Prognostic Evaluation of Re-Resection for Recurrent Glioblastoma Using the Novel RANO Classification for Extent of Resection: A Report of the RANO Resect Group

Authors

Philipp Karschnia
Antonio Dono
Jacob S Young
Stephanie T Juenger
Nico Teske
Levin Häni
Tommaso Sciortino
Christine Y Mau
Francesco Bruno
Luis Nunez
Ramin A Morshed
Alexander F Haddad
Michael Weller
Martin van den Bent
Juergen Beck
Shawn Hervey-Jumper
Annette M Molinaro
Nitin Tandon
Roberta Rudà
Michael A Vogelbaum
Lorenzo Bello
Oliver Schnell
Stefan J Grau
Susan M Chang
Mitchel S Berger
Yoshua Esquenazi
Joerg-Christian Tonn

Publication Date

9-5-2023

Journal

Neuro-Oncology

Abstract

BACKGROUND: The value of re-resection in recurrent glioblastoma remains controversial as a randomized trial that specifies intentional incomplete resection cannot be justified ethically. Here, we aimed to (1) explore the prognostic role of extent of re-resection using the previously proposed Response Assessment in Neuro-Oncology (RANO) classification (based upon residual contrast-enhancing (CE) and non-CE tumor), and to (2) define factors consolidating the surgical effects on outcome.

METHODS: The RANO resect group retrospectively compiled an 8-center cohort of patients with first recurrence from previously resected glioblastomas. The associations of re-resection and other clinical factors with outcome were analyzed. Propensity score-matched analyses were constructed to minimize confounding effects when comparing the different RANO classes.

RESULTS: We studied 681 patients with first recurrence of Isocitrate Dehydrogenase (IDH) wild-type glioblastomas, including 310 patients who underwent re-resection. Re-resection was associated with prolonged survival even when stratifying for molecular and clinical confounders on multivariate analysis; ≤1 cm3 residual CE tumor was associated with longer survival than non-surgical management. Accordingly, "maximal resection" (class 2) had superior survival compared to "submaximal resection" (class 3). Administration of (radio-)chemotherapy in the absence of postoperative deficits augmented the survival associations of smaller residual CE tumors. Conversely, "supramaximal resection" of non-CE tumor (class 1) was not associated with prolonged survival but was frequently accompanied by postoperative deficits. The prognostic role of residual CE tumor was confirmed in propensity score analyses.

CONCLUSIONS: The RANO resect classification serves to stratify patients with re-resection of glioblastoma. Complete resection according to RANO resect classes 1 and 2 is prognostic.

Keywords

classification, extent of resection, glioblastoma recurrence, outcome, surgical re-resection