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Journal Club

Tumor/Skull Base

T2 Fluid-Attenuated Inversion Recovery Resection for Glioblastoma Involving Eloquent Brain Areas Facilitated Through Awake Craniotomy and Clinical Outcome

World Neurosurgery | 2020

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

10.1016/j.wneu.2019.12.130

PMID

N/A

PICO

Population

Adults aged 18-75 years with newly diagnosed single glioblastoma involving or near eloquent brain areas after gross-total resection of contrast-enhancing tumor.

Intervention

Extended resection of FLAIR abnormality to at least 25% beyond the contrast-enhancing tumor, performed with awake craniotomy with or without sodium fluorescein.

Comparator

FLAIR resection below 25%.

Outcomes

Overall survival, progression-free survival, postoperative neurologic function, and Karnofsky Performance Scale.

Design

Type

Retrospective single-center cohort study

Randomized

No

Multicenter

No

Blinded

N/A

Follow-up

Median 12.5 months

Primary endpoint

Overall survival and progression-free survival by extent of FLAIR resection.

Secondary endpoints

  • Postoperative neurologic benefit versus nonbenefit
  • Postoperative and delayed Karnofsky Performance Scale
  • Effect of sodium fluorescein on extent of FLAIR resection

Practice impact

What this means

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.

Bottom line

For selected eloquent-area glioblastomas, aiming for at least 25% additional FLAIR resection after gross-total contrast-enhancing resection may improve survival without a clear signal of worse short-term neurologic function.

Strength of evidence

low

Recommendation

consider change

Why it matters

  • The survival difference was large and remained significant in multivariable analysis.
  • Functional outcomes and KPS did not clearly worsen above the 25% threshold in this cohort.
  • Confidence should stay limited because the study was retrospective, single-center, and threshold-selected after the fact.

What would change my mind

  • A prospective multicenter study that prespecifies the FLAIR target and confirms the same survival gap.
  • Molecularly stratified data showing the association persists after adjusting for MGMT and IDH status.

Critical appraisal

How strong is the paper?

Methods critique

Risk of bias

Retrospective single-center design with surgeon-selected technique introduces confounding by case complexity and center expertise.

Confounding

Patients treated with sodium fluorescein were imbalanced by tumor location, and survival may reflect tumor location as well as resection strategy.

Missing data

The paper reports follow-up duration and recurrence management but does not give a detailed missing-data accounting for functional or imaging outcomes.

Multiplicity

The 25% FLAIR threshold was selected after testing 5% increments and multiple subgroup comparisons were reported without a multiplicity correction.

Notes

  • All patients had gross-total resection of the contrast-enhancing tumor, so the comparison isolates added FLAIR resection rather than standard gross-total resection.
  • Molecular prognostic markers were not reported, which limits adjustment for baseline tumor biology.
  • The threshold search was data-driven rather than prespecified.

Stats check

NNT

N/A

Effect sizes

  • FLAIR resection >=25% was associated with better overall survival on multivariable analysis (HR 0.204, 95% CI 0.074-0.561).
  • FLAIR resection >=25% was associated with better progression-free survival on multivariable analysis (HR 0.316, 95% CI 0.141-0.709).

Absolute effects

  • Median overall survival was 26 months with FLAIR resection >=25% versus 12 months with FLAIR resection <25%.
  • Median progression-free survival was 15 months with FLAIR resection >=25% versus 6 months with FLAIR resection <25%.

Concerns

  • The cohort included only 46 patients, so hazard ratios may be unstable.
  • Post-hoc threshold optimization can overstate the apparent benefit.
  • Neurologic safety was measured without randomization, so equivalence cannot be claimed with confidence.

External validity

Who it applies to

High-volume glioma centers able to combine awake mapping, volumetric MRI assessment, and aggressive resection near eloquent cortex.

Who it does not

Patients with multifocal disease, poor preoperative functional status, or tumors not safely approachable with awake mapping.

Generalizability notes

  • The cohort came from one Chinese center with a specialized awake-craniotomy workflow.
  • Results may not transfer to centers without reliable functional mapping and postoperative volumetric review.
  • The study population was younger than many real-world glioblastoma cohorts.

Evidence trace

Source trace and metadata

Citations (3)

claim_id

methods_critique.confounding

locator

p. 6 Table 3

claim_id

stats_check.effect_sizes

locator

p. 6 Table 3

claim_id

practice_impact.bottom_line

locator

p. 8

quote

FLAIR EOR of no less than 25% may be beneficial to the survival of patients with GBM without additional neurologic damage.

Metadata

Generated at

2026-03-08T03:10:00Z

Version

manual-pdf-repair-v1