====== Butterfly glioma treatment ====== ===== Management ===== [[Glioma]]s invading the anterior [[corpus callosum]] are commonly deemed unresectable due to an unacceptable risk/benefit ratio, including the risk of [[abulia]]. Current management options include biopsy only, followed by radiation and chemotherapy; surgical decompression followed by radiation and chemotherapy; or biopsy followed by palliative measures (comfort care). Management decisions are subjective, based upon physician experience and/or patient/family preferences in light of the prognosis of this disease. ==== Meta-analysis ==== In a Meta-analysis of overall survival and postoperative neurologic deficits after resection or biopsy of butterfly glioblastoma Resection was associated with an increased rate of postoperative neurologic deficit (OR 2.05, 95% CI 1.02-4.09). Resection offers greater OS up to 1-year postintervention than biopsy alone; however, this comes at the cost of higher rates of postoperative neurologic deficits ((Soliman MA, Khan A, Azmy S, Gilbert O, Khan S, Goliber R, Szczecinski EJ, Durrani H, Burke S, Salem AA, Lubanska D, Ghannam MM, Hess RM, Lim J, Mullin JP, Davies JM, Pollina J, Snyder KV, Siddiqui AH, Levy EI, Plunkett RJ, Fenstermaker RA. Meta-analysis of overall survival and postoperative neurologic deficits after resection or biopsy of butterfly glioblastoma. Neurosurg Rev. 2022 Sep 29. doi: 10.1007/s10143-022-01864-7. Epub ahead of print. PMID: 36173528.)). For Chojak et al. surgical resection of bGBM is associated with an improved 6-months overall survival compared with biopsy alone. We have not found strong evidence supporting the superiority of resection over biopsy alone in overall survival at 12 and 18 months ((Chojak R, Koźba-Gosztyła M, Słychan K, Gajos D, Kotas M, Tyliszczak M, Czapiga B. Impact of surgical resection of butterfly glioblastoma on survival: a meta-analysis based on comparative studies. Sci Rep. 2021 Jul 6;11(1):13934. doi: 10.1038/s41598-021-93441-z. PMID: 34230597; PMCID: PMC8260698.)). ==== Case series ==== retrospective population-based cohort study included patients diagnosed with butterfly glioblastoma in Western Norway between 01/01/2007 and 31/12/2014. We enrolled patients with histologically confirmed glioblastoma and patients with a diagnosis based on a typical MRI pattern. Clinical data were extracted from electronic medical records. Molecular and MRI volumetric analyses were retrospectively performed. Survival analyses were performed using the Kaplan-Meier method and Cox proportional hazards regression models. Results: Among 381 patients diagnosed with glioblastoma, 33 patients (8.7%) met the butterfly glioblastoma criteria. Median overall survival was 5.5 months (95% CI 3.1-7.9) and 3-year survival was 9.1%. Hypofractionated radiation therapy with or without temozolomide was the most frequently used treatment strategy, given to 16 of the 27 (59.3%) patients receiving radiation therapy. Best supportive care was associated with poorer survival compared with multimodal treatment [adjusted hazard ratio 5.11 (95% CI 1.09-23.89)]. Conclusion: Outcome from butterfly glioblastoma was dismal, with a median overall survival of less than 6 months. However, long-term survival was comparable to that observed in non-butterfly glioblastoma, and multimodal treatment was associated with longer survival. This suggests that patients with butterfly glioblastoma may benefit from a more aggressive treatment approach despite the overall poor prognosis ((Bjorland LS, Dæhli Kurz K, Fluge Ø, Gilje B, Mahesparan R, Sætran H, Ushakova A, Farbu E. Butterfly glioblastoma: Clinical characteristics, treatment strategies and outcomes in a population-based cohort. Neurooncol Adv. 2022 Jul 1;4(1):vdac102. doi: 10.1093/noajnl/vdac102. PMID: 35892046; PMCID: PMC9307095.)). ---- Opoku-Darko et al. evaluated the management of Butterfly glioblastomas to assess whether surgical resection is feasible, safe, and more effective than [[biopsy]]. They retrospectively reviewed the institutional brain tumor registry for all adult patients treated for glioblastoma (World Health Organization grade IV) between 2004 and 2016 to identify all bGlioblastomas. Survival between biopsy and resection was assessed using the Kaplan-Meier model. Twenty-nine (3.8%) of 764 newly diagnosed Glioblastomas were identified as bGlioblastoma. Of these, 9 patients (31.0%) underwent surgical resection and 20 patients (69.0%) underwent biopsy. Five patients (55.6%) in the surgical resection group had 98% extent of resection or greater. The median survival of our entire cohort of patients was 3.3 months. Median survival was higher in the surgical resection groups (7.8 vs. 2.8 months; P = 0.0019). Increased age is independently associated with an increased risk of death, and adjuvant therapy is independently associated with prolonged survival. Surgical resection of butterfly glioblastoma prolongs survival without increased risk of permanent neurologic deficit. Both anterior and posterior bGlioblastomas can be resected safely ((Opoku-Darko M, Amuah JE, Kelly JJP. Surgical Resection of Anterior and Posterior Butterfly Glioblastoma. World Neurosurg. 2018 Feb;110:e612-e620. doi: 10.1016/j.wneu.2017.11.059. Epub 2017 Nov 21. PMID: 29162526.)). ---- Burks et al. in a study present evidence that anterior butterfly gliomas can be safely removed using a novel, attention-task based, awake brain surgery technique that focuses on preserving the anatomical connectivity of the cingulum and relevant aspects of the [[cingulate gyrus]] ((Burks JD, Bonney PA, Conner AK, Glenn CA, Briggs RG, Battiste JD, McCoy T, O'Donoghue DL, Wu DH, Sughrue ME. A method for safely resecting anterior butterfly gliomas: the surgical anatomy of the default mode network and the relevance of its preservation. J Neurosurg. 2017 Jun;126(6):1795-1811. doi: 10.3171/2016.5.JNS153006. Epub 2016 Sep 16. PubMed PMID: 27636183. )). ---- Adult patients who underwent surgery for a newly diagnosed primary Glioblastoma at an academic tertiary-care institution between 2007 and 2012 were retrospectively reviewed and tumors were volumetrically measured. Of the 336 patients with newly diagnosed Glioblastoma who were operated on, 48 (14 %) presented with bGlioblastoma, where 29 (60 %) and 19 (40 %) underwent surgical resection and biopsy, respectively. In multivariate analysis, a bGlioblastoma was independently associated with poorer survival [HR (95 % CI) 1.848 (1.250-2.685), p < 0.003]. In matched-pair analysis, patients who underwent surgical resection had improved median survival than biopsy patients (7.0 vs. 3.5 months, p = 0.03). In multivariate analysis, increasing percent resection [HR (95 % CI) 0.987 (0.977-0.997), p = 0.01], radiation [HR (95 % CI) 0.431 (0.225-0.812), p = 0.009], and temozolomide [HR (95 % CI) 0.413 (0.212-0. 784), p = 0.007] were each independently associated with prolonged survival among patients with bGlioblastoma. This present study shows that while patients with bGlioblastoma have poorer prognoses compared to non-bGlioblastoma, these patients can also benefit from aggressive treatments including debulking surgery, maximal safe surgical resection, temozolomide chemotherapy, and radiation therapy ((Chaichana KL, Jusue-Torres I, Lemos AM, Gokaslan A, Cabrera-Aldana EE, Ashary A, Olivi A, Quinones-Hinojosa A. The butterfly effect on glioblastoma: is volumetric extent of resection more effective than biopsy for these tumors? J Neurooncol. 2014 Dec;120(3):625-34. doi: 10.1007/s11060-014-1597-9. Epub 2014 Sep 6. PMID: 25193022; PMCID: PMC4313925.)).