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Surgical resection vs watchful waiting in
low-grade glioma
Annals of Oncology
Take-home message
•
The authors of this population-based parallel cohort study compared clinical outcomes in patients with infiltrating low-grade
gliomas treated with resection and those undergoing watchful waiting. Region A favored watchful waiting; region B favored
early resection. The primary endpoint was overall survival. In total, 153 patients were involved (66 from region A and 87 from
region B); 94 underwent early resection (19 from region A and 75 from region B). Overall survival was 5.8 years in region A and
14.4 years in region B.
•
Overall survival was associated with early surgical resection, even after adjustment for molecular markers (P = 0.001).
Abstract
BACKGROUND
Infiltrating low-grade gliomas (LGG;
WHO grade 2) typically present with seizures in
young adults. LGGs grow continuously and usu-
ally transform to higher grade of malignancy,
eventually causing progressive disability and
premature death. The effect of up-front surgery
has been controversial and the impact of molec-
ular biology on the effect of surgery is unknown.
We now present long-term results of upfront sur-
gical resection compared to watchful waiting in
light of recently established molecular markers.
MATERIAL AND METHODS
Population-based paral-
lel cohorts were followed from two Norwegian
university hospitals with different surgical treat-
ment strategies and defined geographical
catchment regions. In region A watchful waiting
was favored while early resection was favored
in region B. Thus, the treatment strategy in indi-
vidual patients depended on their residential
address. The inclusion criteria were histopatho-
logical diagnosis of supratentorial LGG from
1998 through 2009 in patients 18 years or
older. Follow-up ended 1st January 2016. Mak-
ing regional comparisons, the primary end-point
was overall survival.
RESULTS
153 patients (66 from region A, 87 from
region B) were included. Early resection was
carried out in 19 (29%) patients in region A com-
pared to 75 (86%) patients in region B. Overall
survival was 5.8 years (95% CI 4.5–7.2) in region
A compared to 14.4 years (95% CI 10.4–18.5) in
region B (P<0.01). The effect of surgical strategy
remained after adjustment for molecular mark-
ers (P=0.001).
CONCLUSION
In parallel population based cohorts
of LGGs, early surgical resection resulted in a
clinical relevant survival benefit. The effect on
survival persisted after adjustment for molecu-
lar markers.
Surgical resection versus watchful waiting
in low-grade gliomas.
Ann Oncol
2017 May
05;[EPub Ahead of Print], AS Jakola, AJ Skjuls-
vik, KS Myrmel, et al.
This report provides
reasonably compelling
evidence, and additional
evidence to other more
conventional retrospective
series, that early surgery
results in a better prognosis
in this population, perhaps
by delaying malignant
transformation.
COMMENT
By Gene H. Barnett
MD, MBA,FAANS, FACS
I
n this retrospective review from Norway, the authors compared the results of two
different hospitals’ (widely separated geographically) strategies for management
of newly diagnosed low-grade gliomas. In one, early surgery was favored; in the
other, biopsy and watchful waiting was the preferred approach. The overall survival
in the early-surgery group was about 8 years longer than in the observation group
(14.4 vs 5.8 years), and this difference was not explained by histological, molecular,
or other characteristics of the group. As a randomized trial addressing the question
of which approach is best is unlikely to ever be done, this report provides reasonably
compelling evidence, and additional evidence to other more conventional retrospec-
tive series, that early surgery results in a better prognosis in this population, perhaps
by delaying malignant transformation.
Dr Barnett is Professor and Director, Rose Ella Burkhardt Brain Tumor &
Neuro-Oncology Center, Cleveland Clinic Neurological Institute, The
Cleveland Clinic in Ohio.
EDITOR’S PICKS
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VOL. 1 • NO. 2 • 2017