Timing Considerations in Repeat Resection for Recurrent Glioblastoma

Overview

This study evaluated the impact of timing on repeat resection outcomes in 150 patients with recurrent IDH-wildtype glioblastoma. Early repeat resection (within 54 days of radiological suspicion) was compared to delayed surgery, revealing no significant differences in postoperative neurological deficits or survival outcomes.

Background

Glioblastoma (GB), particularly IDH-wildtype, is a highly aggressive brain tumor with a median overall survival of approximately 15 months despite multimodal therapy. Tumor recurrence is nearly inevitable, and treatment options at recurrence are limited. Repeat resection has shown clinical benefit in selected patients, but the optimal timing for surgery after recurrence suspicion remains unclear. Imaging challenges such as pseudo-progression complicate decision-making, leading to heterogeneous management strategies including upfront surgery, watch-and-wait, or salvage therapies.

Data Highlights

Key Findings

• Median overall survival for GB remains around 15 months despite multimodal therapy.
• Repeat resection median survival ranges from 12 to 18 months with an 8% rate of permanent postoperative neurological deficits.
• Upfront repeat resection was performed in 53% of patients, while 29% received salvage non-surgical therapy before surgery.
• Delayed repeat resection (beyond 54 days) did not increase postoperative neurological deficits or negatively impact survival compared to early surgery.
• Imaging challenges such as pseudo-progression complicate timing decisions for repeat resection.
• Eligibility for repeat resection requires good performance status, accessible tumor location, and multidisciplinary consensus.

Clinical Implications

Clinicians can consider a watch-and-wait approach or salvage therapies without necessarily compromising surgical outcomes or survival, as delayed repeat resection does not appear to increase surgical risk or worsen prognosis. Multidisciplinary evaluation remains crucial to select appropriate candidates for repeat surgery and to optimize timing based on individual patient and tumor characteristics.

Conclusion

Repeat resection timing in recurrent glioblastoma can be individualized without adversely affecting postoperative neurological outcomes or survival. This supports flexible clinical decision-making incorporating patient status, tumor behavior, and imaging findings.

References

1. WHO 2021 Classification -- IDH-wildtype Glioblastoma
2. RANO Criteria -- Response Assessment in Neuro-Oncology
3. Stummer et al. -- RANO Resect Criteria and Tumor Volume Threshold
4. Chang et al. -- Definition of Eloquent Brain Areas