade and high-grade gliomas), the same diagnostic accuracy measures were found to be 82.2%, 97.2% and 5.6%, respectively. The most common diagnostic mismatch was between low-grade gliomas, high-grade gliomas and metastases. Accuracy of 90.2% was achieved for differentiation between diffuse low-grade gliomas and high-grade gliomas. CONCLUSIONS: The current accuracy of a preoperative clinico-radiological diagnosis of brain tumours is high. Future non-invasive diagnostic methods need to outperform our results in order to add much value in a routine clinical setting in unselected patients.

Survival of glioblastoma in relation to tumor location: a statistical tumor atlas of a population-based cohort.

PURPOSE: Previous studies on the effect of tumor location on overall survival in glioblastoma have found conflicting results. Based on statistical maps, we sought to explore the effect of tumor location on overall survival in a population-based cohort of patients with glioblastoma and IDH wild-type astrocytoma WHO grade II-III with radiological necrosis. METHODS: Patients were divided into three groups based on overall survival: < 6 months, 6-24 months, and > 24 months. Statistical maps exploring differences in tumor location between these three groups were calculated from pre-treatment magnetic resonance imaging scans. Based on the results, multivariable Cox regression analyses were performed to explore the possible independent effect of centrally located tumors compared to known prognostic factors by use of distance from center of the third ventricle to contrast-enhancing tumor border in centimeters as a continuous variable. RESULTS: A total of 215 patients were included in the statistical maps. Central tumor location (corpus callosum, basal ganglia) was associated with overall survival < 6 months. There was also a reduced overall survival in patients with tumors in the left temporal lobe pole. Tumors in the dorsomedial right temporal lobe and the white matter region involving the left anterior paracentral gyrus/dorsal supplementary motor area/medial precentral gyrus were associated with overall survival > 24 months. Increased distance from center of the third ventricle to contrast-enhancing tumor border was a positive prognostic factor for survival in elderly patients, but less so in younger patients. CONCLUSIONS: Central tumor location was associated with worse prognosis. Distance from center of the third ventricle to contrast-enhancing tumor border may be a pragmatic prognostic factor in elderly patients.

Perioperative fatigue in patients with diffuse glioma.

PURPOSE: Few studies have assessed fatigue in relation to glioma surgery. The purpose of this study was to explore the prevalence of pre- and postoperative high fatigue, perioperative changes, and factors associated with pre- and postoperative high fatigue in patients undergoing primary surgery for diffuse glioma. METHODS: A total of 112 adult patients were prospectively included. Patient-reported fatigue was assessed before and one month after surgery using the cancer-specific European Organization for Research and Treatment of Cancer questionnaire fatigue subscale. The scores were dichotomized as high fatigue (≥ 39) or low fatigue (< 39). A change in score of ≥ 10 was considered as a clinically significant change. Factors associated with pre- and postoperative high fatigue were explored in multivariable regression analyses. RESULTS: High fatigue was reported by 45% of the patients preoperatively and by 42% of the patients postoperatively. Female gender and low Karnofsky Performance Status (KPS) were associated with preoperative high fatigue, while postoperative complications, low KPS and low-grade histopathology were associated with postoperative high fatigue. In total 35/92 (38%) patients reported a clinically significant improvement of fatigue scores after surgery, 36/92 (39%) patients reported a clinically significant worsening of fatigue scores after surgery, and 21/92 (23%) patients reported no clinically significant change in fatigue scores after surgery. Patients with low-grade gliomas more often reported low fatigue before surgery and high fatigue after surgery, while patients with high-grade gliomas more often reported high fatigue before surgery and low fatigue after surgery. CONCLUSIONS: Our findings indicate that fatigue is a common symptom in patients with diffuse glioma, both pre- and postoperatively. Perioperative changes were frequently seen. This is important knowledge when informing patients before and after surgery.

Spatial distribution of malignant transformation in patients with low-grade glioma.

BACKGROUND: Malignant transformation represents the natural evolution of diffuse low-grade gliomas (LGG). This is a catastrophic event, causing neurocognitive symptoms, intensified treatment and premature death. However, little is known concerning the spatial distribution of malignant transformation in patients with LGG. MATERIALS AND METHODS: Patients histopathological diagnosed with LGG and subsequent radiological malignant transformation were identified from two different institutions. We evaluated the spatial distribution of malignant transformation with (1) visual inspection and (2) segmentations of longitudinal tumor volumes. In (1) a radiological transformation site < 2 cm from the tumor on preceding MRI was defined local transformation. In (2) overlap with pretreatment volume after importation into a common space was defined as local transformation. With a centroid model we explored if there were particular patterns of transformations within relevant subgroups. RESULTS: We included 43 patients in the clinical evaluation, and 36 patients had MRIs scans available for longitudinal segmentations. Prior to malignant transformation, residual radiological tumor volumes were > 10 ml in 93% of patients. The transformation site was considered local in 91% of patients by clinical assessment. Patients treated with radiotherapy prior to transformation had somewhat lower rate of local transformations (83%). Based upon the segmentations, the transformation was local in 92%. We did not observe any particular pattern of transformations in examined molecular subgroups. CONCLUSION: Malignant transformation occurs locally and within the T2w hyperintensities in most patients. Although LGG is an infiltrating disease, this data conceptually strengthens the role of loco-regional treatments in patients with LGG.

Does preoperative health-related quality of life predict survival in high-grade glioma patients? - a prospective study.

Purpose: To explore if preoperative patient-reported health-related quality of life (HRQoL) provides additional prognostic value as a supplement to other preoperatively known clinical factors in patients with high-grade glioma (HGG).Methods: In a prospective explorative study, 114 patients with high-grade glioma were included. The participants completed the generic HRQoL questionnaire EQ-5D 3L, and the disease-specific questionnaires EORTC QLQ-C30 and EORTC QLQ-BN20 1-3 days before surgery. Operating neurosurgeons scored the patient's preoperative functional level by using Karnofsky Performance Status (KPS). Univariate and multivariate Cox regression analyses were performed to identify HRQoL domains that were associated with survival. Kaplan-Meier survival curves and Log-rank tests were used to visualize differences in survival between groups.Results: In addition to preoperative KPS and age, the EORTC QLQ-BN20 subdomains 'seizures' (HR 0.98, p < .006), 'itchy skin' (HR 1.01, p < .036) and 'bladder control' (HR 1.01, p < .023) were statistically significant independent predictors of survival in a multivariate cox model.Conclusions: Our results suggest that in patients with HGG, certain preoperative symptom scales within EORTC QLQ-BN20 may provide additional prognostic information to supplement other clinical prognostic factors. However, further studies are required to validate our findings. Overall the instruments EQ-5D 3L and EORTC QLQ-C30 do not seem to provide much additional valuable prognostic information to already known prognostic factors.

A new acoustic coupling fluid with ability to reduce ultrasound imaging artefacts in brain tumour surgery-a phase I study.

BACKGROUND: A novel acoustic coupling fluid (ACF), with the potential to reduce surgically induced image artefacts during intraoperative ultrasound imaging in brain tumour surgery, has been evaluated with respect to image quality and safety in a clinical phase 1 study. METHODS: Fifteen patients with glioblastoma (WHO grade IV) were included. All adverse events were registered in a 6-month study period. During acquisition of 3D ultrasound image volumes, three different concentrations of the ACF and Ringer's solution were filled into the resection cavity. The effect of ACF on the ultrasound images was rated by the operating surgeon, and by five independent neurosurgeons evaluating a pair of blinded images from all patients. Images from all patients were analysed by comparing pixel brightness in a noise-affected region and a reference region. RESULTS: The operating surgeon deemed the ACF images to have less noise than images obtained with Ringers's solution. The blinded evaluations by the independent neurosurgeons were significantly in favour of ACF (p < 0.0001). The analyses of pixel intensities showed that the ACF images had lower amount of noise than images obtained with Ringer's solution. No radiological sign of inflammation nor circulatory changes was found in the early postoperative MR images. Of the nine complications registered as serious events in the study period, none was deemed to be caused by the ACF. CONCLUSION: The ultrasound (US) images obtained using ACF have significantly less noise than US images obtained with Ringer's solution. The rate of adverse events was comparable to what has been reported for similar groups of patients.

Impact of transsphenoidal surgery for pituitary adenomas on overall health-related quality of life: a longitudinal cohort study.

Background: Previous studies show a moderate improvement in health-related quality of life (HRQoL) following transsphenoidal surgery for pituitary adenomas, but no consistent predictors of HRQoL outcome have been identified. We aimed to evaluate overall HRQoL changes following such surgery, and assess potential patient or tumour characteristics that predict HRQoL outcome.Materials and methods: Sixty adult patients undergoing transsphenoidal resection of pituitary adenomas were prospectively enrolled. They completed the EQ-5D 3L, a generic HRQoL questionnaire, preoperatively, and at one (n = 57) and six months (n = 56) postoperatively. HRQoL was assessed as both postoperative change in median EQ-5D 3L score, and as change greater than the minimal clinically important difference (MCID) in EQ-5D 3L score. A multivariable logistic regression analysis was performed to assess potential predictors of clinically significant HRQoL changes (>MCID) at six months postoperatively.Results: There was a slight, but statistically significant, improvement in median EQ-5D 3L scores at six months postoperatively compared to preoperatively. Sixteen patients (29%) reported a clinically significant improvement in HRQoL at six months postoperatively, and larger preoperative tumour volume was a statistically significant predictor of such improvement. Eight patients (14%) reported a clinically significant deterioration in HRQoL at six months, but none of the assessed variables predicted such deterioration.Conclusions: Patient-reported overall HRQoL improved slightly after transsphenoidal surgery for pituitary adenomas at group level. Patients with larger tumours might have more HRQoL benefits from surgery, but the mechanisms behind the predictive nature of tumour volume remain unknown.

Is there a response shift in generic health-related quality of life 6 months after glioma surgery?

BACKGROUND: Patients may recalibrate internal standards when faced with a serious diagnosis or neurological deficits. This so-called response shift is important to understand in longitudinal health-related quality of life (HRQoL) data, but this is not quantitatively assessed in glioma patients. METHODS: Patients with gliomas were eligible for this HRQoL study. We used EuroQol-5D 3 L to assess generic HRQoL with assessment preoperatively and at 6 months postoperatively. At time of follow-up, patients scored how they considered their baseline HRQoL in retrospect using the same questionnaire ("then-test"). RESULTS: Seventy-three patients were enrolled between January 2013 and September 2015. With the then-test approach, the mean EQ-5D 3 L index was similar compared to baseline (0.77, mean difference 0.01, 95% CI -0.57 to 0.07, p = 0.82). Also, then-test and baseline VAS score were similar (mean difference 0, 95% CI -7 to 7, p = 0.97). However, a 0.10-0.13 difference from baseline was observed in patients that improved or deteriorated in HRQoL at follow-up according to the then-test EQ-5D 3 L index value. The direction of change as observed from the then-test was similar to the direction of clinical change, reducing the impact of any HRQoL change from baseline to follow-up. CONCLUSIONS: On average, we observed no response shift using EQ-5D 3 L in the selection of glioma patients able to participate at 6 months after surgery. However, following change in HRQoL at follow-up, response shift seems to reduce the effects of HRQoL changes by lowering of internal standards in patients that deteriorate and raising the standards in patients that improve.

Quality of life assessed with EQ-5D in patients undergoing glioma surgery: what is the responsiveness and minimal clinically important difference?

PURPOSE: To evaluate the responsiveness of EQ-5D 3L in patients undergoing intracranial glioma surgery and estimate the minimal clinically important difference (MCID). MATERIALS AND METHODS: EQ-5D 3L index values from 164 patients who underwent glioma surgery in the period 2007-2012 were analysed. Responsiveness and MCID were estimated using a combination of distribution-based and anchor-based methods. Karnofsky performance status served as an anchor. RESULTS: Patients who improved functionally did not report significantly higher EQ-5D 3L scores post operatively with a standardized response mean (SRM) of 0.04 (p = 0.13). Patients who deteriorated functionally reported significantly lower EQ-5D 3L scores post operatively with a SRM of 0.72 (p < 0.001). With different approaches, we determined a range of MCID values from 0.13 to 0.15. CONCLUSIONS: EQ-5D 3L is responsive to changes when glioma patients are deteriorating functionally after surgery but not responsive when the patients are improving. The MCID values for EQ-5D 3L in glioma surgery seem higher than reported MCID values for other types of cancers.

Growth dynamics of untreated meningiomas.

Background: Knowledge about meningioma growth characteristics is needed for developing biologically rational follow-up routines. In this study of untreated meningiomas followed with repeated magnetic resonance imaging (MRI) scans, we studied growth dynamics and explored potential factors associated with tumor growth. Methods: In a single-center cohort study, we included 235 adult patients with radiologically suspected intracranial meningioma and at least 3 MRI scans during follow-up. Tumors were segmented using an automatic algorithm from contrast-enhanced T1 series, and, if needed, manually corrected. Potential meningioma growth curves were statistically compared: linear, exponential, linear radial, or Gompertzian. Factors associated with growth were explored. Results: In 235 patients, 1394 MRI scans were carried out in the median 5-year observational period. Of the models tested, a Gompertzian growth curve best described growth dynamics of meningiomas on group level. 59% of the tumors grew, 27% remained stable, and 14% shrunk. Only 13 patients (5%) underwent surgery during the observational period and were excluded after surgery. Tumor size at the time of diagnosis, multifocality, and length of follow-up were associated with tumor growth, whereas age, sex, presence of peritumoral edema, and hyperintense T2-signal were not significant factors. Conclusions: Untreated meningiomas follow a Gompertzian growth curve, indicating that increasing and potentially doubling subsequent follow-up intervals between MRIs seems biologically reasonable, instead of fixed time intervals. Tumor size at diagnosis is the strongest predictor of future growth, indicating a potential for longer follow-up intervals for smaller tumors. Although most untreated meningiomas grow, few require surgery.

Advancements in predicting outcomes in patients with glioma: a surgical perspective.

Introduction: Diffuse glioma is a challenging neurosurgical entity. Although surgery does not provide a cure, it may greatly influence survival, brain function, and quality of life. Surgical treatment is by nature highly personalized and outcome prediction is very complex. To engage and succeed in this balancing act it is important to make best use of the information available to the neurosurgeon.Areas covered: This narrative review provides an update on advancements in predicting outcomes in patients with glioma that are relevant to neurosurgeons.Expert opinion: The classical 'gut feeling' is notoriously unreliable and better prediction strategies for patients with glioma are warranted. There are numerous tools readily available for the neurosurgeon in predicting tumor biology and survival. Predicting extent of resection, functional outcome, and quality of life remains difficult. Although machine-learning approaches are currently not readily available in daily clinical practice, there are several ongoing efforts with the use of big data sets that are likely to create new prediction models and refine the existing models.