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Occipital WHO grade II gliomas: oncological, surgical and functional considerations

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Abstract

Background

Diffuse WHO grade II glioma (GIIG) involving the occipital lobe is a rare entity. Its surgical resection remains controversial as it implies inducing a permanent visual deficit. For the first time to our knowledge, we report a consecutive surgical series of patients who underwent an occipital lobectomy for an LGG invading visual structures.

Method

Six right-handed patients harboring a GIIG revealed by seizures (normal examination except a quadrantanopsia in one case) and located within the occipital lobe (4 left and 2 right tumors) were submitted to surgery. Before making this decision, the benefit-to-risk ratio of the resection was extensively discussed with the patient and his/her family, especially concerning the price to pay to remove the tumor, that is, to voluntarily generate a permanent hemianopsia. All the procedures were performed under awake condition using intraoperative electrostimulation, in order to pursue the resection until sensory-motor and/or language structures were encountered.

Findings

An extensive occipital lobectomy was achieved in the six patients, with identification and preservation of sensory-motor pathways in the two cases with a right tumor and detection of language pathways in the four cases with a left tumor. The mean extent of resection was 93% (range: 91–100%). All patients experienced an expected postoperative deficit of the visual field (homonymous hemianopsia). Nonetheless, the six patients resumed a normal social and professional life (KPS at 90 in the 6 cases) with a mean follow-up of 58 months (range: 3–147 months)—with adjuvant treatment in three cases (in addition to a reoperation in two of them).

Conclusions

Our findings suggest that, despite a definitive hemianopsia, an extensive surgical resection can be considered in the rare cases of occipital GIIG involving the primary visual structures, with patients able to maintain a normal life—except regarding the medico-legal problem of driving.

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Conflicts of interest

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Authors and Affiliations

  1. Department of Neurosurgery, Hospital Garcia de Orta, Almada, Portugal

    Catarina Viegas

  2. Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France

    Sylvie Moritz-Gasser

  3. Team “Brain Plasticity, Stem Cells and Glial Tumors”, INSERM U1051, Institute for Neurosciences of Montpellier, Montpellier, France

    Sylvie Moritz-Gasser & Hugues Duffau

  4. Department of Neuropathology, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France

    Valérie Rigau

  5. Department of Neurosurgery, Hôpital Gui de Chauliac, CHU Montpellier, Montpellier University Medical Center, 80 Av Augustin Fliche, 34295, Montpellier, France

    Hugues Duffau

Authors
  1. Catarina Viegas
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  2. Sylvie Moritz-Gasser
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  3. Valérie Rigau
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  4. Hugues Duffau
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Corresponding author

Correspondence to Hugues Duffau.

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Comment

Professor Hugues Duffau of Montpellier is a world leader in the functional connectivity of the human brain. And how did he achieve this? It was by realising that awake craniotomy is a wonderful research window on the living human brain and that intraoperative stimulation mapping provides hard evidence on how different areas of the brain communicate with each other—just for the knowledge for those neurosurgeons who still think that awake craniotomy is a barbarous act.

Professor Duffau now reports near total resections of six occipital WHO grade II diffuse gliomas using awake craniotomy and intraoperative cortical and subcortical stimulation mapping. He found that the ensuing permanent homonymous hemianopia allowed return to almost all previous activities and that the patients accepted the deficit as a price for the near total removal. This is controversial in many neurosurgical minds and raises several questions such as:

(1) What degree of neurological deficit is acceptable—and by whom—when in very experinced hands the outcome is not cure but delay of malignant transformation?

(2) How prepared are our patients to mentally process something that is controversial even among neurosurgeons?

(3) How to act optimally when terrified patients and eager media expect god-like foresight and procedures?

I find this report conceptually highly important with long-term impact on the field of resective surgery of lesions of the brain.

Juha E Jääskeläinen

Kuopio, Finland

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Viegas, C., Moritz-Gasser, S., Rigau, V. et al. Occipital WHO grade II gliomas: oncological, surgical and functional considerations. Acta Neurochir 153, 1907–1917 (2011). https://doi.org/10.1007/s00701-011-1125-z

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  • DOI: https://doi.org/10.1007/s00701-011-1125-z

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