Aust.
N . Z . J . Surg. 1992,62,677-679
677
EDITORIAL COMMENT RE-OPERATION FOR RECURRENT MALIGNANT BRAIN TUMOURS: IS IT WORTHWHILE? Malignant primary brain turnours invariably recur. appearance may be other than a tumour recurrence (such as tumour necrosis or abscess); and if other Brain tumours account for 2 % of cancer deaths and nearly all of these are due to the infiltrating high therapies could be performed at the time of operagrade cerebral glioma. I Initial treatment of these tion or after surgery. The most important factor affecting the likelitumours usually involves surgery and radiotherapy, hood of improving survival with re-operation for although some other adjuvant therapies such as recurrent tumour is the histological characteristics chemotherapy and photodynamic therapy are sometimes used.' Whatever the treatment, high grade of the recurrence. Frequently, a recurrent tumour gliomas recur. Despite the best conventional treatwill show the appearance of more malignant bioment, the median survival of patients with primary logical activity than the initial tumour. An anabrain tumours is less than 1 year and only 5% of plastic astrocytoma may recur with the histological patients live longer than 2 years.".' In general, the pattern of a glioblastoma multiforme. The histological features of recurrent glioblastoma may show frequency of re-operation for recurrent cerebral even more pronounced malignant activity, as indiglioma has been low, and the operation is performed only in patients in good neurological condition with cated by poorer differentiation and increased mitotic activity. Recurrent anaplastic astrocytoma tumours in surgically accessible sites. Re-operation has usually been undertaken in a sporadic f a ~ h i o n ~ - ~ has a significantly better prognosis than the higher and there are only a few large modem series that grade glioblastoma multiforme. Ammirati et al. reported a median survival of 61 weeks for anaplastic have been able to use the technical advances develastrocytoma compared with 29 weeks for gliooped during the past decade.'-" The usual nihilisblastoma.' Whereas surgery for recurrent glioblastic approach to recurrent malignant gliomas has been thought to be justified because of the poor toma is essentially aimed at improving the quality prognosis. However, this belief should be tempered of survival in patients with anaplastic astrocytoma, by a realistic attitude that re-operation can be useful the operation may substantially enhance the length in some patients by both improving their quality of of high quality survival. life and enhancing their length of survival. In a time The tumour free interval is clearly related to the of limited medical resources re-appraisal of the useprognostic factors at the time of the initial treatment. The most important of these are the grade of fulness of surgery for recurrent gliomas is appropriate and it is essential to identify those patients most the tumour, patient age and performance status, and extent of initial resection. l3,I4 In general, the longer likely to benefit from further surgery. The decision to re-operate on patients with high the tumour free interval, the better is the chance of grade gliomas, such as anaplastic astrocytoma and enhancing the length of survival with further treatglioblastoma multiforme, will depend upon the ment. For recurrent high grade gliomas it is reasonpatients' general and neurological condition, their able to expect that the length of satisfactory high age and an understanding of the biological activity quality life after re-operation will be approximately of the particular tumour. Re-operation is performed half that of the initial tumour free period. This has to improve the quality of patient survival and to been the case in the last SO high grade recurrent enhance the length of survival. In various studies gliomas treated at the Royal Melbourne Hospital the likelihood of achieving these aims is related to and in only two patients was the length of survival after resection greater than the initial tumour free the histology of the recurrent tumour, the length of period if no adjuvant therapy was administered. time of recurrence from the initial operation, the The ability to perform a satisfactory resection intracerebral location of the recurrence, the morthat will palliate the symptoms of raised intracranial phological characteristics of the recurrent tumour and the patient's age and clinical status.7-" Other pressure and provide sufficient reduction of tumour factors that need to be taken into consideration are: burden to improve survival depends on the position the advisability of operating when there is radioof the tumour recurrence, its macroscopic characlogical (i.e. computerized tomography (CT) scan) teristics and its extension through the adjacent recurrence before the symptoms of clinical recurbrain. A large cyst can be drained simply to relieve rence; whether the clinical features or CT scan pressure symptoms and debulking is easily achieved
'
678
if there is a large necrotic centre to the tumour. Tumours that are diffusely infiltrating cannot usually be resected satisfactorily, particularly if eloquent areas are involved. Debulking of the tumour mass within the confines of a tumour can be safely achieved but in order to deal with viable tumour at the margins the resection must extend into the gliotic and oedematous surrounding brain. Resection of the tumour margins depends on the location of the tumour and whether vital structures are involved. Re-operation entailing excision of the main tumour bulk only and without resection of the tumour margins that are invading eloquent regions will palliate symptoms of raised intracranial pressure. This may be justified because the operation will improve the quality of survival, although it will have only a marginal effect on length of survival due to only a slight reduction in the total tumour burden. Younger patients benefit much more after further treatment of recurrent tumours. In the Royal Melbourne Hospital series only one of the last eight patients aged more than 70 years with recurrent high-grade glioma has survived more than half the initial tumour free period. The remainder have all failed to achieve a satisfactory period of remission of less than 35% of the initial tumour free period. Although the patient’s performance status at the time of recurrence does indicate the likelihood of a satisfactory response following further treatment, there are many factors that may cause a poor performance status and some of these may be reversible. If deteriorating conscious state is due to raised intracranial pressure, resection of tumour mass may result in dramatic improvement. On the other hand, neurological deterioration due to tumour invading deep vital structures will not be improved with surgery. A patient debilitated by excessive chemotherapy or electrolyte imbalance may improve after intensive medical treatment, and could be subsequently considered for further surgery. Re-operation for recurrent high grade gliomas requires careful planning before surgery. The patients are often frail, having been debilitated by the neurological deficit associated with a recurrent tumour, steroid medication and sometimes chemotherapy. These factors may also influence wound healing, blood coagulation and risk of infection. The brain tissues are fragile and there is little functional reserve. Minimizing the peri-operative mortality and postoperative morbidity depends on patient selection and careful technique. In the last 50 patients having re-operation for high grade gliomas at the Royal Melbourne Hospital there has been no perioperative mortality. Six patients had initial worsening of their pre-operative neurological deficit after re-operation and the neurological disability in two of these was significant and permanent. There was
KAY%
no substantial change to the pre-operative neurological disability in 16 patients and there was marked improvement in the remainder who showed an increase in the Karnofsky performance status ranging from 10 to 45 points (median 25 points). Other recent series report a postoperative mortality of up to 4% and morbidity of S-16%.7-“’ In the Royal Melbourne Hospital series postoperative survival and ‘high quality survival’ after re-operation depended on the tumour grade, patient age and tumour free interval after the first operation. In other series the relative importance of the tumour and patient characteristics have varied. Salcman indicated that the length of survival after the second operation was not correlated with the patient’s age, performance status, tumour grade or the intraoperative period.* In other series survival following re-operation has been influenced by the pre-operative functional the extent of tumour resection,’ and the age and histology of recurrent glioma.’.’” Young et al. also found a correlation between the pre-operative neurological status and the length of inter-operative interval in their series of re-operation for glioblastoma.’ Although some series have not found an association with the length of survival and age of patient there has been a correlation between longer maintenance of a higher Karnofsky score and a higher quality of survival after re-operation in younger patients. ’(’ The difference noted in the Royal Melbourne Hospital series may be an indication of the patient selection. Ammirati et ul. reported a median survival after re-operation of 36 weeks and a mean interval between the first operation and re-operation of 43 weeks.’ Forty-five per cent of patients had improved Karnofsky rating after re-operation. The median survival for glioblastoma was 29 weeks compared with 61 weeks for anaplastic astrocytoma. In a study by Harsh er ul. the median survival after re-operation for glioblastoma multiforme was 36 weeks and 88 weeks for anaplastic astrocytoma. ‘(’ The duration of high quality survival after re-operation for glioblastoma multiforme was less than 3 months in 56% of patients, greater than 6 months in 44% of patients and greater than 1 year in 18% of patients. Two patients had high quality survival for more than 3 years. A longer interval between operations was associated with longer total survival. The median duration of high quality survival after re-operation for anaplastic astrocytoma was 83 weeks. Fifty-two per cent of patients had at least 1 year of high quality survival and 13% had at least 4 years of high quality survival. A longer interval between operations correlated positively with longer total survival. In the series reported by Young et ul. the median survival time after reoperation was 14 weeks and 24 patients lived six months or longer after surgery.’ Both the interval
Ausr. N . Z . J . Surg. 1992,62,680-690
INAUGURAL WILLIAM MANCHESTER LECTURE THE INFLUENCE OF MICROSURGERY RESEARCH ON PLASTIC AND RECONSTRUCTIVE SURGERY BERNARD McC. O’BRIEN Microsurgery Research Centre, St Vincent’sHospital, Melbourne, Victoria, Australia This lecture embodies much of the research carried out in the Microsurgery Research Centre at St Vincent’s Hospital, Melbourne, over the past 25 years with my colleagues Wayne Morrison, Allan MacLeod, more than 100 Research Fellows and Registrars and a growing number of basic scientists working full time within the Research Centre. It is timely that the life and work of Sir William Manchester be recorded and I am indebted to him and his colleagues for some of this material. Sir William’s ancestry can be traced to John Manchester, who was born in 1751 in Eaton, Leicestershire, England. Then came a son, Thomas, and a grandson, George, Sir William’s grandfather. George ManChester, aged 21, with his older brother John, arrived in Timaru in the South Island of New Zealand in 1859 on the Strathallan. George Manchester died in 1907 and was buried in the old Wairnate cemetery. James Manchester, Sir William’s father, died in 1962. Sir William’s schooldays were stated to be uneventful, but there is one episode worthy of comment. At the age of 15 he dived into a shallow pool and received an extensive laceration of the scalp. He was so impressed by the surgical repair that he immediately decided on a surgical career. He returned to school with a shaven head and he remains to this day probably the only Knight of the realm nicknamed ‘Baldy’. Sir William had a distinguished undergraduate career at the Otago University, Dunedin and obtained his primary English fellowship as a student in 1934. The Otago Times featured the two English examiners, Mr Gordon Taylor and Professor Buckmaster. Sir William joined the New Zealand Medical Corps in 1940 (Fig. 1) and was shipped to England
Delivered at the Gcncral Scientific Meeting of the Royal Australasian College of Surgeons, Wellington. New Zealand, May 1990. Correspondence: B. McC O’Brien, Director, St Vincent’s Hospital, 41 Victoria Pde, Fitzroy, Vic. 3065, Australia. Acccptcd for publication 27 February 1992
Fig. 1. W. Manchester, Officer in the New Zealand Medical Corps, March 1940.
just after Dunkirk. He was trained in plastic surgery units in East Grinstead under Mr (later Sir) Archibald McIndoe, Sir Harold Gillies at Basingstoke and Mr Rainsford Mowlem at St Albans, all New Zealanders. In 194 I he established a plastic surgery unit in the No. 1 New Zealand General Hospital near Cairo. In 1944 he returned to New Zealand to the plastic surgery unit at Bunvood Hospital, Chnstchurch, becoming Surgeon in Charge 9 months later. In 1946 he was appointed Civilian Surgeon in Charge of this 60-bed unit, the first Civilian Plastic Surgery Unit in New Zealand. One of the highlights of that period was the visit by Field Marshal Lord
N . Z . J . Surg. 1992,62,677-679
677
EDITORIAL COMMENT RE-OPERATION FOR RECURRENT MALIGNANT BRAIN TUMOURS: IS IT WORTHWHILE? Malignant primary brain turnours invariably recur. appearance may be other than a tumour recurrence (such as tumour necrosis or abscess); and if other Brain tumours account for 2 % of cancer deaths and nearly all of these are due to the infiltrating high therapies could be performed at the time of operagrade cerebral glioma. I Initial treatment of these tion or after surgery. The most important factor affecting the likelitumours usually involves surgery and radiotherapy, hood of improving survival with re-operation for although some other adjuvant therapies such as recurrent tumour is the histological characteristics chemotherapy and photodynamic therapy are sometimes used.' Whatever the treatment, high grade of the recurrence. Frequently, a recurrent tumour gliomas recur. Despite the best conventional treatwill show the appearance of more malignant bioment, the median survival of patients with primary logical activity than the initial tumour. An anabrain tumours is less than 1 year and only 5% of plastic astrocytoma may recur with the histological patients live longer than 2 years.".' In general, the pattern of a glioblastoma multiforme. The histological features of recurrent glioblastoma may show frequency of re-operation for recurrent cerebral even more pronounced malignant activity, as indiglioma has been low, and the operation is performed only in patients in good neurological condition with cated by poorer differentiation and increased mitotic activity. Recurrent anaplastic astrocytoma tumours in surgically accessible sites. Re-operation has usually been undertaken in a sporadic f a ~ h i o n ~ - ~ has a significantly better prognosis than the higher and there are only a few large modem series that grade glioblastoma multiforme. Ammirati et al. reported a median survival of 61 weeks for anaplastic have been able to use the technical advances develastrocytoma compared with 29 weeks for gliooped during the past decade.'-" The usual nihilisblastoma.' Whereas surgery for recurrent glioblastic approach to recurrent malignant gliomas has been thought to be justified because of the poor toma is essentially aimed at improving the quality prognosis. However, this belief should be tempered of survival in patients with anaplastic astrocytoma, by a realistic attitude that re-operation can be useful the operation may substantially enhance the length in some patients by both improving their quality of of high quality survival. life and enhancing their length of survival. In a time The tumour free interval is clearly related to the of limited medical resources re-appraisal of the useprognostic factors at the time of the initial treatment. The most important of these are the grade of fulness of surgery for recurrent gliomas is appropriate and it is essential to identify those patients most the tumour, patient age and performance status, and extent of initial resection. l3,I4 In general, the longer likely to benefit from further surgery. The decision to re-operate on patients with high the tumour free interval, the better is the chance of grade gliomas, such as anaplastic astrocytoma and enhancing the length of survival with further treatglioblastoma multiforme, will depend upon the ment. For recurrent high grade gliomas it is reasonpatients' general and neurological condition, their able to expect that the length of satisfactory high age and an understanding of the biological activity quality life after re-operation will be approximately of the particular tumour. Re-operation is performed half that of the initial tumour free period. This has to improve the quality of patient survival and to been the case in the last SO high grade recurrent enhance the length of survival. In various studies gliomas treated at the Royal Melbourne Hospital the likelihood of achieving these aims is related to and in only two patients was the length of survival after resection greater than the initial tumour free the histology of the recurrent tumour, the length of period if no adjuvant therapy was administered. time of recurrence from the initial operation, the The ability to perform a satisfactory resection intracerebral location of the recurrence, the morthat will palliate the symptoms of raised intracranial phological characteristics of the recurrent tumour and the patient's age and clinical status.7-" Other pressure and provide sufficient reduction of tumour factors that need to be taken into consideration are: burden to improve survival depends on the position the advisability of operating when there is radioof the tumour recurrence, its macroscopic characlogical (i.e. computerized tomography (CT) scan) teristics and its extension through the adjacent recurrence before the symptoms of clinical recurbrain. A large cyst can be drained simply to relieve rence; whether the clinical features or CT scan pressure symptoms and debulking is easily achieved
'
678
if there is a large necrotic centre to the tumour. Tumours that are diffusely infiltrating cannot usually be resected satisfactorily, particularly if eloquent areas are involved. Debulking of the tumour mass within the confines of a tumour can be safely achieved but in order to deal with viable tumour at the margins the resection must extend into the gliotic and oedematous surrounding brain. Resection of the tumour margins depends on the location of the tumour and whether vital structures are involved. Re-operation entailing excision of the main tumour bulk only and without resection of the tumour margins that are invading eloquent regions will palliate symptoms of raised intracranial pressure. This may be justified because the operation will improve the quality of survival, although it will have only a marginal effect on length of survival due to only a slight reduction in the total tumour burden. Younger patients benefit much more after further treatment of recurrent tumours. In the Royal Melbourne Hospital series only one of the last eight patients aged more than 70 years with recurrent high-grade glioma has survived more than half the initial tumour free period. The remainder have all failed to achieve a satisfactory period of remission of less than 35% of the initial tumour free period. Although the patient’s performance status at the time of recurrence does indicate the likelihood of a satisfactory response following further treatment, there are many factors that may cause a poor performance status and some of these may be reversible. If deteriorating conscious state is due to raised intracranial pressure, resection of tumour mass may result in dramatic improvement. On the other hand, neurological deterioration due to tumour invading deep vital structures will not be improved with surgery. A patient debilitated by excessive chemotherapy or electrolyte imbalance may improve after intensive medical treatment, and could be subsequently considered for further surgery. Re-operation for recurrent high grade gliomas requires careful planning before surgery. The patients are often frail, having been debilitated by the neurological deficit associated with a recurrent tumour, steroid medication and sometimes chemotherapy. These factors may also influence wound healing, blood coagulation and risk of infection. The brain tissues are fragile and there is little functional reserve. Minimizing the peri-operative mortality and postoperative morbidity depends on patient selection and careful technique. In the last 50 patients having re-operation for high grade gliomas at the Royal Melbourne Hospital there has been no perioperative mortality. Six patients had initial worsening of their pre-operative neurological deficit after re-operation and the neurological disability in two of these was significant and permanent. There was
KAY%
no substantial change to the pre-operative neurological disability in 16 patients and there was marked improvement in the remainder who showed an increase in the Karnofsky performance status ranging from 10 to 45 points (median 25 points). Other recent series report a postoperative mortality of up to 4% and morbidity of S-16%.7-“’ In the Royal Melbourne Hospital series postoperative survival and ‘high quality survival’ after re-operation depended on the tumour grade, patient age and tumour free interval after the first operation. In other series the relative importance of the tumour and patient characteristics have varied. Salcman indicated that the length of survival after the second operation was not correlated with the patient’s age, performance status, tumour grade or the intraoperative period.* In other series survival following re-operation has been influenced by the pre-operative functional the extent of tumour resection,’ and the age and histology of recurrent glioma.’.’” Young et al. also found a correlation between the pre-operative neurological status and the length of inter-operative interval in their series of re-operation for glioblastoma.’ Although some series have not found an association with the length of survival and age of patient there has been a correlation between longer maintenance of a higher Karnofsky score and a higher quality of survival after re-operation in younger patients. ’(’ The difference noted in the Royal Melbourne Hospital series may be an indication of the patient selection. Ammirati et ul. reported a median survival after re-operation of 36 weeks and a mean interval between the first operation and re-operation of 43 weeks.’ Forty-five per cent of patients had improved Karnofsky rating after re-operation. The median survival for glioblastoma was 29 weeks compared with 61 weeks for anaplastic astrocytoma. In a study by Harsh er ul. the median survival after re-operation for glioblastoma multiforme was 36 weeks and 88 weeks for anaplastic astrocytoma. ‘(’ The duration of high quality survival after re-operation for glioblastoma multiforme was less than 3 months in 56% of patients, greater than 6 months in 44% of patients and greater than 1 year in 18% of patients. Two patients had high quality survival for more than 3 years. A longer interval between operations was associated with longer total survival. The median duration of high quality survival after re-operation for anaplastic astrocytoma was 83 weeks. Fifty-two per cent of patients had at least 1 year of high quality survival and 13% had at least 4 years of high quality survival. A longer interval between operations correlated positively with longer total survival. In the series reported by Young et ul. the median survival time after reoperation was 14 weeks and 24 patients lived six months or longer after surgery.’ Both the interval
Ausr. N . Z . J . Surg. 1992,62,680-690
INAUGURAL WILLIAM MANCHESTER LECTURE THE INFLUENCE OF MICROSURGERY RESEARCH ON PLASTIC AND RECONSTRUCTIVE SURGERY BERNARD McC. O’BRIEN Microsurgery Research Centre, St Vincent’sHospital, Melbourne, Victoria, Australia This lecture embodies much of the research carried out in the Microsurgery Research Centre at St Vincent’s Hospital, Melbourne, over the past 25 years with my colleagues Wayne Morrison, Allan MacLeod, more than 100 Research Fellows and Registrars and a growing number of basic scientists working full time within the Research Centre. It is timely that the life and work of Sir William Manchester be recorded and I am indebted to him and his colleagues for some of this material. Sir William’s ancestry can be traced to John Manchester, who was born in 1751 in Eaton, Leicestershire, England. Then came a son, Thomas, and a grandson, George, Sir William’s grandfather. George ManChester, aged 21, with his older brother John, arrived in Timaru in the South Island of New Zealand in 1859 on the Strathallan. George Manchester died in 1907 and was buried in the old Wairnate cemetery. James Manchester, Sir William’s father, died in 1962. Sir William’s schooldays were stated to be uneventful, but there is one episode worthy of comment. At the age of 15 he dived into a shallow pool and received an extensive laceration of the scalp. He was so impressed by the surgical repair that he immediately decided on a surgical career. He returned to school with a shaven head and he remains to this day probably the only Knight of the realm nicknamed ‘Baldy’. Sir William had a distinguished undergraduate career at the Otago University, Dunedin and obtained his primary English fellowship as a student in 1934. The Otago Times featured the two English examiners, Mr Gordon Taylor and Professor Buckmaster. Sir William joined the New Zealand Medical Corps in 1940 (Fig. 1) and was shipped to England
Delivered at the Gcncral Scientific Meeting of the Royal Australasian College of Surgeons, Wellington. New Zealand, May 1990. Correspondence: B. McC O’Brien, Director, St Vincent’s Hospital, 41 Victoria Pde, Fitzroy, Vic. 3065, Australia. Acccptcd for publication 27 February 1992
Fig. 1. W. Manchester, Officer in the New Zealand Medical Corps, March 1940.
just after Dunkirk. He was trained in plastic surgery units in East Grinstead under Mr (later Sir) Archibald McIndoe, Sir Harold Gillies at Basingstoke and Mr Rainsford Mowlem at St Albans, all New Zealanders. In 194 I he established a plastic surgery unit in the No. 1 New Zealand General Hospital near Cairo. In 1944 he returned to New Zealand to the plastic surgery unit at Bunvood Hospital, Chnstchurch, becoming Surgeon in Charge 9 months later. In 1946 he was appointed Civilian Surgeon in Charge of this 60-bed unit, the first Civilian Plastic Surgery Unit in New Zealand. One of the highlights of that period was the visit by Field Marshal Lord
