title: Results of a multicenter survey showing interindividual variability among neurosurgeons when deciding on the radicality of surgical resection in glioblastoma highlight the need for more objective guidelines.
abstract: OBJECTIVE
  We assessed agreement among neurosurgeons on surgical approaches to individual glioblastoma patients and between their approach and those recommended by the topographical staging system described by Shinoda.
  
  
  METHODS
  Five neurosurgeons were provided with pre-surgical MRIs of 76 patients. They selected the surgical approach [biopsy, partial resection, or gross total resection (GTR)] that they would recommend for each patient. They were blinded to each other's response and they were told that patients were younger than 50 years old and without symptoms. Three neuroradiologists classified each case according to the Shinoda staging system.
  
  
  RESULTS
  Biopsy was recommended in 35.5-82.9%, partial resection in 6.6-32.9%, and GTR in 3.9-31.6% of cases. Agreement among their responses was fair (global kappa = 0.28). Nineteen patients were classified as stage I, 14 as stage II, and 43 as stage III. Agreement between the neurosurgeons and the recommendations of the staging system was poor for stage I (kappa = 0.14) and stage II (kappa = 0.02) and fair for stage III patients (kappa = 0.29). An individual analysis revealed that in contrast to the Shinoda system, neurosurgeons took into account T2/FLAIR sequences and gave greater weight to the involvement of eloquent areas.
  
  
  CONCLUSIONS
  The surgical approach to glioblastoma is highly variable. A staging system could be used to examine the impact of extent of resection, monitor post-operative complications, and stratify patients in clinical trials. Our findings suggest that the Shinoda staging system could be improved by including T2/FLAIR sequences and a more adequate weighting of eloquent areas.
authors.affiliation: Neuro-radiology Service, Hospital del Mar, 08003, Barcelona, Spain.
authors.forename: J
authors.identifier: http://orcid.org/0000-0003-0771-0390
authors.initials: J
authors.lastname: Capellades
authors.affiliation: Neurosurgery Service, Hospital Universitari Germans Trias i Pujol, IGTP, 08916, Badalona, Spain.
authors.forename: P
authors.initials: P
authors.lastname: Teixidor
authors.affiliation: Neurosurgery Service, Hospital del Mar, 08003, Barcelona, Spain.
authors.forename: G
authors.initials: G
authors.lastname: Villalba
authors.affiliation: Neurosurgery Service, Hospital Universitari Germans Trias i Pujol, IGTP, 08916, Badalona, Spain.
authors.forename: C
authors.initials: C
authors.lastname: Hostalot
authors.affiliation: Neurosurgery Service, Hospital de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
authors.forename: G
authors.initials: G
authors.lastname: Plans
authors.affiliation: Neurosurgery Service, Hospital Universitari Germans Trias i Pujol, IGTP, 08916, Badalona, Spain.
authors.forename: R
authors.initials: R
authors.lastname: Armengol
authors.affiliation: Neuro-radiology Service, Hospital del Mar, 08003, Barcelona, Spain.
authors.forename: S
authors.initials: S
authors.lastname: Medrano
authors.affiliation: Medical Oncology Service, Institut Catala d'Oncologia, Hospital Universitari Germans Trias i Pujol, IGTP, Ctra Canyet, s/n, 08916, Badalona, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Estival
authors.affiliation: Medical Oncology Service, Hospital Universitario Virgen de las Nieves, 18014, Granada, Spain.
authors.forename: R
authors.initials: R
authors.lastname: Luque
authors.affiliation: Neuro-radiology Service, Hospital del Mar, 08003, Barcelona, Spain.
authors.forename: S
authors.initials: S
authors.lastname: Gonzalez
authors.affiliation: Medical Oncology Service, Institut Catala d'Oncologia, Hospital Duran i Reynals, IDIBELL, L'Hospitalet de Llobregat, 08908, Barcelona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Gil-Gil
authors.affiliation: Radiation Oncology Service, Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, IGTP, 08916, Badalona, Spain.
authors.forename: S
authors.initials: S
authors.lastname: Villa
authors.affiliation: Medical Oncology Service, Hospital Universitario 12 de Octubre, 28041, Madrid, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Sepulveda
authors.affiliation: Medical Oncology Service, Institut Catala d'Oncologia, Hospital Universitari Germans Trias i Pujol, IGTP, Ctra Canyet, s/n, 08916, Badalona, Spain.
authors.forename: J J
authors.initials: JJ
authors.lastname: García-Mosquera
authors.affiliation: Medical Oncology Service, Institut Catala d'Oncologia, Hospital Universitari Germans Trias i Pujol, IGTP, Ctra Canyet, s/n, 08916, Badalona, Spain. cbalana@iconcologia.net.
authors.forename: C
authors.initials: C
authors.lastname: Balana
mesh_terms: D000328:Adult; D001932:Brain Neoplasms / Q000473:pathology / Q000601:surgery*; D017322:Clinical Trials, Phase II as Topic; D005909:Glioblastoma / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000379:methods*; D000069471:Neurosurgeons / Q000592:standards; D019635:Neurosurgical Procedures / Q000379:methods / Q000592:standards*; D016032:Randomized Controlled Trials as Topic; D011795:Surveys and Questionnaires
keywords: Glioblastoma; Intention; Inter-observer variability; Radicality; Staging; Surgery