FLAIRectomy
see Extent of resection.
Several articles have demonstrated a positive correlation between glioblastoma supramarginal resection, based on MRI fluid-attenuated inversion-recovery (FLAIR) sequences (ie, FLAIRectomy), and prolonged survival.
💡 Clinical pearl:
FLAIRectomy = Maximal Safe Resection + intentional, careful removal of infiltrative zones seen on FLAIR MRI
A study analyses the efficacy, safety, and reliability of FLAIRectomy in a multicentric cohort of patients, correlating the extent of FLAIR resection (EOFR) with clinical outcome and survival.
Methods: One hundred fifty glioblastoma or grade IV astrocytoma patients (82 men), with a mean age of 58.2 years (range 36-82 years), from 3 neurosurgical centers were included. In all cases, supramarginal resection was deemed feasible preoperatively; multicentric neoplasms or tumors with enhancing nodules involving eloquent areas were excluded. EOFR analysis was based on comparing preoperative and postoperative 3-dimensional FLAIR images. EOFR was compared with the extent of tumor resection (EOTR) based on gadolinium-enhanced T1 sequences; these data were also statistically correlated with survival parameters and clinical and biomolecular data.
Results: EOFR rate was 78.8% in the entire cohort, whereas EOTR based on T1 sequences was 98.3%. Mean progression-free survival (PFS) and overall survival (OS) were 16.33 and 28.4 months, respectively. Adjusted Cox-regression models showed that a higher EOTR based on T1 sequences and EOFR were both associated with improved OS in individuals with either isocytrate dehydrogenase-1 wild-type or isocytrate dehydrogenase-1 mutated tumors. After adjustment, only the EOFR retained a statistically significant association with OS. Specifically, the risk of mortality decreased by 6.8% and 12.1% with each one-unit increase in EOFR, respectively. Further analysis based on artificial intelligence demonstrated that the cluster of patients with higher values of PFS and OS received a greater rate of FLAIRectomy.
Conclusion: This multicenter study demonstrates that EOFR is a more reliable predictor of PFS and OS than the extent of resection based on gadolinium-enhanced T1 sequences, if supramarginal resection is performed according to specific preoperative planning. 3-dimensional FLAIR navigation-guided resection may represent the optimal strategy to achieve a real FLAIRectomy 1).