Tumor/Skull Base

This meta-analysis suggests that awake craniotomy may improve survival, extent of resection, and 3-month neurologic outcomes for selected patients with high-grade glioma, especially in eloquent areas. The catch is that most of the signal comes from observational studies, so read the paper as supportive rather than definitive proof.

This consecutive 230-patient vestibular schwannoma microsurgery series says that hearing-preservation surgery can work well in experienced hands, but timing matters. Overall hearing preservation was 61%, it rose to 72% when tumors were 10 mm or smaller, and facial nerve outcomes remained excellent. The result is useful for counseling patients already leaning toward surgery, but it does not compare surgery with observation or radiosurgery.

This paper asks whether a third awake-mapping resection is worth considering for recurrent diffuse low-grade glioma. In this selected 31-patient series, permanent morbidity was rare, most evaluable patients returned to work, and outcomes looked better when the third surgery was done before enhancement appeared on MRI. The result supports discussing another resection in highly functional patients, but the evidence is still a specialized retrospective experience rather than a definitive comparative study.

This study argues that going beyond the enhancing margin may help in selected IDH-wildtype glioblastoma cases, but it is still retrospective evidence. The practical lesson is to consider safe supramarginal resection when anatomy allows, not to chase a fixed percentage at the expense of neurologic function.

This study is useful because it tells patients what recovery after endoscopic skull base meningioma surgery actually feels like. Quality of life dips early, recovers by roughly 6 weeks, and improves beyond baseline by 6 months, especially when vision improves. That is valuable counseling data, but it is not a head-to-head proof that endoscopy is the best route for every anterior skull base meningioma.

This paper is useful because it avoids the lazy question of 'endonasal or transcranial?' and asks 'for which craniopharyngioma type?' Endoscopy looked particularly good for Q-CP tumors and for visual outcomes overall, but it also carried more CSF leak and nasal complications. The right takeaway is tailored approach selection, not dogma.

This randomized glioblastoma trial says something practical: a basic intraoperative ultrasound setup can help surgeons achieve complete contrast-enhancing resection more often than standard neuronavigation alone. It is a useful operative tool study, but it is still a small single-center trial, so it supports adding ultrasound as an adjunct rather than claiming a proven survival win.

The 2021 WHO CNS tumor classification represents a major shift toward integrated molecular-histological diagnosis. It introduces new entities like diffuse pediatric-type high-grade gliomas and requires testing for IDH, 1p/19q, H3 mutations, and other markers. This update is now the standard for all CNS tumor diagnoses and reporting.

This review is useful because it pushes back against oversimplifying awake surgery. For motor mapping specifically, both awake and asleep approaches looked workable, and the pooled data did not prove a clear universal winner. The practical choice should still be driven by tumor anatomy, mapping goals, and team experience.

TRANSSPHER says the microscopy-versus-endoscopy argument is not mainly about gross-total resection. Resection rates were similar, but postoperative pituitary dysfunction was lower with endoscopy. The practical message is that endoscopy looks attractive when a center is already good at it, but this study does not prove that it is universally superior for every pituitary surgeon.

In this retrospective glioblastoma series, patients who had at least 25% of the FLAIR abnormality removed after gross-total resection of the contrast-enhancing tumor lived longer and had longer progression-free survival than those below that threshold. The result is clinically interesting, but it comes from a small, nonrandomized, single-center study with a post-hoc cutoff.

This CBTRUS report provides comprehensive US epidemiological data on 392,982 primary brain and CNS tumors diagnosed 2011-2015. It establishes current incidence rates (23.41/100,000), mortality patterns, and survival outcomes by histology and demographics. While descriptive rather than interventional, it serves as the authoritative reference for understanding brain tumor burden and planning clinical services.

This phase III trial shows TTFields plus temozolomide improves median PFS by 2.7 months and OS by 4.9 months compared to temozolomide alone in glioblastoma. The open-label design and industry involvement require consideration, but the survival benefit supports TTFields as an option for motivated patients who can tolerate device use.

This phase 3 trial is practice-changing. After resection of a brain metastasis, postoperative cavity SRS preserved cognition better than WBRT and did not worsen overall survival. The short version is simple: if a patient can safely receive cavity SRS, routine WBRT should usually stop being the default.

This CBTRUS report provides comprehensive US epidemiology data for 2009-2013, covering 368,117 primary brain and CNS tumors. It documents incidence, mortality, and survival patterns by histology and demographic factors using national registry data. Essential for understanding disease burden and planning clinical trials.

This randomized trial compared SRS alone versus SRS+WBRT in patients with 1-3 brain metastases. SRS alone resulted in significantly less cognitive deterioration at 3 months (63.5% vs 91.7%) but had higher intracranial failure (HR 3.6). There was no difference in overall survival. For patients prioritizing cognitive preservation, SRS alone may be preferred despite increased local failure risk.

This TCGA analysis of 1,122 diffuse gliomas uses molecular profiling to identify biologically discrete subsets. DNA methylation recapitulates IDH/1p19q classification and reveals new prognostic groups, including an IDH-mutant subset with poor outcome and an IDH-wildtype group resembling pilocytic astrocytoma. While not directly therapeutic, it strengthens the rationale for molecular classification in clinical decision-making.

This phase III RCT demonstrates that adding PCV chemotherapy to radiation therapy significantly improves both progression-free and overall survival in adults with grade 2 gliomas. With median follow-up of 11.9 years, the radiation+PCV group had 5.5 years longer median overall survival (13.3 vs 7.8 years) and double the 10-year progression-free survival (51% vs 21%). This supports adjuvant PCV for eligible patients despite its toxicity profile.

The 2016 WHO CNS tumor classification represents a paradigm shift, requiring molecular testing alongside histology for diagnosis of gliomas, medulloblastomas, and other entities. Key changes include: diffuse gliomas now classified by IDH and 1p/19q status, new entities like H3 K27M-mutant midline glioma, and brain invasion as criterion for atypical meningioma. This integrated approach aims to create more biologically homogeneous diagnostic categories.

This TCGA study of 293 lower-grade gliomas demonstrates that molecular classification (IDH mutation, 1p/19q codeletion, TP53 status) defines three prognostically distinct groups better than histology alone. IDH-mut/1p19q-codeleted tumors have best survival (median 8.0 years), while IDH-wild-type behave like glioblastoma (median 1.7 years). The findings support integrating molecular markers into clinical decision-making.

This landmark 2015 study defined five molecular groups of adult diffuse gliomas based on IDH, TERT promoter, and 1p/19q status. The groups have distinct ages at onset and prognoses, with the triple-positive group (IDH-mut, TERT-mut, 1p/19q codeleted) having the best survival in lower-grade gliomas. This work directly informed the 2016 WHO classification, making molecular testing standard for glioma diagnosis.

This phase III RCT tested adding bevacizumab to standard temozolomide/radiotherapy for newly diagnosed GBM. While PFS improved from 7.3 to 10.7 months, overall survival was unchanged (15.7 vs 16.1 months). Bevacizumab increased toxicity and worsened quality of life. First-line bevacizumab should not be used outside clinical trials.

This phase III trial (REGAL) randomized 325 patients with recurrent GBM to cediranib (VEGF inhibitor) monotherapy, cediranib plus lomustine, or lomustine alone. Neither cediranib arm significantly improved progression-free survival versus lomustine alone. While cediranib showed some steroid-sparing effects, it should not replace current standard therapies for recurrent GBM.

This phase III RCT compared PCV chemotherapy plus RT vs RT alone in anaplastic oligodendroglioma. While no OS benefit was seen in the entire cohort, patients with 1p/19q codeleted tumors had doubled median survival with PCV+RT (14.7 vs 7.3 years). However, this key finding comes from an unplanned subgroup analysis. For codeleted tumors, consider PCV+RT, but temozolomide-based regimens are now more common.

This molecular survey of 1,230 tumors found TERT promoter mutations in 83% of primary glioblastomas, defining a TERT-high group of tumors from tissues with low self-renewal. TERT and ATRX mutations were mutually exclusive, suggesting alternative telomere maintenance pathways. These mutations are now used as biomarkers for glioma classification.

This TCGA study characterizes genomic alterations in over 500 GBM tumors, defining molecular subtypes (proneural, mesenchymal, classical) and identifying frequent mutations in TERT promoter and EGFR. It links the G-CIMP phenotype to better survival in the proneural subtype. While not directly therapeutic, it establishes a genomic framework for future targeted trials and prognostic stratification in neuro-oncology.

RTOG 9802 randomized 251 adults with unfavorable-risk low-grade glioma to RT alone vs RT+PCV. Primary analysis showed improved PFS (HR 0.6) but no significant OS benefit. Post hoc analysis found that among 2-year survivors, RT+PCV improved 5-year OS probability (74% vs 59%, HR 0.52). This suggests a delayed chemotherapy benefit, but results are exploratory.

This 2012 Nature Genetics paper identified recurrent somatic histone H3 mutations in pediatric DIPG and non-brainstem glioblastomas. 78% of DIPGs harbored H3F3A or HIST1H3B K27M mutations, while 22% of non-brainstem glioblastomas had similar mutations plus 14% with G34R mutations. These findings established a molecular signature for pediatric high-grade gliomas distinct from adult counterparts, though clinical implications remain to be determined.

This EORTC phase III trial randomized 359 patients with 1-3 brain metastases to adjuvant WBRT or observation after surgery/radiosurgery. WBRT reduced 2-year intracranial relapses (e.g., surgery initial sites: 59% to 27%) and neurologic deaths (44% to 28%) but did not improve time to functional deterioration (10.0 vs 9.5 months, P=0.71) or overall survival (10.7 vs 10.9 months, P=0.89). Omission of adjuvant WBRT is reasonable when prioritizing quality of life over relapse prevention.

This TCGA analysis identifies four molecular GBM subtypes (Proneural, Neural, Classical, Mesenchymal) defined by distinct genomic abnormalities. The Classical subtype showed greatest benefit from aggressive therapy while Proneural showed none. This framework supports biologically-informed stratification but requires prospective validation.

This landmark study identified IDH1/IDH2 mutations in >70% of grade II-III gliomas and secondary glioblastomas. Mutations define a distinct molecular subgroup with better survival, establishing IDH status as a key prognostic biomarker. While practice-changing for classification, therapeutic implications required subsequent trials.

This phase II trial of single-agent bevacizumab in 48 recurrent GBM patients showed 29% PFS6 and median PFS of 16 weeks, with 71% radiographic response by Levin criteria. Toxicity included thromboembolic events (12.5%). Bevacizumab+irinotecan at progression had no responses in 19 patients. While promising, the single-arm design requires confirmation in randomized trials.