Surgical Approaches to CNS Tumors

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**Chapter 5**

**Abstract**

tive, randomized trial.

**1. Introduction**

rGB—recurrent glioblastoma

Surgery for Recurrent

*Vamsi Krishna Yerramneni, Ramanadha Reddy Kanala,* 

Recurrence of glioblastoma (GB) is inevitable. As the optimal management for recurrent glioblastoma continues to evolve, clear treatment guidelines for are lacking. Existing literature does not clarify the role that second surgery plays in the treatment of these patients. Although few studies report that second surgery is beneficial in select patients and leads to longer overall survival (OS), other studies have demonstrated the limited impact that repeat surgery has on the eventual patient outcome. Maximal safe resection (high extent of resection—EOR) has been proven to improve the OS at reoperation, even when undertaken for cases where the first surgery achieved only a limited EOR. Karnofsky Performance Score (KPS) and age at presentation are valuable prognostic factors that predict better OS and aid in better patient selection for surgical management. The true value of reoperation versus systemic treatment, their effects the patient's QoL and the added increase in overall survival is better judged after detailed investigation by means of a prospec-

**Keywords:** EOR—extent of resection, KPS—Karnofsky Performance Score,

Glioblastoma (GB) is not only the most common primary intrinsic brain tumor of adulthood, but also the most frequently encountered malignant subtype. The standard treatment for newly diagnosed GB remains maximal surgical resection followed by concomitant or adjuvant chemotherapy [1]. The culmination of all the developments in diagnostics, imaging, surgical refinements and adjuvant therapies has not translated into any significant boost to the median overall survival (OS) of these patients. Prognosis continues to be dismal and OS has risen by just about 3.3 months (from 11.3 to 14.6 months) [2]. In select cohorts (consisting of a very favorable subset of patients), a median OS of 20.5 months has been observed. Recurrence is inevitable in GB despite every kind of known therapy. The standard care of the recurrent GB (rGB) is incompletely defined. Considering the ineffectiveness of therapy for first time disease, patients with recurrent disease are left with even more limited truly useful treatment options. With no clear standard of care, available options include reexcision of the lesion, angiogenesis inhibitor agents, and other targeted therapies, some of which have been the subject of clinical trials. In current practice, second surgery is performed in less than one half of the patients

*Vasundhara S. Rangan and Thirumal Yerragunta*

Glioblastoma

## **Chapter 5**
