The impact of surgery on butterfly gliomas - A real-life study of biopsy vs. surgical resection

The impact of surgery on butterfly gliomas - A real-life study of biopsy vs. surgical resection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report The impact of surgery on butterfly gliomas - A real-life study of biopsy vs. surgical resection Helder Picarelli, Vitor Macedo Brito Medeiros, Pedro Henrique Fonseca Castro, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4472967/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Despite the extent of resection affecting the overall survival of patients with gliomas, cytoreduction in patients with butterfly gliomas (BG) remains controversial. Contemporary studies suggest that wide removal is feasible, but there is a lack of controlled, randomized, multicenter studies on the subject. The aim of this study was to evaluate the impact of safe maximal surgical resection (SMSR) as a primary treatment strategy in patients with BG. Methods 30 consecutive patients, primarily treated with neurosurgery, were categorized into Group-A when SMSR was equal to or greater than 50% and Group-B when it was less than 50% (biopsy). The groups were studied and compared for clinical, epidemiological, functionality, survival time (ST), and progression-free survival (PFS) characteristics. Results were analyzed by descriptive and inferential statistics. Results The most frequent tumors were glioblastoma IDH-wild type, WHO grade 4. Most patients (80%) had KPS < 70%, however, there was no significant worsening of functionality associated with interventions. Wider resection (Group-A) was associated with a better Kaplan-Meier curve and ST (68.35 versus 17.32 weeks, p = 0.014). PFS was also longer in this group (57.70 versus 4.77 weeks, p = 0.012). In multivariate analysis, resections > 50% were associated with reduced risk of recurrence (HR = 0.20, 95% CI 0.06–0.67, p = 0.009). Complication rates and functional decline were similar between groups. Conclusion Surgical resections (> 50%) in patients with BG improved ST and PFS without a significant increase in morbidity and dysfunction. Butterfly Glioblastoma Biopsy Surgical Resection Survival Progression-Free Survival Figures Figure 1 Figure 2 Background Gliomas are one of the most common primary neoplasm of the central nervous system (CNS) (25,5% of cases) and the most common malignant brain tumor in the adult population (80,8% of cases) [ 1 ]. A growth pattern involving both radial hemispheres and the corpus callosum, termed butterfly glioma (bG), is usually associated with poor prognosis, short survival, difficult management, cognitive impairment, and functional rapid movement[ 2 – 5 ]. Despite the histology most commonly seen to be glioblastoma (GB), this growth pattern can also be seen in low-grade gliomas and in lymphoproliferative disorders. The role of cytoreduction as a primary treatment strategy for bB is still controversial, particularly in cases of butterfly Glioblastomas (bGB) [ 2 – 11 ]. The involvement of eloquent areas and long fibers of critical association intervention, limit its approval and significantly increase health morbidity and mortality [ 12 ]. Currently, the improvement of surgical techniques and the growing number of evidences of the positive impact of surgical resection in the treatment of bGB question the value of more conservative management of these patients, including the strategy of biopsy (Bx) followed by radiotherapy (RDT) and chemotherapy (CT). The objective of this study was to evaluate the maximal safe surgical resection (MSSR) of the tumor used as a primary treatment strategy in a cohort of patients with bGB, considering the survival time (ST) and the progression-free survival (PFS). The results were compared with those observed in patients treated in the same period with biopsy or removal of less than 50% of the total tumor volume (TTV). They were also studied as clinical and epidemiological characteristics of these patients, as well as complications related to hospital procedures. OBJECTIVE To evaluate the impact of MSSR used as a primary treatment strategy in patients with BG, considering TS and TLP associated with the intervention. METHODS Study Design and Inclusion Criteria The study was conducted through a careful retrospective analysis of information documented in institutional medical records. All patients with BG, primarily treated with surgical resection and undergoing adjuvant therapy (Stupp Protocol), at the São Paulo Octávio Frias de Oliveira Cancer Institute (ICESP), between January 2011 and August 2022, were considered for inclusion in the study. Exclusion Criteria Were excluded from the study all patients without radiological and histological confirmation of the diagnosis and those with severe diseases that could interfere with survival time, such as other malignant neoplasms, decompensated systemic diseases and COVID-19. Ethic The Teaching and Research Commission and the Local Ethics Committee have approved the study (CCEP number: 1842/20). All living patients, or their legal representatives, signed the Free and Informed Consent Form to participate in the study. Procedures Participants were categorized into 2 subgroups based on the extent of tumor removal. Group-A comprised patients with MSSR ≥ 50% of TTV, while Group-B included patients who underwent biopsy or MSSR < 50% of TTV. The choice of intervention type was made in multidisciplinary discussions, taking into account the oncological and functional prognosis, as well as the impact and feasibility of the procedure. Relevant clinical and epidemiological variables encompassed gender, race, age, symptoms, hydrocephalus presence, involvement of 3 or more brain lobes (gliomatosis), overall health conditions, pre- and post-operative functional status, tumor histology, R132H mutation presence in the IDH1 gene (determined via immunohistochemistry), as well as progression-free survival (PFS) and overall survival (ST). General health conditions and functional status were evaluated using the ASA (American Society of Anesthesiologists), ECOG (Eastern Cooperative Oncology Group) and KPS (Karnofsky Performance Status) classifications, respectively. For statistical analysis, the time elapsed between surgery and the first radiological evidence of tumor volume increase was considered as PFS. TS was defined as the time interval between surgery and death. Statistical analysis Jamovi® and SPSS Stata® software were used for statistical analysis. Categorical variables were compared using the chi-square test and presented in terms of absolute and relative frequency. Continuous variables had their normality assessed by Shapiro-Wilk tests. Parametric variables were presented as means and standard deviations and compared by Student's t-test. Non-parametric variables were evaluated using the Mann-Whitney U test. We used the log-rank test to compare survival curves constructed using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards models were used to analyze possible variables associated with survival time. In the statistical analyzes, values ​​of p < 0.05 were considered significant. RESULTS Thirty patients were included in the study equally distributed between Groups-A and -B. The demographic, clinical and epidemiological profile of the patients are presented in Table 1 . The mean age of the patients was 60.54 years (± 11.43), with no statistically significant difference between the groups. In the group treated with biopsy, there was a predominance of males (40.0% versus 80.0%, p = 0.025). Table 1 Clinical and Demographic Data All* A-Group* B-Group* p-Value Number of cases 30 (100.0) 15 (50.0) 15 (50.0) Age in years (± SD) 60.54 ± 11.43 58.19 ± 8.73 61.65 ± 13.86 0.619 Sex Male 18 (60.0) 6 (40.0) 12 (80.0) 0.025 Female 12 (40.0) 9 (60.0) 3 (20.0) Comorbidity Arterial Hypertension 10 (33.3) 5 (33.3) 5 (33.3) 1.000 Diabetes Mellitus 7 (23.3) 5 (33.3) 2 (13.3) 0.195 Cardiovascular disease 3 (10.0) 2 (13.3) 1 (6.7) 0.543 Stroke 2 (6.7) 2 (13.3) 0 (0.0) 0.143 Smoke 5 (16.6) 3 (20.0) 2 (13.3) 0.510 Symptoms Headache 19 (63.3) 11 (73.3) 8 (53.3) 0.256 Epilepsy 9 (30.0) 4 (26.7) 5 (33.3) 0.690 Motor Impairment 16 (53.3) 9 (60.0) 7 (46.7) 0.464 Gait Impairment 16 (53.3) 9 (60.0) 7 (46.7) 0.464 Sensitive Impairment 1 (3.3) 1 (6.7) 0 (0.0) 0.309 Decreased Sphincter Control 13 (43.3) 7 (46.7) 6 (40.0) 0.713 Decreased Level of Consciouness 12 (40.0) 8 (53.3) 4 (26.7) 0.136 Delirium/Mental Confusion 23 (76.7) 13 (86.7) 10 (66.7) 0.195 Cognitive impairment 14 (46.7) 7 (46.7) 7 (46.7) 1.000 Visual Disturbance 5 (16.7) 3 (20.0) 2 (13.3) 0.624 ECOG ≤ 2 12 (40) 6 (40) 6 (40) 1,000 ≥ 3 18 (60) 9 (60) 9 (60) KPS (%) ≤ 60 24 (80.0) 11 (73,3) 13 (86,7) 0.361 ≥ 70 6 (20.0) 4 (26,7) 2 (13,3) ASA ≤ 2 10 (33.3) 8 (53.3) 2 (13.3) 0.020 ≥ 3 20 (66.7) 7 (46,7) 13 (86.7) Histology Astrocytoma G2 1 (3.3) 0 (0.0) 1 (6.7) 0.510 Astrocytoma G3 3 (10.0) 2 (13.3) 1 (6.7) Glioblastoma G4 26 (86.7) 13 (86.7) 13 (86.6) IDH 1 Mutation Mutation 1 (3.3) 0 (0.0) 1 (6.7) 0.030 Non-mutation 16 (53.4) 5 (33.3) 11 (73.3) NOS 13 (43.3) 10 (66.7) 3 (20.0) Hydrocephalus 13 (43.0) 6 (46.2) 7 (53.8) 0.713 Gliomatosis 22 (73.3) 10 (45.5) 12 (54.5) 0.409 Survival in weeks (± SD) 42.84 ± 65.16 68.35 ± 29.57 17.32 ± 29.57 0.014 Recurrence in weeks (± SD) 30.23 ± 70.41 57.70 ± 93.97 4.77 ± 7.15 0.012 Subtitles: ASA - American Society Of Anaesthesiologists Physical Status Classification; ECOG - Eastern Cooperative Oncology Group; SD – Standard deviation, KPS - Karnofsky Performance Scale; HR : Hazard Ratio. * Frequency in % The most frequent symptoms were delirium/mental confusion (76.7%), headache (63.3%), motor alterations (53.3%), and gait alterations (53.3%), reported uniformly in both groups. Loss of sphincter control and epilepsy were reported by 43.3% and 30% of patients, respectively. There were also no statistically significant differences in the presence of hydrocephalus or the pattern of gliomatosis growth at presentation. The groups were also similar regarding the most prevalent comorbidities, which included hypertension (33.3%), diabetes mellitus (23.3%), and cardiovascular disease (10%). They were also similar when categorized by functional performance, considering the KPS (≥ 70 and < 70) and ECOG (≥ 3 and < 3) scales. Despite this, patients in Group-B were in better general health conditions (ASA < 3) at the time of the intervention (p = 0.02). Malignant gliomas (WHO grade 3 and 4) were predominant and represented 86.7% and 10% of cases respectively. Only 1 patient (3.3%) was classified as Diffuse Astrocytoma, WHO grade 2, mutated IDH1. The surgical mortality rate (death up to the 7th day after the intervention) in this study was 0% (zero). Two patients in Group-A and 1 patient in Group-B showed functional deterioration related to the intervention, which corresponds to 13.33% and 6.66% of cases, respectively (P > 0.05). Survival Time (ST) The mean ST was higher in Group–A (68.35 versus 17.32 weeks, p = 0.014) and the statistically significant differences were maintained in the univariate analysis models (HR = 0.39, 95% CI = 0.18–0.85, p = 0.018) and multivariate (HR = 0.22, 95% CI = 0.07–0.69, p = 0.010) used ( Table 2 ) . Comparison of Kaplan-Meier survival curves is shown in Fig. 1 . Table 2 Cox-Regression - Survival Time Univariate Multivariate HR 95% CI p-Value HR 95% CI p-Value Sex (Male) 0.65 0.30–1.39 0.262 0.65 0.24–1.73 0.382 Age (< 60y) 1.73 0.79–3.76 0.168 2.33 0.82–6.62 0.113 ASA (< 3) 0.95 0.43–2.08 0.890 5.06 1.33–19.29 0.017 KPS ( ≥ 70) 0.38 0.14–1.02 0.054 0.63 0.19–2.13 0.460 Surgery 0.39 0.18–0.85 0.018 0.22 0.07–0.69 0.010 Subtitles: ASA - American Society Of Anaesthesiologists Physical Status Classification; SD – Standard deviation; KPS - Karnofsky Performance Scale; HR - Hazard Ratio; CI - Confidence Interval. The patient who achieved the longest survival underwent surgical excision of the tumor, which was a glioblastoma, IDH1-wild type, WHO grade 4. In addition to the gross total resection, the patient received comprehensive adjuvant therapy, following Stupp's protocol. Remarkably, this individual remains alive, with a Karnofsky Performance Status of 90%, and has remained free of recurrence for 6 years and 7 month of follow-up. Progression Free-Survival (PFS) The mean time to recurrence was 30.23 weeks (± 70.41). PFS was significantly higher in Group-A (57.70 versus 4.77 weeks, p = 0.012) and differences in Kaplan-Meier curves for recurrence are shown in Fig. 2 . After 25 weeks of follow-up, all patients treated with biopsy (versus 60% of Group-A) already presented recurrence. Only in Group-A was the reduction in the risk of recurrence statistically significant both in the univariate (HR = 0.35, 95% CI 0.15–0.79, p = 0.011) and multivariate (HR = 0.20, CI 95% 0.06–0.67, p = 0.009) ( Table 3 ) . Table 3 Cox-Regression - Progression-Free Survival Univariate Multivariate HR 95% CI p-Value HR 95% CI p-Value Sex (Male) 0.54 0.25–1.18 0.121 0.51 0.19–1.40 0.192 Age (< 60y) 1.94 0.88–4.29 0.100 2.02 0.71–5.75 0.190 ASA (< 3) 0.63 0.28–1.43 0.274 4.11 1.00–16.93 0.050 KPS ( ≥ 70) 0.51 0.19–1.36 0.180 0.74 0.22–2.56 0.638 Surgery 0.35 0.15–0.79 0.011 0.20 0.06–0.67 0.009 Subtitles: ASA - American Society Of Anaesthesiologists Physical Status Classification; SD – Standard deviation; KPS - Karnofsky Performance Scale; HR - Hazard Ratio; CI - Confidence Interval. DISCUSSION Butterfly gliomas are commonly characterized by aggressive behavior, unfavorable histological and molecular profiles, short survival times, early recurrence, and poor prognosis, regardless of treatment. Nevertheless, many cases necessitate surgical intervention due to rapid progression, symptom relief, or simply to establish a histological diagnosis. Although historically MSSE has been infrequently indicated to treat BG, there are compelling reasons to consider it. Adequate surgical removal, when combined with adjuvant therapies such as radiotherapy and chemotherapy, can substantially extend survival and enhance the quality of life for patients. This is achieved by reducing intracranial pressure, alleviating pressure on surrounding brain structures, and potentially mitigating neurological symptoms such as headaches, motor and cognitive deficits, and seizures. Consistent with existing literature, our study predominantly featured gliomas classified as WHO grades 3 and 4 of astrocytic origin, with wild-type IDH1 status. Only 1 case was categorized as a diffuse astrocytoma, mutant IDH-1, WHO grade 2. Despite this, we noted a significant improvement in both survival time (ST) and progression-free survival (PFS) among patients in whom surgical resection exceeded 50% of the total tumor volume (Group-A). Our analysis of the clinical and epidemiological profile underscored the advanced mean age, functional impairment, and overall frailty of the affected population. Surprisingly, 66.7% and 80% of cases were classified as ASA ≥ 3 and KPS < 70, respectively. Noteworthy comorbidities included hypertension, diabetes mellitus, cardiovascular diseases, and a history of smoking. The most common symptoms reported were headache, epileptic seizures, and frontal and psychiatric manifestations (delirium, motor changes, cognitive impairments, and loss of sphincter control). The demographic profile, combined with the disease's aggressive nature, justifies the apprehension many neurosurgeons experience when managing these cases and opting for more conservative interventions. However, in our study, the increase in ST and PFS observed in Group-A was not associated with higher rates of surgical morbidity and mortality or functional impairment resulting from the intervention. The effect was particularly pronounced in PFS, which extended by more than 12 times. Notably, surgery emerged as an independent factor, even in statistical models incorporating established factors such as age, IDH status, and functional performance. These findings support recent literature suggesting the favorable impact of maximal safe surgical resection (MSSR) as a primary treatment modality in such cases [ 3 – 8 , 10 , 12 – 18 ]. Despite technological advances, established and described techniques for resection of these tumors, and evidence favorable to this strategy, surgery is still little used in the primary treatment of BG [ 4 , 9 , 11 ]. This is possibly due to the poor results reported in the past and the lack of know-how and expertise of neurosurgeons in this type of intervention. In spite of the infiltrative and diffuse character of these tumors, we believe that most of the symptoms, dysfunctions and mechanisms of death are due to edema, distortion of CNS areas and fibers. A recent study found that GBs can increase in volume by an average of 1.1% per day, potentially doubling in size in just 22 days [ 19 ]. Analogous to the management of other tumors, and gliomas affecting different parts of the CNS, we believe that preserving the quality of life for patients with butterfly gliomas BG and reversing or delaying dysfunctions and causes of death may be achieved through broader surgical resections. However, definitive conclusions on this matter would require better designed and randomized studies. Yet, the rarity of the disease and ethical considerations pose challenges, potentially rendering such studies unfeasible. Real-world data, like those presented here, are vital for supporting evidence-based practices without depriving functionally sound patients of optimal treatment options or wasting resources on those with poor prognosis. Nevertheless, our study has notable limitations, including its retrospective design, single-center nature, sample size, molecular data availability, patient inclusion period, and estimation of TTV. CONCLUSION Surgically removing at least 50% of a butterfly glioma emerged as a positive independent factor linked to a more favorable outcome in terms of both survival time and progression-free survival. This improvement was not accompanied by elevated surgical morbidity and mortality rates. However, our study did not identify specific subgroups that might benefit the most from this approach. These findings align with recent research suggesting the superiority of extensive surgical resection over primary management with biopsy alone. Nonetheless, further well-designed multicenter randomized studies are still required to reach definitive conclusions. Abbreviations Acronyms: ASA - American Society of Anesthesiologists, BG - butterfly gliomas, bGB - butterfly glioblastoma, Bx - biopsy, CNS- central nervous system, CT - chemotherapy, ERC - extent of surgical resection, ECOG - Eastern Cooperative Oncology Group, GB - glioblastoma, KPS - Karnofsky Performance Status, PFS - progression-free survival, RT - radiotherapy, SMSR - safe maximal surgical resection, ST - survival time, TTV - total tumor volume, TU - tumor. Declarations Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by HP, VMBM, PHFC, GBC and BMM. The statistical analysis were performed by AMTC and VMBM.The first draft of the manuscript was written by HP and PHFC. The review of manuscript were performed by VNY, EGF and MJT. All authours approved the final version of manuscript. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4472967","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":310812419,"identity":"33ef0875-8dec-4f35-9229-d3ffea4962c2","order_by":0,"name":"Helder Picarelli","email":"","orcid":"","institution":"Instituto do Câncer do Estado de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Helder","middleName":"","lastName":"Picarelli","suffix":""},{"id":310812420,"identity":"5c3d2452-efec-4c39-91e7-3b7dab3158a8","order_by":1,"name":"Vitor Macedo Brito Medeiros","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYDACZgiVAMQGYJIfzC3Ap4UZTYtkA4hrQNgaiBYQMDjAAGdjBQbH+Q8+rmDYlqfb3rzxwcM9NvbG51cnfnhgwCDPL3YAu5bDzMyGZxhuF5udOVZskPAsLXHbjbebJYAOM5w5OwGrFslmZjag628DVeaYSSQcOJxgduPsBpCWBIPbhLTcf2P+A6jF3njG2c0/8GnhZ4bbwmPGANTCuIG/dxteW4BajA0bDEB+SSsGOiwtccYN3m0WCQYSOP3Cxn/w4cOGitt5ZscPb/z444CNPX//2c03f1TYyPNLY9cCDTdkjgRYpQQe5ZhuPUCK6lEwCkbBKBgBAABvl2GsxXT7TwAAAABJRU5ErkJggg==","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":true,"prefix":"","firstName":"Vitor","middleName":"Macedo Brito","lastName":"Medeiros","suffix":""},{"id":310812421,"identity":"b11b25f6-4f71-44e0-b211-78831e67db73","order_by":2,"name":"Pedro Henrique Fonseca Castro","email":"","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Pedro","middleName":"Henrique Fonseca","lastName":"Castro","suffix":""},{"id":310812422,"identity":"27129d5a-3601-4ed8-b963-b3f2d77cb927","order_by":3,"name":"Guilherme Bezerra Carneiro","email":"","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Guilherme","middleName":"Bezerra","lastName":"Carneiro","suffix":""},{"id":310812423,"identity":"a97d9012-a9d1-44d6-bcfb-b4354ac37614","order_by":4,"name":"Bruno Massanori Matsumura","email":"","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Bruno","middleName":"Massanori","lastName":"Matsumura","suffix":""},{"id":310812424,"identity":"45ee80aa-8b53-4061-9386-fbf19ca01aef","order_by":5,"name":"Augusto Magno Tranquezi Cordeiro","email":"","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Augusto","middleName":"Magno Tranquezi","lastName":"Cordeiro","suffix":""},{"id":310812425,"identity":"a53f7c33-7664-4349-a4be-262bf3e71211","order_by":6,"name":"Vitor Nagai Yamaki","email":"","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Vitor","middleName":"Nagai","lastName":"Yamaki","suffix":""},{"id":310812426,"identity":"6ca7ec88-dd72-4d0b-b32d-1c737b005334","order_by":7,"name":"Eberval Gadelha Figueiredo","email":"","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Eberval","middleName":"Gadelha","lastName":"Figueiredo","suffix":""},{"id":310812427,"identity":"dac81c4d-6d9d-4125-a70e-46ced7042c5d","order_by":8,"name":"Manoel Jacobsen Teixeira","email":"","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Manoel","middleName":"Jacobsen","lastName":"Teixeira","suffix":""}],"badges":[],"createdAt":"2024-05-24 14:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4472967/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4472967/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58086188,"identity":"9f9ebb6f-3bfe-41c0-a865-980f1e8e1217","added_by":"auto","created_at":"2024-06-11 02:47:23","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":261719,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meyer Analysis - Survival Time\u003c/p\u003e","description":"","filename":"Figure1KaplanMeyerAnalysisSurvivalTime.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4472967/v1/e5d203da6957c6fa57a1d091.jpg"},{"id":58086506,"identity":"fb855592-337c-46be-b216-514dac195b23","added_by":"auto","created_at":"2024-06-11 02:55:23","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":266303,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meyer Analysis – Progression Free Survival\u003c/p\u003e","description":"","filename":"Figure2KaplanMeyerAnalysisProgressionFreeSurvival.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4472967/v1/69148e32c2ce9b2b7647d155.jpg"},{"id":58442755,"identity":"dae0a698-7f62-4d4e-b72b-94378d67ec78","added_by":"auto","created_at":"2024-06-16 12:24:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1158802,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4472967/v1/8f7daf00-83ae-4331-98d9-7bc8112a14ef.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of surgery on butterfly gliomas - A real-life study of biopsy vs. surgical resection","fulltext":[{"header":"Background","content":"\u003cp\u003eGliomas are one of the most common primary neoplasm of the central nervous system (CNS) (25,5% of cases) and the most common malignant brain tumor in the adult population (80,8% of cases) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A growth pattern involving both radial hemispheres and the corpus callosum, termed butterfly glioma (bG), is usually associated with poor prognosis, short survival, difficult management, cognitive impairment, and functional rapid movement[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Despite the histology most commonly seen to be glioblastoma (GB), this growth pattern can also be seen in low-grade gliomas and in lymphoproliferative disorders.\u003c/p\u003e \u003cp\u003eThe role of cytoreduction as a primary treatment strategy for bB is still controversial, particularly in cases of butterfly Glioblastomas (bGB) [\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The involvement of eloquent areas and long fibers of critical association intervention, limit its approval and significantly increase health morbidity and mortality [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Currently, the improvement of surgical techniques and the growing number of evidences of the positive impact of surgical resection in the treatment of bGB question the value of more conservative management of these patients, including the strategy of biopsy (Bx) followed by radiotherapy (RDT) and chemotherapy (CT). The objective of this study was to evaluate the maximal safe surgical resection (MSSR) of the tumor used as a primary treatment strategy in a cohort of patients with bGB, considering the survival time (ST) and the progression-free survival (PFS). The results were compared with those observed in patients treated in the same period with biopsy or removal of less than 50% of the total tumor volume (TTV). They were also studied as clinical and epidemiological characteristics of these patients, as well as complications related to hospital procedures.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eOBJECTIVE\u003c/h2\u003e \u003cp\u003eTo evaluate the impact of MSSR used as a primary treatment strategy in patients with BG, considering TS and TLP associated with the intervention.\u003c/p\u003e \u003c/div\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Inclusion Criteria\u003c/h2\u003e \u003cp\u003eThe study was conducted through a careful retrospective analysis of information documented in institutional medical records. All patients with BG, primarily treated with surgical resection and undergoing adjuvant therapy (Stupp Protocol), at the S\u0026atilde;o Paulo Oct\u0026aacute;vio Frias de Oliveira Cancer Institute (ICESP), between January 2011 and August 2022, were considered for inclusion in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eExclusion Criteria\u003c/h2\u003e \u003cp\u003eWere excluded from the study all patients without radiological and histological confirmation of the diagnosis and those with severe diseases that could interfere with survival time, such as other malignant neoplasms, decompensated systemic diseases and COVID-19.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eEthic\u003c/h2\u003e \u003cp\u003e The Teaching and Research Commission and the Local Ethics Committee have approved the study (CCEP number: 1842/20). All living patients, or their legal representatives, signed the Free and Informed Consent Form to participate in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003eParticipants were categorized into 2 subgroups based on the extent of tumor removal. Group-A comprised patients with MSSR\u0026thinsp;\u0026ge;\u0026thinsp;50% of TTV, while Group-B included patients who underwent biopsy or MSSR\u0026thinsp;\u0026lt;\u0026thinsp;50% of TTV. The choice of intervention type was made in multidisciplinary discussions, taking into account the oncological and functional prognosis, as well as the impact and feasibility of the procedure. Relevant clinical and epidemiological variables encompassed gender, race, age, symptoms, hydrocephalus presence, involvement of 3 or more brain lobes (gliomatosis), overall health conditions, pre- and post-operative functional status, tumor histology, R132H mutation presence in the IDH1 gene (determined via immunohistochemistry), as well as progression-free survival (PFS) and overall survival (ST). General health conditions and functional status were evaluated using the ASA (American Society of Anesthesiologists), ECOG (Eastern Cooperative Oncology Group) and KPS (Karnofsky Performance Status) classifications, respectively. For statistical analysis, the time elapsed between surgery and the first radiological evidence of tumor volume increase was considered as PFS. TS was defined as the time interval between surgery and death.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eJamovi\u0026reg; and SPSS Stata\u0026reg; software were used for statistical analysis. Categorical variables were compared using the chi-square test and presented in terms of absolute and relative frequency. Continuous variables had their normality assessed by Shapiro-Wilk tests. Parametric variables were presented as means and standard deviations and compared by Student's t-test. Non-parametric variables were evaluated using the Mann-Whitney U test. We used the log-rank test to compare survival curves constructed using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards models were used to analyze possible variables associated with survival time. In the statistical analyzes, values ​​of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThirty patients were included in the study equally distributed between Groups-A and -B. The demographic, clinical and epidemiological profile of the patients are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of the patients was 60.54 years (\u0026plusmn;\u0026thinsp;11.43), with no statistically significant difference between the groups. In the group treated with biopsy, there was a predominance of males (40.0% versus 80.0%, p\u0026thinsp;=\u0026thinsp;0.025).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical and Demographic Data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAll*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA-Group*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB-Group*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of cases\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge in years (\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.54\u0026thinsp;\u0026plusmn;\u0026thinsp;11.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.19\u0026thinsp;\u0026plusmn;\u0026thinsp;8.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.65\u0026thinsp;\u0026plusmn;\u0026thinsp;13.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.619\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eComorbidity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArterial Hypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (23.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.195\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCardiovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.543\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmoke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (16.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.510\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003e\u003cb\u003eSymptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (63.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpilepsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.690\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMotor Impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.464\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGait Impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.464\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitive Impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.309\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecreased Sphincter Control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (43.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.713\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecreased Level of Consciouness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelirium/Mental Confusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (76.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.195\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisual\u0026nbsp;Disturbance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.624\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eECOG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1,000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eKPS (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (73,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (86,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.361\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (26,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (13,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eASA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (46,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (86.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eHistology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAstrocytoma G2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.510\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAstrocytoma G3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGlioblastoma G4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (86.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eIDH 1\u0026nbsp;Mutation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMutation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-mutation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (53.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (73.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (43.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHydrocephalus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (43.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.713\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGliomatosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.409\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurvival in weeks (\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.84\u0026thinsp;\u0026plusmn;\u0026thinsp;65.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.35\u0026thinsp;\u0026plusmn;\u0026thinsp;29.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.32\u0026thinsp;\u0026plusmn;\u0026thinsp;29.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecurrence in weeks (\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.23\u0026thinsp;\u0026plusmn;\u0026thinsp;70.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.70\u0026thinsp;\u0026plusmn;\u0026thinsp;93.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.77\u0026thinsp;\u0026plusmn;\u0026thinsp;7.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubtitles: ASA\u003c/b\u003e - American Society Of Anaesthesiologists Physical Status Classification; \u003cb\u003eECOG\u003c/b\u003e - Eastern Cooperative Oncology Group; \u003cb\u003eSD\u003c/b\u003e \u0026ndash; Standard deviation, \u003cb\u003eKPS\u003c/b\u003e - Karnofsky Performance Scale; \u003cb\u003eHR\u003c/b\u003e: Hazard Ratio.\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003eFrequency in %\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe most frequent symptoms were delirium/mental confusion (76.7%), headache (63.3%), motor alterations (53.3%), and gait alterations (53.3%), reported uniformly in both groups. Loss of sphincter control and epilepsy were reported by 43.3% and 30% of patients, respectively. There were also no statistically significant differences in the presence of hydrocephalus or the pattern of gliomatosis growth at presentation. The groups were also similar regarding the most prevalent comorbidities, which included hypertension (33.3%), diabetes mellitus (23.3%), and cardiovascular disease (10%). They were also similar when categorized by functional performance, considering the KPS (\u0026ge;\u0026thinsp;70 and \u0026lt;\u0026thinsp;70) and ECOG (\u0026ge;\u0026thinsp;3 and \u0026lt;\u0026thinsp;3) scales. Despite this, patients in Group-B were in better general health conditions (ASA\u0026thinsp;\u0026lt;\u0026thinsp;3) at the time of the intervention (p\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e \u003cp\u003eMalignant gliomas (WHO grade 3 and 4) were predominant and represented 86.7% and 10% of cases respectively. Only 1 patient (3.3%) was classified as Diffuse Astrocytoma, WHO grade 2, mutated IDH1. The surgical mortality rate (death up to the 7th day after the intervention) in this study was 0% (zero). Two patients in Group-A and 1 patient in Group-B showed functional deterioration related to the intervention, which corresponds to 13.33% and 6.66% of cases, respectively (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSurvival Time (ST)\u003c/h2\u003e \u003cp\u003eThe mean ST was higher in Group\u0026ndash;A (68.35 versus 17.32 weeks, p\u0026thinsp;=\u0026thinsp;0.014) and the statistically significant differences were maintained in the univariate analysis models (HR\u0026thinsp;=\u0026thinsp;0.39, 95% CI\u0026thinsp;=\u0026thinsp;0.18\u0026ndash;0.85, p\u0026thinsp;=\u0026thinsp;0.018) and multivariate (HR\u0026thinsp;=\u0026thinsp;0.22, 95% CI\u0026thinsp;=\u0026thinsp;0.07\u0026ndash;0.69, p\u0026thinsp;=\u0026thinsp;0.010) used \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Comparison of Kaplan-Meier survival curves is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCox-Regression - Survival Time\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnivariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eMultivariate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex (Male)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.30\u0026ndash;1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.262\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.24\u0026ndash;1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.382\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (\u0026lt;\u0026thinsp;60y)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.79\u0026ndash;3.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.82\u0026ndash;6.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA (\u0026lt;\u0026thinsp;3)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.43\u0026ndash;2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.890\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.33\u0026ndash;19.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKPS (\u003c/b\u003e\u0026ge;\u0026thinsp;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.14\u0026ndash;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.19\u0026ndash;2.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.460\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.18\u0026ndash;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.07\u0026ndash;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubtitles: ASA -\u003c/b\u003e American Society Of Anaesthesiologists Physical Status Classification; \u003cb\u003eSD \u0026ndash;\u003c/b\u003e Standard deviation; \u003cb\u003eKPS -\u003c/b\u003e Karnofsky Performance Scale; \u003cb\u003eHR -\u003c/b\u003e Hazard Ratio; \u003cb\u003eCI -\u003c/b\u003e Confidence Interval.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient who achieved the longest survival underwent surgical excision of the tumor, which was a glioblastoma, IDH1-wild type, WHO grade 4. In addition to the gross total resection, the patient received comprehensive adjuvant therapy, following Stupp's protocol. Remarkably, this individual remains alive, with a Karnofsky Performance Status of 90%, and has remained free of recurrence for 6 years and 7 month of follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eProgression Free-Survival (PFS)\u003c/h2\u003e \u003cp\u003eThe mean time to recurrence was 30.23 weeks (\u0026plusmn;\u0026thinsp;70.41). PFS was significantly higher in Group-A (57.70 versus 4.77 weeks, p\u0026thinsp;=\u0026thinsp;0.012) and differences in Kaplan-Meier curves for recurrence are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. After 25 weeks of follow-up, all patients treated with biopsy (versus 60% of Group-A) already presented recurrence. Only in Group-A was the reduction in the risk of recurrence statistically significant both in the univariate (HR\u0026thinsp;=\u0026thinsp;0.35, 95% CI 0.15\u0026ndash;0.79, p\u0026thinsp;=\u0026thinsp;0.011) and multivariate (HR\u0026thinsp;=\u0026thinsp;0.20, CI 95% 0.06\u0026ndash;0.67, p\u0026thinsp;=\u0026thinsp;0.009) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCox-Regression - Progression-Free Survival\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnivariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eMultivariate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex (Male)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.25\u0026ndash;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.19\u0026ndash;1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.192\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (\u0026lt;\u0026thinsp;60y)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.88\u0026ndash;4.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.71\u0026ndash;5.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA (\u0026lt;\u0026thinsp;3)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.28\u0026ndash;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u0026ndash;16.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKPS (\u003c/b\u003e\u0026ge;\u0026thinsp;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.19\u0026ndash;1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.22\u0026ndash;2.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.15\u0026ndash;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.06\u0026ndash;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubtitles: ASA -\u003c/b\u003e American Society Of Anaesthesiologists Physical Status Classification; \u003cb\u003eSD \u0026ndash;\u003c/b\u003e Standard deviation; \u003cb\u003eKPS -\u003c/b\u003e Karnofsky Performance Scale; \u003cb\u003eHR -\u003c/b\u003e Hazard Ratio; \u003cb\u003eCI -\u003c/b\u003e Confidence Interval.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eButterfly gliomas are commonly characterized by aggressive behavior, unfavorable histological and molecular profiles, short survival times, early recurrence, and poor prognosis, regardless of treatment. Nevertheless, many cases necessitate surgical intervention due to rapid progression, symptom relief, or simply to establish a histological diagnosis. Although historically MSSE has been infrequently indicated to treat BG, there are compelling reasons to consider it. Adequate surgical removal, when combined with adjuvant therapies such as radiotherapy and chemotherapy, can substantially extend survival and enhance the quality of life for patients. This is achieved by reducing intracranial pressure, alleviating pressure on surrounding brain structures, and potentially mitigating neurological symptoms such as headaches, motor and cognitive deficits, and seizures.\u003c/p\u003e \u003cp\u003eConsistent with existing literature, our study predominantly featured gliomas classified as WHO grades 3 and 4 of astrocytic origin, with wild-type IDH1 status. Only 1 case was categorized as a diffuse astrocytoma, mutant IDH-1, WHO grade 2. Despite this, we noted a significant improvement in both survival time (ST) and progression-free survival (PFS) among patients in whom surgical resection exceeded 50% of the total tumor volume (Group-A). Our analysis of the clinical and epidemiological profile underscored the advanced mean age, functional impairment, and overall frailty of the affected population. Surprisingly, 66.7% and 80% of cases were classified as ASA\u0026thinsp;\u0026ge;\u0026thinsp;3 and KPS\u0026thinsp;\u0026lt;\u0026thinsp;70, respectively. Noteworthy comorbidities included hypertension, diabetes mellitus, cardiovascular diseases, and a history of smoking. The most common symptoms reported were headache, epileptic seizures, and frontal and psychiatric manifestations (delirium, motor changes, cognitive impairments, and loss of sphincter control). The demographic profile, combined with the disease's aggressive nature, justifies the apprehension many neurosurgeons experience when managing these cases and opting for more conservative interventions. However, in our study, the increase in ST and PFS observed in Group-A was not associated with higher rates of surgical morbidity and mortality or functional impairment resulting from the intervention. The effect was particularly pronounced in PFS, which extended by more than 12 times. Notably, surgery emerged as an independent factor, even in statistical models incorporating established factors such as age, IDH status, and functional performance. These findings support recent literature suggesting the favorable impact of maximal safe surgical resection (MSSR) as a primary treatment modality in such cases [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite technological advances, established and described techniques for resection of these tumors, and evidence favorable to this strategy, surgery is still little used in the primary treatment of BG [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This is possibly due to the poor results reported in the past and the lack of know-how and expertise of neurosurgeons in this type of intervention. In spite of the infiltrative and diffuse character of these tumors, we believe that most of the symptoms, dysfunctions and mechanisms of death are due to edema, distortion of CNS areas and fibers.\u003c/p\u003e \u003cp\u003eA recent study found that GBs can increase in volume by an average of 1.1% per day, potentially doubling in size in just 22 days [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Analogous to the management of other tumors, and gliomas affecting different parts of the CNS, we believe that preserving the quality of life for patients with butterfly gliomas BG and reversing or delaying dysfunctions and causes of death may be achieved through broader surgical resections. However, definitive conclusions on this matter would require better designed and randomized studies. Yet, the rarity of the disease and ethical considerations pose challenges, potentially rendering such studies unfeasible. Real-world data, like those presented here, are vital for supporting evidence-based practices without depriving functionally sound patients of optimal treatment options or wasting resources on those with poor prognosis. Nevertheless, our study has notable limitations, including its retrospective design, single-center nature, sample size, molecular data availability, patient inclusion period, and estimation of TTV.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eSurgically removing at least 50% of a butterfly glioma emerged as a positive independent factor linked to a more favorable outcome in terms of both survival time and progression-free survival. This improvement was not accompanied by elevated surgical morbidity and mortality rates. However, our study did not identify specific subgroups that might benefit the most from this approach. These findings align with recent research suggesting the superiority of extensive surgical resection over primary management with biopsy alone. Nonetheless, further well-designed multicenter randomized studies are still required to reach definitive conclusions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAcronyms:\u003c/strong\u003e \u003cstrong\u003eASA\u003c/strong\u003e- American Society of Anesthesiologists, \u003cstrong\u003eBG\u003c/strong\u003e- butterfly gliomas, \u0026nbsp;\u003cstrong\u003ebGB\u003c/strong\u003e- butterfly glioblastoma, \u003cstrong\u003eBx\u003c/strong\u003e- biopsy, \u003cstrong\u003eCNS-\u003c/strong\u003e central nervous system, \u003cstrong\u003eCT\u003c/strong\u003e- chemotherapy, \u003cstrong\u003eERC\u003c/strong\u003e- extent of surgical resection, \u003cstrong\u003eECOG\u0026nbsp;\u003c/strong\u003e- Eastern Cooperative Oncology Group, \u003cstrong\u003eGB\u003c/strong\u003e- glioblastoma, \u003cstrong\u003eKPS\u003c/strong\u003e- Karnofsky Performance Status, \u003cstrong\u003ePFS\u003c/strong\u003e- progression-free survival, \u003cstrong\u003eRT\u003c/strong\u003e- radiotherapy, \u003cstrong\u003eSMSR\u003c/strong\u003e- safe maximal surgical resection, \u003cstrong\u003eST\u003c/strong\u003e- survival time, \u003cstrong\u003eTTV\u003c/strong\u003e- total tumor volume,\u003cstrong\u003e\u0026nbsp;TU\u003c/strong\u003e- tumor.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by HP, VMBM, PHFC, GBC and BMM. The statistical analysis were performed by AMTC and VMBM.The first draft of the manuscript was written by HP and PHFC. The review of manuscript were performed by VNY, EGF and MJT. All authours approved the final version of manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOstrom QT, Price M, Neff C et al (2022) CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2015\u0026ndash;2019. 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Neurooncol Adv 3(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/noajnl/vdab053\u003c/span\u003e\u003cspan address=\"10.1093/noajnl/vdab053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Butterfly Glioblastoma, Biopsy, Surgical Resection, Survival, Progression-Free Survival","lastPublishedDoi":"10.21203/rs.3.rs-4472967/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4472967/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite the extent of resection affecting the overall survival of patients with gliomas, cytoreduction in patients with butterfly gliomas (BG) remains controversial. Contemporary studies suggest that wide removal is feasible, but there is a lack of controlled, randomized, multicenter studies on the subject. The aim of this study was to evaluate the impact of safe maximal surgical resection (SMSR) as a primary treatment strategy in patients with BG.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e30 consecutive patients, primarily treated with neurosurgery, were categorized into Group-A when SMSR was equal to or greater than 50% and Group-B when it was less than 50% (biopsy). The groups were studied and compared for clinical, epidemiological, functionality, survival time (ST), and progression-free survival (PFS) characteristics. Results were analyzed by descriptive and inferential statistics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe most frequent tumors were glioblastoma IDH-wild type, WHO grade 4. Most patients (80%) had KPS\u0026thinsp;\u0026lt;\u0026thinsp;70%, however, there was no significant worsening of functionality associated with interventions. Wider resection (Group-A) was associated with a better Kaplan-Meier curve and ST (68.35 versus 17.32 weeks, p\u0026thinsp;=\u0026thinsp;0.014). PFS was also longer in this group (57.70 versus 4.77 weeks, p\u0026thinsp;=\u0026thinsp;0.012). In multivariate analysis, resections\u0026thinsp;\u0026gt;\u0026thinsp;50% were associated with reduced risk of recurrence (HR\u0026thinsp;=\u0026thinsp;0.20, 95% CI 0.06\u0026ndash;0.67, p\u0026thinsp;=\u0026thinsp;0.009). Complication rates and functional decline were similar between groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSurgical resections (\u0026gt;\u0026thinsp;50%) in patients with BG improved ST and PFS without a significant increase in morbidity and dysfunction.\u003c/p\u003e","manuscriptTitle":"The impact of surgery on butterfly gliomas - A real-life study of biopsy vs. surgical resection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-11 02:47:18","doi":"10.21203/rs.3.rs-4472967/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"43e1e8c0-a8ba-476f-863d-35540a7fd4e2","owner":[],"postedDate":"June 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-16T12:16:00+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-11 02:47:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4472967","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4472967","identity":"rs-4472967","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}