June 24, 2022

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Is the second craniotomy dangerous for glioblastoma?

Is the second craniotomy dangerous for glioblastoma?



 

Is the second craniotomy dangerous for glioblastoma?

What are the concerns of the patient? Is the second craniotomy dangerous for glioblastoma? What are the new treatments? What is the significance of biopsy?

 

The treatment of glioblastoma multiforme (GBM) usually involves multimodal interventions, including craniotomy and radiotherapy, combined with temozolomide (TMZ) chemotherapy. Although there are currently available treatment options, treatment resistance remains one of the main challenges.

 

For neuro-oncologists, exploring other feasible personalized treatment options may allow clinicians to improve patient prognosis. Is the second craniotomy dangerous for glioblastoma? What are the new treatments? What is the significance of biopsy?

 

There is new evidence that, as a result of clonal evolution, recurrent tumors are usually genetically different from the disease at the time of diagnosis. We cannot expect treatment decisions to be made on the initial diagnostic samples to guide effective treatment of the entire disease.

 

In particular, the use of the standard care agent temozolomide was associated with a significant increase in the number of mutation events, suggesting that treatments that help improve survival also lead to a more complex disease progression. In order to understand the key genomic changes and possible different therapeutic targets at the time of relapse, we must obtain a sample of the patient’s “new” disease, because the original sample is genetically out of date.

 

For patients with hematological malignancies with a low risk of bone marrow biopsy, this is a routine examination, but for patients with glioblastoma, it means re-opening the craniotomy and/or needle at some time after starting treatment and/or asymptomatic relapse Suction biopsy. This may be particularly relevant for glioblastoma, as there are several different molecular subtypes recently.

 

From a clinical point of view, using tumor resampling standards as an important indicator to measure the evolution of each patient’s GBM will be a paradigm shift. Although the potential advantages of tumor sampling are long-term, the potential advantages of tumor sampling must also be recognized.

 

After treatment begins and/or asymptomatic recurrence, patients undergoing repeated craniotomy for re-sampling may encounter the following problems: increased risk of infection; increased risk of neurological deficits; increased risk of psychological complications such as depression; Additional loss of normal life time; and increase in GBM processing costs.

 

Planned repeated surgery may have potential survival benefits. Repeated sampling can help to better understand the evolution of glioblastoma and help determine new potential treatment goals or adjust prognosis. Although in the long run, this strategy is necessary.

 

 

 

Influencing factors of secondary craniotomy for glioblastoma

 

The main reason patients are willing to undergo surgery is their surgeon

All patients stated that they would agree to the operation only if they were confident in the skill, experience and qualifications of the surgeon. Many patients have made it clear that if their surgeon is the same as the first operation, they will receive the operation again. Some patients also need to trust the surgeon’s intentions.

 

Patients believe that if surgeons can use patient trust to increase their qualifications and/or obtain new publications, ethical issues may arise. If they feel that the surgeon is most concerned about their interests, they will be more willing to undergo surgery. Many patients will ask if the surgeon would recommend surgery to their family members and accept their answers as a powerful measure of the effectiveness of the surgery.

 

Time is an important but variable factor for patients, which mainly depends on the patient’s leave requirements, recovery time and time to reintegrate into normal life

 

In the recovery phase, or the time and distance the patient needs are important. Some patients think the operation is worth the extra time, while others think it is a deterrent. Those who set goals for the future and are asymptomatic, regardless of their prognosis, are less interested in surgery.

 

 

The desire for altruism is very strong, and this includes patients who disagree with routine surgery but agree to participate in the trial

Some patients said that if the surgery was performed outside of the study, they would not be interested in the surgery because they were worried that it might have side effects and negative effects on their quality of life.

Despite such reservations, the patient agreed to a clinical trial of this operation.

They said they believe in the benefits of this kind of surgery, although they may not want it. They hope their participation will bring better treatment to others.

 

The first operation and/or previous clinical trial experience is the main factor in determining whether the patient is willing to undergo the second operation

Patients who have complications during the first operation are reluctant to consider repeat operations.

Every patient who agrees to undergo a second operation has a relatively quick recovery and minimal side effects.

Except for two patients, all patients said that the previous complications would greatly change their willingness to agree, and explained that the complications are a matter of luck and can happen to anyone at any time.

Trust in clinical trials will be enhanced by previous positive clinical trial experience.

 

The second operation performed within 3 months after the first operation may be too heavy for many patients

Some patients were willing and ready, while others said that they had just begun to receive the diagnosis at that time and they were not ready for the second operation.

The patient’s emotional health determines whether they are willing to consider surgery. Patients mentioned the role of hope in their emotional health.

The second operation and/or asymptomatic relapse reminds them of a serious problem and reduces the feeling of hope.

The two patients will agree to the operation because they feel that their lives are over, they want to be altruists and “voluntarily dedicate their brains.” This raises ethical issues, because the despair of some patients may be used inadvertently.

 

No matter what decision they make, patients don’t want to sacrifice quality of life

Patients are afraid that surgery will disable them and rely on their family members. Becoming a physical and financial burden can cause anxiety and reluctance to undergo surgery. In the trial, patients paid more attention to family opinions than surgery.

 

Generally speaking, patients are very interested in this kind of surgery

Of the 30 patients interviewed in this study, 22 patients would be interested if a routine GBM re-sampling biopsy were provided, provided that all the ethics and patient comfort mentioned above were resolved.

Eight patients would not be interested in surgery for personal comfort, although all eight patients expressed support for the study.

Taking into account that all ethical issues have been resolved, 16 patients agreed to participate in the clinical trial of this operation.

Two other patients indicated that they might be interested in clinical trials; however, this largely depends on their emotional and physical stability at the time. Twelve patients are not interested in participating in clinical trials at all.

 

For most patients interviewed, complete communication before surgery is a major issue

The patient expressed concern about the incomplete explanation of the operation. Before agreeing to the operation, the patient hopes to have a clearer understanding of the operation.

Some patients are very interested in the specific research behind the experimental surgery.

Patients also stated that they hope to provide this information early in the first diagnosis or treatment plan so that they can psychologically prepare for being asked about the second invasive surgery.

Some patients are interested in where/how the tumor is handled and the legality of the ownership of the tumor after resection.

 

 

 


Conclusion

When considering any surgery, the patient must consider several facts, weigh the pros and cons of the surgery, and then make a decision. The GBM resampling procedure is a surgical innovation.

Some of the factors that patients consider when accepting this innovation include: the surgeon’s trust, time spent, financial burden on themselves and their families, altruistic desires, mental and physical health, and their experience during the first operation.

 

Participants also highlighted many ethical issues that they or other potential patients may have, which may lead to patients’ reluctance to participate, including financial incentives, lack of communication, exploiting patient vulnerability, and surgeon transparency.

 

From the results of this study, the trust of the surgeon is the most important, arguably the most important factor for the patient to undergo this kind of surgery. The importance of trust is not surprising for patients participating in many other qualitative studies.

 

Because this operation is the second or third operation, probably the patient should have earned the trust of his/her surgeon because they passed the operation for the first time. Some concepts, such as re-sampling, are subtle and complex, and one person’s trust in another person, such as their surgeon, is basic and may outweigh other factors.

 

This process will also be assisted by neuro-oncologists and radiation oncologists; these team members have apparently seen and understood every patient considering re-sampling surgery.

 

It seems that most patients are interested in resampling surgery after treatment or asymptomatic recurrence of glioblastoma. If conventional treatment is used, many patients will also be interested in participating in clinical trials.

 

 

 

 

(source:chinanetnet, reference only)


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