Role of multimodal use of surgery adjuncts for overall survival of patients with supratentorial WHO grade 4 gliomas.

Background: In recent years, numerous advanced techniques supporting surgery (TSS) have been utilized to maximize glioma resection. However, the impact of the multimodal use of TSS, such as awake surgery, intraoperative neurophysiological monitoring, neuronavigation, fluorescence-guided surgery, fMRI, and DTT, on improving OS remains uncertain. Methods: In retrospective analysis of 81 patients with supratentorial WHO grade 4 gliomas, we assessed the effect of age, sex, tumor location, number of TSS used, EOR, postoperative KPS, IDH-1 status, and use of postoperative adjuvant therapy (PAT) i.e. radiotherapy and chemotherapy on overall survival. Kaplan-Meyer plots with F-Cox test and Cox proportional hazards model were used for univariate and multivariate survival analyses. Results: We used none, one, two, three or four TSS in 30, 20, 15, 9 and 7 patients, respectively. The number of TSS used (none vs. 1-2 vs. 3-4) correlated with OS in eloquent areas (P=0.029, univariate; P=0.006, multivariate) with median survival of 194, 364, and 674 days, respectively, whereas no correlation was observed in non-eloquent areas. In univariate analysis but not in multivariate analysis, significant factors for OS in gliomas in eloquent areas were younger age (P=0.026), EOR (gross total vs. subtotal vs. partial resection) (P=0.015), PAT use (P= 0.00066), and in gliomas in non-eloquent areas were EOR (P=0.01), postoperative KPS (≥70 vs.<70) (P=0.023), PAT use (P=0.015). Conclusion: The simultaneous use of multiple techniques supporting surgery appears to be associated with improved overall survival in patients with supratentorial WHO grade 4 gliomas in eloquent areas, in contrast to non-eloquent areas.