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Journal Club

Tumor/Skull Base

Intraoperative B-Mode Ultrasound Guided Surgery and the Extent of Glioblastoma Resection: A Randomized Controlled Trial

Frontiers in Oncology | 2021

Rapid review note

Journal Club is a rapid, AI-assisted appraisal layer. It highlights study design, effect estimates, and practice relevance, but it is still a briefing, not a replacement for the paper.

For education only. Not medical advice.

Paper snapshot

Rapid study overview

Open paper

DOI

10.3389/fonc.2021.649797

PMID

N/A

PICO

Population

Adults with newly diagnosed presumed glioblastoma deemed totally resectable at a single Dutch center, excluding multifocal, deep, midline-crossing, low-KPS, or pre-existing-deficit cases.

Intervention

Intraoperative 2-D B-mode ultrasound-guided glioblastoma resection.

Comparator

Standard neuronavigation-guided surgery.

Outcomes

Complete contrast-enhancing resection on early postoperative MRI, extent of resection, residual tumor volume, neurologic outcome, quality of life, and survival.

Design

Type

Single-center randomized controlled trial

Randomized

Yes

Multicenter

No

Blinded

Primary neuroradiologist was blinded; surgeons and patients were not

Follow-up

Quality-of-life and functional follow-up through 6 months

Primary endpoint

Complete resection of contrast-enhancing tumor on early postoperative MRI.

Secondary endpoints

  • Extent of resection and residual tumor volume
  • Neurologic status and Karnofsky performance
  • Quality of life, progression-free survival, and overall survival

Practice impact

What this means

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.

Bottom line

If your goal is to increase the chance of complete contrast-enhancing glioblastoma resection without adding an expensive intraoperative MRI workflow, adding B-mode ultrasound is a reasonable practice change.

Strength of evidence

moderate

Recommendation

consider change

Why it matters

  • The trial was randomized and used a blinded radiologic primary outcome.
  • Ultrasound improved complete resection without a signal of worse neurologic or quality-of-life outcomes.
  • The evidence is still only one small center and does not by itself prove survival benefit.

What would change my mind

  • A larger multicenter trial showing the complete-resection advantage disappears outside expert centers.
  • Evidence that advanced ultrasound interpretation burden or false-positive residual signals offset the resection benefit in routine practice.

Critical appraisal

How strong is the paper?

Methods critique

Risk of bias

This was a small single-center trial with only 47 analyzed patients after post-randomization exclusions, so precision is limited despite randomization.

Confounding

Randomization reduced baseline imbalance, but the study only tested one ultrasound setup and one center's surgical workflow, which can confound transportability.

Missing data

Three randomized patients were excluded from analysis after surgery, and the paper was not powered to show survival differences.

Multiplicity

The trial had one primary outcome and many secondary functional, quality-of-life, and survival outcomes that were not powered for strong inferential claims.

Notes

  • The trial used only 2-D B-mode ultrasound rather than more advanced ultrasound modalities.
  • The primary outcome was blinded radiologic complete resection, which is stronger than surgeon impression alone.

Stats check

NNT

N/A

Effect sizes

  • Complete resection occurred in 8 of 23 ultrasound patients (35%) versus 2 of 24 standard-surgery patients (8%), with OR 5.9 (95% CI 1.1-31.6).
  • When surgeons believed complete resection had been achieved, this matched radiologic complete resection in 46.7% with ultrasound versus 11.8% with standard surgery (OR 6.6, 95% CI 1.1-39.3).

Absolute effects

  • Median extent of resection was 97% with ultrasound versus 95% with standard surgery.
  • Median residual tumor volume was 0.9 cm3 with ultrasound versus 1.4 cm3 with standard surgery.

Concerns

  • The confidence intervals are wide because the study is small.
  • The trial was designed around complete resection, not survival or quality-of-life superiority.
  • A more frequent complete resection rate did not translate into a proven survival benefit within this study.

External validity

Who it applies to

Glioblastoma programs looking for a lower-cost real-time imaging adjunct to improve complete resection during surgery.

Who it does not

Patients with multifocal, deep, brainstem, cerebellar, or midline-crossing tumors, or centers without enough ultrasound experience to interpret the images reliably.

Generalizability notes

  • This was a single Dutch center with a defined neuronavigation and MRI workflow.
  • The result supports ultrasound as an adjunct to maximize resection, especially where intraoperative MRI is impractical.
  • Advanced ultrasound techniques may perform differently than the simple 2-D B-mode protocol used here.

Evidence trace

Source trace and metadata

Citations (3)

claim_id

methods_critique.risk_of_bias

locator

p. 3

claim_id

stats_check.effect_sizes

locator

p. 3-4

claim_id

practice_impact.bottom_line

locator

p. 6

quote

Intraoperative ultrasound is a safe and useful intraoperative imaging alternative

Metadata

Generated at

2026-03-08T04:15:00Z

Version

manual-pdf-repair-v1