title: The Survival Advantage of "Supratotal" Resection of Glioblastoma Using Selective Cortical Mapping and the Subpial Technique.
abstract: BACKGROUND
  A substantial body of evidence suggests that cytoreductive surgery is a prerequisite to prolonging survival in patients with glioblastoma (GBM).
  
  
  OBJECTIVE
  To evaluate the safety and impact of "supratotal" resections beyond the zone of enhancement seen on magnetic resonance imaging scans, using a subpial technique.
  
  
  METHODS
  We retrospectively evaluated 86 consecutive patients with primary GBM, managed by the senior author, using a subpial resection technique with or without carmustine (BCNU) wafer implantation. Multivariate Cox proportional hazards regression was used to analyze clinical, radiological, and outcome variables. Overall impacts of extent of resection (EOR) and BCNU wafer placement were compared using Kaplan-Meier survival analysis.
  
  
  RESULTS
  Mean patient age was 56 years. The median OS for the group was 18.1 months. Median OS for patients undergoing gross total, near-total, and subtotal resection were 54, 16.5, and 13.2 months, respectively. Patients undergoing near-total resection ( P = .05) or gross total resection ( P < .01) experienced statistically significant longer survival time than patients undergoing subtotal resection as well as patients undergoing ≥95% EOR ( P < .01) when compared to <95% EOR. The addition of BCNU wafers had no survival advantage.
  
  
  CONCLUSIONS
  The subpial technique extends the resection beyond the contrast enhancement and is associated with an overall survival beyond that seen in similar series where resection of the enhancement portion is performed. The effect of supratotal resection on survival exceeded the effects of age, Karnofsky performance score, and tumor volume. A prospective study would help to quantify the impact of the subpial technique on quality of life and survival as compared to a traditional resection limited to the enhancing tumor.
authors.affiliation: Vivian L. Smith Department of Neurosurgery and Mischer Neuroscience Institute, Houston, Texas.
authors.forename: Yoshua
authors.initials: Y
authors.lastname: Esquenazi
authors.affiliation: Department of Radiology, Medical School, University of Texas Health Science Center at Houston, Houston, Texas.
authors.forename: Elliott
authors.initials: E
authors.lastname: Friedman
authors.affiliation: Department of Biostatistics, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas.
authors.forename: Zheyu
authors.initials: Z
authors.lastname: Liu
authors.affiliation: Vivian L. Smith Department of Neurosurgery and Mischer Neuroscience Institute, Houston, Texas.
authors.forename: Jay-Jiguang
authors.initials: JJ
authors.lastname: Zhu
authors.affiliation: Vivian L. Smith Department of Neurosurgery and Mischer Neuroscience Institute, Houston, Texas.
authors.forename: Sigmund
authors.initials: S
authors.lastname: Hsu
authors.affiliation: Vivian L. Smith Department of Neurosurgery and Mischer Neuroscience Institute, Houston, Texas.
authors.forename: Nitin
authors.initials: N
authors.lastname: Tandon
mesh_terms: D001921:Brain / Q000601:surgery; D001931:Brain Mapping / Q000379:methods / Q000401:mortality; D001932:Brain Neoplasms / Q000401:mortality / Q000601:surgery; D065426:Cytoreduction Surgical Procedures / Q000379:methods / Q000401:mortality; D005909:Glioblastoma / Q000401:mortality / Q000601:surgery; D006801:Humans; D053208:Kaplan-Meier Estimate; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods / Q000401:mortality; D012189:Retrospective Studies
keywords: Carmustine wafer; Glioblastoma multiforme; Subpial technique; Supratotal resection