Joost W. Schouten’s research while affiliated with Erasmus MC and other places

Background and objectives Tumor location and its proximity to eloquent brain areas are key factors in glioma surgery decision-making. However, the absence of a consensus definition for eloquent brain areas leads to variability in surgical decision-making. This survey aimed to assess this heterogeneity in defining eloquent brain regions. Methods A survey was distributed among neurosurgeons in the United States, Europe, Latin America, and Australasia between February and November 2023. Respondents rated the eloquence of various brain structures on a Likert scale and reported their use of preoperative techniques. Twelve glioma and glioblastoma cases were presented to assess opinions on tumor location eloquence and preferred surgical approaches. Results 157 neurosurgeons from 25 countries responded to the survey. Two-thirds (68%) agreed on the need for a standardized definition of eloquence, while only 23% applied existing eloquence grading scales. Eloquence ratings varied, with the highest variation reported for the corona radiata, uncinate fasciculus and superior longitudinal fasciculus. In patient cases, variability was observed at four levels of decision-making: (1) degree of eloquence; (2) preferred surgical modality; (3) use of intraoperative mapping; (4) the preferred mapping modality (asleep or awake). Conclusions This survey highlights the variability in defining eloquence and its impact on glioma surgery decision-making. This lack of consensus limits the reliability of eloquence as a descriptor of tumor location, affecting patient care and comparability across studies. Future research should focus on the development of an easy-to-use, objective method (based on intraoperative data) for identifying eloquent brain regions preoperatively.

Ultrafast Doppler ultrasound imaging allows for detailed images of blood flow inside the brain during neurosurgical interventions. In this work, we extend this new imaging technique to geometrically accurate volumetric reconstructions using freehand 2D ultrafast ultrasound acquisitions in conjunction with optical position tracking. We show how the Doppler signal can be derived from a moving freehand ultrasound scan. These filtered 2D images are subsequently mapped onto a shared 3D reference space using a normalized convolution function. The proposed methodology allows for highly detailed volumetric reconstructions of cerebral and tumor blood flow. The dense vascular networks show intriguing blood vessel morphology with vessels down to several hundred micrometers in diameter. By adding patient-co-registered volumetric reconstruction to ultrafast Doppler ultrasound, we have created a 3D intra-operative imaging technique that is unmatched in terms of resolution, ease of use, and visualization capabilities.

Objective To examine whether MRI with routine gadolinium-based contrast agent (GBCA) administration in the long-term surveillance of adult-type diffuse glioma identifies tumour progression earlier than T2-weighted (T2w) and/or T2w fluid-attenuated inversion recovery (FLAIR) MRI only. Materials and methods In this longitudinal retrospective multicentre cohort study patients with histopathologically confirmed adult-type diffuse glioma and at least two years survival after diagnosis in 2009–2010 were included. Progression was determined by the treating physician or during the multidisciplinary team meeting and defined as the moment a change in treatment or follow-up was required. The primary outcome was the proportion of patients that showed an increase of abnormalities on both contrast-enhanced T1-weighted (CET1w) and T2w/T2w-FLAIR at the time of progression. Chi-square testing was performed to analyse the relationship between the detection of progression on both scan sequences, with calculating the Phi coefficient to determine the degree of association. Results One hundred eight consecutive patients were included (58 male; 53 grade 2, 21 grade 3, 34 grade 4). Progression was present in 82 patients and was determined on both CET1w and T2w/T2w-FLAIR images in 59 patients (72.0%). In 20 patients (24.4%), progression was determined based solely on T2w/T2w-FLAIR abnormalities. Only three patients showed progression exclusively on CET1w (3.7%). There was a strong positive significant relationship between the detection of progression on both scan types ( p < 0.001; Phi = 0.467). Conclusion An increase in CET1w abnormalities was generally accompanied by an increase in T2w/T2w-FLAIR abnormalities, raising the question of whether routine administration of GBCA is always necessary for long-term survivors of glioma. Key Points Question Long-term survivors with glioma undergo many contrast-enhanced MRI scans, which involve a patient, financial, and environmental burden. Findings In almost all patients, an increase in T2w/T2w-FLAIR abnormalities was present at the time of tumour progression, mostly but not always accompanying contrast-enhancing findings. Clinical relevance T2w/T2-FLAIR MRI seems to detect glioma progression in long-term surviving patients similar to contrast-enhanced T1w MRI, raising the question of whether the routine administration of GBCA is necessary and justified in patients under long-term surveillance of glioma. Graphical Abstract

Background The diagnosis and awake removal of a brain tumor is a major life event. A better understanding of the needs of this group of patients and their primary contacts in the perioperative trajectory can further improve care. Methods Adult patients who underwent an awake craniotomy (AC) in the Erasmus MC, the Netherlands and their primary contacts were interviewed 1–2 weeks prior to surgery and 2–4 weeks after surgery. Semi-structured interviews on the impact of the diagnosis on their lives and coping mechanisms with the AC procedure were conducted. Interview transcripts were analyzed in accordance with the principles of grounded theory. Results Twenty-one patients and 19 primary contacts were interviewed at least once during this period. Analyses and coding of the transcripts resulted in a conceptual model, distinguishing coping with the disease and coping with specific procedures of AC. In general, participants tended to rely on their pre-existing ways of coping. Situation-specific coping mostly refers to perceiving control, and related to that, trust in the medical team. Conclusions Patients with a brain tumor and their primary contacts perceive coping with the AC procedure as a part of coping with the disease. Although the procedure may be perceived as stressful, at the same time it offers hope and prospect. In coping with the specifics of the AC procedure, we found that feeling in control and as an extension of that, trust in the AC team were key aspects.

Background The combined impact of complete resection (oncological goal) and no functional loss (functional goal) in glioblastoma subgroups is currently unknown. This study aimed to develop a novel onco-functional outcome (OFO) to merge these two goals into one outcome, resulting in four classes: complete without deficits (OFO1), incomplete without deficits (OFO2), complete with deficits (OFO3), or incomplete with deficits (OFO4). Methods Between 2010–2020, 858 patients with tumor resection for eloquent glioblastoma were included. We analyzed the impact of OFO class on postoperative surgical outcomes using Cox proportional-hazards models with hazard ratios (HR) or logistic regression with odds ratios (OR), followed by specific subgroup analyses. We developed a risk model to predict OFO class preoperatively using logistic regression. Results The OFO classification stratified the four OFO classes for overall survival (OS:19.0 versus 14.0 versus 12.0 versus 9.0 months), progression-free survival (PFS), and adjuvant therapy. OFO1 was associated with improved OS [HR= 0.67, (0.55–0.81); p < 0.001], and PFS [HR = 0.68, (0.57–0.81); p < 0.001] in the overall cohort and all clinical and molecular subgroups, except for MGMT-unmethylated tumors; and higher rate of adjuvant therapy [OR= 2.81, (1.71–4.84);p < 0.001]. In patients≥ 70 years, only OFO1 improved their survival outcomes. Safe surgery was especially important in patients with a preoperative KPS ≤ 80 to qualify for adjuvant treatment. Awake craniotomy more often led to OFO1 compared to asleep resection [OR = 1.93, (1.19–3.14); p = 0.008]. Conclusions OFO1 was associated with improved OS, PFS, and receipt of adjuvant therapy in all glioblastoma patients with IDH-wildtype and MGMT-methylated tumors. Awake craniotomy was associated with achieving this optimal OFO status. Preventing deficits was more important than complete surgery.

e14017 Background: Minimizing residual volume and preventing functional loss are the main goals in glioblastoma resections in eloquent areas. However, their combined impact on patient outcomes remains poorly understood. We therefore developed a novel onco-functional outcome (OFO) classification and evaluated its benefit in subgroups based on age, preoperative neurological morbidity (NIHSS), and Karnofsky Performance Score (KPS). Methods: Propensity-score matching was used to match OFO 1 (gross total resection, no functional loss) vs. OFO 2-3-4, OFO 2 (no gross total resection, no functional loss) vs. OFO 1-3-4, OFO 3 (gross total resection, functional loss) vs. OFO 1-2-4, and OFO 4 (no gross total resection, no functional loss) vs. OFO 1-2-3 for the overall cohort and subgroups. Cox proportional-hazard regressions and logistic regressions were performed to analyze the association between OFO class and postoperative outcomes, and the predictive value of perioperative factors on OFO class, respectively. Results: Between 2010 and 2020, 3919 patients were recruited, of whom 858 were included as the overall unmatched cohort. After propensity-score matching, the overall matched cohort comprised of 512 patients, of whom 256 had OFO 1 and 256 had OFO 2-3-4. Overall survival differed significantly between OFO groups: 21.0 months [19.0-25.0] (OFO 1) versus 14.0 months [13.0-16.0] (OFO 2) versus 12.0 [11.0-15.0] (OFO 3) versus 8.5 months [7.0-10.0] (OFO 4) (p<0.0001). In the overall matched cohort, OFO 1 versus OFO 2-3-4 resulted in fewer neurological deficits at 6 weeks (26 [10.2%] of 256 vs. 66 [25.8%] of 256, p <0.001), 3 months (30 [12.7%] of 237 vs. 69 [29.9%] of 231, p <0.001), and 6 months postoperatively (48 [21.0%] of 229 vs. 72 [35.1%] of 205, p = 0.0010), lower frequencies of KPS deterioration at 3 months (34 [14.2%] of 239 vs. 121 [52.4%] of 231, p <0.001), and 6 months postoperatively (61 [26.5%] of 230 vs. 110 [52.9%] of 208, p<0.001), longer overall survival (median 21.0 months [19.0-25.0] vs. 13.0 months [12.0-15.5], p<0.001), and longer progression-free survival (median 10.0 months [9.0-11.0] vs. 7.5 months [6.0-8.0], p<0.001). OFO 1 was associated with higher frequencies of receipt of adjuvant chemotherapy and radiotherapy, and longer overall survival and progression-free survival in all subgroups except the KPS 90-100 subgroup. Awake craniotomy more often led to OFO 1 compared to asleep resection (43.0% vs. 26.9%, p<0.001; OR 1.91, p = 0.0080). Conclusions: OFO 1 was associated with improved survival outcomes, neurological outcomes, and receipt of adjuvant therapy in all glioblastoma patients. Awake craniotomy was significantly associated with achieving this more often. Aggressive and safe resections (OFO 1) were superior to resections that were defensive but safe (OFO 2), aggressive but unsafe (OFO 3), or defensive but unsafe (OFO 4).

We describe a 46‐year‐old patient with an IDH ‐wildtype diffusely infiltrating atypical teratoid/rhabdoid tumour (AT/RT), SHH‐1B molecular subtype. The unusual histology and subsequent diagnosis in an adult patient will be discussed.

A diagnosis of brain metastasis (BM) significantly affects quality of life in patients with metastatic renal cell cancer (mRCC). Although systemic treatments have shown efficacy in mRCC, active surveillance (AS) is still commonly used in clinical practice. In this single‐center cohort study, we assessed the impact of different initial treatment strategies for metastatic RCC (mRCC) on the development of BM. All consecutive patients diagnosed with mRCC between 2011 and 2022 were included at the Erasmus MC Cancer Institute, the Netherlands, and a subgroup of patients with BM was selected. In total, 381 patients with mRCC (ECM, BM, or both) were identified. Forty‐six patients had BM of whom 39 had metachronous BM (diagnosed ≥1 month after ECM). Twenty‐five (64.1%) of these 39 patients with metachronous BM had received prior systemic treatment for ECM and 14 (35.9%) patients were treatment naive at BM diagnosis. The median BM‐free survival since ECM diagnosis was significantly longer (p = .02) in previously treated patients (29.0 [IQR 12.6–57.0] months) compared to treatment naive patients (6.8 [IQR 1.0–7.0] months). In conclusion, patients with mRCC who received systemic treatment for ECM prior to BM diagnosis had a longer BM‐free survival as compared to treatment naïve patients. These results emphasize the need for careful evaluation of treatment strategies, and especially AS, for patients with mRCC.

INTRODUCTION Minimizing residual tumor volume and preventing functional loss are the primary goal in glioblastoma resections in eloquent areas. However, their combined impact on patient outcomes remains poorly understood. METHODS Propensity-score matching was used to match OFO 1 (gross-total resection with no functional loss), OFO 2 (no gross-total resection with no functional loss), OFO 3 (gross-total resection with functional loss) and OFO 4 patients (no gross-total resection with functional loss) for the overall cohort and subgroups. Cox proportional-hazard regressions were performed to analyze the association between OFO class and surgical outcomes. Logistic regressions were performed to identify preoperative predictors for OFO class. RESULTS Between 2010 and 2020, 858 patients were included as the overall unmatched cohort. After matching, the cohort comprised of 512 patients: 256 received OFO 1 and 256 received non-OFO 1. OFO 1 resulted in fewer postoperative neurological deficits at 6 weeks (10.2% vs. 25.8%, p < 0.001), 3 months (12.7% vs. 9.9%, p < 0.001), and 6 months (21.0% vs. 35.1%, p = 0.0010); lower rates of KPS deterioration at 3 months (14.2% vs. 52.4%, p < 0.001), and 6 months (26.5% vs. 52.9%, p < 0.001); higher rate of receipt of adjuvant therapy (HR 3.91, p < 0.001), longer overall survival (median 21.0 vs. 13.0 months, p < 0.001), and longer progression-free survival (median 10.0 vs. 7.5 months, p < 0.001). Patients who underwent awake craniotomy more often received OFO 1 (43.0% vs. 26.9%, p < 0.001; OR 1.92, p = 0.0070). CONCLUSIONS OFO 1 is beneficial in patients with eloquent glioblastoma to improve outcomes - irrespective of age, preoperative NIHSS, or KPS - in terms of survival, functional outcomes, and receipt of adjuvant therapy. Awake craniotomy was significantly associated with achieving this.