Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review - Scorecard - MDSpire

Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review

  • By

  • Tamara Ius

  • Giovanni Sabatino

  • Pier Paolo Panciani

  • Marco Maria Fontanella

  • Roberta Rudà

  • Antonella Castellano

  • Giuseppe Maria Vincenzo Barbagallo

  • Francesco Belotti

  • Riccardo Boccaletti

  • Giuseppe Catapano

  • Gabriele Costantino

  • Alessandro Della Puppa

  • Francesco Di Meco

  • Filippo Gagliardi

  • Diego Garbossa

  • Antonino Francesco Germanò

  • Maurizio Iacoangeli

  • Pietro Mortini

  • Alessandro Olivi

  • Federico Pessina

  • Fabrizio Pignotti

  • Giampietro Pinna

  • Antonino Raco

  • Francesco Sala

  • Francesco Signorelli

  • Silvio Sarubbo

  • Miran Skrap

  • Giannantonio Spena

  • Teresa Somma

  • Carmelo Sturiale

  • Filippo Flavio Angileri

  • Vincenzo Esposito

  • March 24, 2023

  • 0 min

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Clinical Scorecard: Advancements in Surgical Approaches for Grade 4 Glioma: A Systematic Review from the Neuro-Oncology Division of the Italian Society of Neurosurgery (SINch®)

At a Glance

CategoryDetail
ConditionGrade 4 Glioma (GG4), including Astrocytomas IDH-mutant Grade 4 and Glioblastoma (IDH wild-type)
Key MechanismsInfiltrative tumor growth, molecular heterogeneity including IDH mutation status, MGMT methylation, and other genetic markers influencing prognosis and treatment response
Target PopulationAdult patients diagnosed with Grade 4 Glioma
Care SettingNeurosurgical and neuro-oncology centers with access to advanced surgical and molecular diagnostic tools

Key Highlights

  • Extent of resection (EOR) is a major predictive survival factor in GG4 patients, though radical surgery is limited by tumor infiltration and multifocality.
  • Technological advances such as intraoperative ultrasound, cortical mapping, sodium fluorescein, and 5-ALA fluorescence improve surgical safety and increase rates of total resection.
  • Despite maximal safe resection and adjuvant therapies (radiotherapy and temozolomide chemotherapy), tumor relapse near resection margins remains common due to infiltrative growth and treatment-resistant clones.

Guideline-Based Recommendations

Diagnosis

  • Use molecular testing and genomic analysis to classify GG4 tumors according to 2021 WHO Classification, including IDH mutation and MGMT methylation status.
  • Employ comprehensive imaging and intraoperative tools to delineate tumor margins and guide resection.

Management

  • Aim for maximal safe resection guided by intraoperative technologies to optimize extent of resection while preserving neurological function.
  • Follow surgery with radiotherapy and concomitant/adjuvant temozolomide chemotherapy (Stupp protocol) as standard of care.
  • Consider preoperative use of antiepileptic drugs and steroids based on current literature.

Monitoring & Follow-up

  • Monitor for tumor recurrence primarily within 2 cm of resection margins using imaging and clinical assessment.
  • Regularly assess neurological function and molecular markers to guide ongoing management.

Risks

  • Surgical risks include neurological deficits due to tumor location and infiltrative margins.
  • High likelihood of tumor relapse due to infiltrative growth and treatment-resistant cell clones despite maximal resection.

Patient & Prescribing Data

Adult patients with Grade 4 Glioma undergoing surgical and adjuvant treatment

Surgical resection extent correlates with survival; adjuvant temozolomide chemotherapy remains standard post-surgery; molecular markers guide prognosis and potential therapeutic decisions.

Clinical Best Practices

  • Utilize advanced intraoperative technologies (iUS, cortical mapping, fluorescence-guided surgery) to maximize safe tumor resection.
  • Incorporate molecular profiling (IDH, MGMT, TERT, 1p19q codeletion) into diagnostic and prognostic evaluation.
  • Adopt a multidisciplinary approach integrating surgery, radiotherapy, and chemotherapy following established protocols.
  • Preoperatively manage seizures and cerebral edema with antiepileptics and steroids as indicated.
  • Apply maximal safe resection principle balancing tumor removal and preservation of neurological function.

References

Original Source(s)

Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review

  • by Tamara Ius, Giovanni Sabatino, Pier Paolo Panciani, Marco Maria Fontanella, Roberta Rudà, Antonella Castellano, Giuseppe Maria Vincenzo Barbagallo, Francesco Belotti, Riccardo Boccaletti, Giuseppe Catapano, Gabriele Costantino, Alessandro Della Puppa, Francesco Di Meco, Filippo Gagliardi, Diego Garbossa, Antonino Francesco Germanò, Maurizio Iacoangeli, Pietro Mortini, Alessandro Olivi, Federico Pessina, Fabrizio Pignotti, Giampietro Pinna, Antonino Raco, Francesco Sala, Francesco Signorelli, Silvio Sarubbo, Miran Skrap, Giannantonio Spena, Teresa Somma, Carmelo Sturiale, Filippo Flavio Angileri, Vincenzo Esposito

  • March 24, 2023

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