Tissue Acquisition: Surgery Versus Biopsy

Chapter 7 - Surgery, Indications and Limitations

The goal of surgery in suspected glioblastoma is histological (+ molecular genetic) confirmation, and cytoreduction with the aim of safely removing the solid tumour volume. 

Tissue Acquisition Surgery Versus Biopsy Figure 1

Courtesy of F.-W. Kreth, Dept. of Neurosurgery, Klinikum der Universität

Indications for either tumour resection or stereotactic biopsy in glioblastomas should take into account risk factors and relevant comorbidities in older patients.

Molecular genetic analyses (e.g. MGMT promoter Methylation, IDH mutation or loss of heterogeneity 1p/19q) can be performed reliably from small biopsy specimens.

Surgical resection is considered the treatment of choice if complete resection of at least all contrast-enhancing tumour on MRI can be achieved safely.

Only complete resection has prognostic benefit, whereas partial tumour resection does not seem to improve prognosis compared with biopsy alone.

Tumour debulking, in order to realise external beam radiation and to avoid the risk of brain herniation in cases of existing mass effects, may sometimes be necessary.

In the case of tumour recurrence, surgical resection may be an option, depending on the tumour biology (including molecular profile, previous treatment and location).

Different studies have revealed younger age, a good preoperative clinical status (Karnofsky Performance Status [KPS]) and greater extent of resection as prognostically favourable.

However, the DIRECTOR trial indicated that only complete resection of contrast-enhancing tumour at first recurrence of glioblastoma improves patient outcome.

Revision Questions

  1. Describe indications for tumour resection versus biopsy for suspected malignant gliomas.
  2. What are the primary goals and limitations of the different surgical procedures?
  3. Which prognostic factors are favourable/unfavourable for tumour resection in recurrent gliomas?

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Last update: 18 September 2017