ABSTRACT
Objective:
To evaluate the efficacy of microsurgery on cognitive function, activities of daily living (ADL), and serum biomarkers in patients with glioma.
Methodology:
This was a retrospective study. A total of 120 eligible patients with glioma were enrolled from Baoding No.1 Hospital from May 2023 to December 2024 and randomly divided into two groups. The control group underwent conventional craniotomy for tumor resection, while the study group opted for microsurgery. The surgical outcomes were compared between the two groups. Additionally, levels of inflammatory markers (interleukin-6 [IL-6], serum amyloid A [SAA], C-reactive protein [CRP], and tumor necrosis factor-alpha [TNF-α]) and cytokines (arginine vasopressin [AVP], oxytocin [OT], and β-endorphin [β-EP]), cognitive function, and ADL were assessed before and after surgery.
Results:
The surgical outcomes of study group were significantly superior to control group. After treatment, levels of IL-6, CRP, SAA, and TNF-α were significantly lower in the study group than in the control group, while the levels of AVP, OT, and β-EP were significantly higher in the study group (p = 0.00, respectively). Postoperative cognitive function, including language, memory, and orientation, was significantly better in the study group than in the control group (p = 0.00). At three and six months postoperative, the ADL scores in the study group were higher than in the control group (p = 0.00).
Conclusion:
Microsurgery is an effective, efficient treatment modality for the treatment of glioma, which is worthy of clinical promotion.
KEYWORDS: Microsurgery, Glioma, Cognitive function, ADL, Serum biomarker, Treatment
INTRODUCTION
Glioma is a common type of primary malignant intracranial tumor, accounting for approximately 40% of all intracranial tumors and 27% of central nervous system tumors.1 It is highly invasive and tends to spread from the primary site to normal brain tissue, making complete tumor resection challenging and severely affecting treatment outcomes.2 Glioma can lead to increased intracranial pressure, nausea, vomiting, headaches, seizures, and blurred vision, ultimately affecting neurological function and causing declines in cognitive function and activities of daily living (ADL).3 Traditional craniotomy with large bone flaps for tumor removal has several disadvantages, including large trauma, low visibility for the naked eye, and a high risk of damaging normal brain tissue.4 In recent years, traditional large-bone-flap craniotomy for tumor resection has gradually been replaced by microsurgical tumor removal under a microscope.
Microsurgery allows for more precise manipulation of tissues, accurate localization, and visualization of the tumor and its boundaries, leading to a higher rate of complete tumor resection.5 This improves surgical outcomes and extends the patient’s progression-free survival. Studies have shown that tumor development is closely related to inflammatory responses and cytokines, and the degree of change in these factors is associated with postoperative cognitive function and ADL in patients with glioma.6 On this basis, this comparative analysis of microsurgery and traditional open surgery in the treatment of glioma was conducted, and the findings suggest that microsurgery offers certain advantages, as reported below:
METHODOLOGY
This was a retrospective study. A total of 120 patients with glioma who met the inclusion criteria were enrolled from Baoding No.1 Hospital May 2023 to December 2024 and randomly divided into the control group underwent conventional craniotomy for tumor resection and the study group opted for microsurgery (n=60 each group).
Ethical Approval:
The study was approved by the Institutional Ethics Committee of Baoding No.1 Hospital (No.:2023-122; Date: April 20, 2023), and written informed consent was obtained from all participants.
Inclusion criteria:
Exclusion criteria:
patients with severe liver or kidney dysfunction or other organic diseases.
patients with a history of cranial surgery.
patients who were non-compliant with follow-up or had psychiatric disorders or cognitive impairments.
pregnant or lactating women;
patients with incomplete clinical data.
Treatment methods:
Before surgery, both groups of patients underwent computed tomography or magnetic resonance imaging to determine the tumor location. Patients in the control group underwent conventional craniotomy for tumor resection. The patients were placed in the supine position. Under general anesthesia, the bone flap was removed, the dura mater was opened, and the tumor was resected. The bone flap was preserved or replaced based on the condition of brain tissue bulging after tumor removal.
Patients in the study group underwent tumor resection under the microscope. A conventional craniotomy was performed at a location near the tumor, with the dura mater opened. The surgery was performed via the coronal or pterional approach, avoiding major blood vessels and functional areas. After exploration, the tumor was accessed from the surrounding glial proliferation or edema region and resected from the center toward the periphery. After hemostasis and confirmation that no abnormalities were present, the incision was sutured, and the surgery was completed.
Outcome measures:
Surgery-related parameters:
Duration of operation (DoO), intraoperative blood loss (IBL), length of hospital stay (LoHS), incision length (IL), ambulation time (AT).
Serum biomarker levels:
Peripheral venous blood was drawn from both groups of patients before and after surgery. Enzyme-linked immunosorbent assay (ELISA) was used to measure the levels of inflammatory markers (interleukin-6 [IL-6], serum amyloid A [SAA], C-reactive protein [CRP], and tumor necrosis factor-alpha [TNF-α]) and cytokines (arginine vasopressin [AVP], oxytocin [OT], and β-endorphin [β-EP]).
Cognitive function:
Cognitive function was assessed using the Mini-Mental State Examination (MMSE)9 before surgery and three months after surgery for both groups. The MMSE includes three dimensions: language, memory, and orientation, with each dimension scoring from zero to five points. Higher scores indicate better cognitive function.
ADL:
ADL was evaluated using the Instrumental Activities of Daily Living Scale (IADL)10 preoperative, three months postoperative, and six months postoperative for both groups. The total score of the IADL scale is 100 points. The higher the score, the better the ADL.
Statistical analysis:
Statistical analysis was performed using SPSS 20.0. Measurement data were represented by (χ̅±s). Between-group comparisons were performed using an independent sample t-test. Within-group comparisons were conducted using a paired t-test. Repeated measurement data were analyzed using analysis of variance (ANOVA). Comparisons of rates were performed using the chi-square (χ²) test. A p-value of less than 0.05 was considered statistically significant.
RESULTS
No significant differences were observed in the baseline data between the two groups, indicating a high level of comparability (Table-I).
Table-I.
Comparative analysis of general patient data between the study and control groups (χ̅±S), n = 60.
| Item | Study group | Control group | t/χ2 | p-value |
|---|---|---|---|---|
| Age (years) | 47.32±5.71 | 47.84±5.36 | 0.51 | 0.60 |
| Male (n, %) | 38 (63%) | 36 (60%) | 0.14 | 0.71 |
| Disease duration (months) | 5.26±1.33 | 5.42±1.27 | 0.67 | 0.50 |
| Past history | 0.05 | 0.82 | ||
| Hypertension | 13(22%) | 12(20%) | ||
| Diabetes | 8(13%) | 11(18%) | ||
| Hyperlipidemia | 14(23%) | 15(25%) | ||
| BMI (kg/m²) | 23.48±3.15 | 23.73±3.09 | 0.44 | 0.67 |
| Glioma grading | 0.59 | 0.44 | ||
| Grade I–II | 41(68%) | 37(62%) | ||
| Grade III–IV | 19(32%) | 23(38%) |
p > 0.05.
The study group demonstrated significantly shorter DoO, less IBL, shorter LoHS, shorter average IL, and faster AT compared with the control group (p = 0.00, respectively) (Table-II). Before treatment, there were no statistically significant differences between the two groups in inflammatory markers (IL-6, CRP, SAA, TNF-α) (all p > 0.05). After treatment, these markers were significantly lower in the study group than in the control group (p = 0.00, respectively) (Table-III).
Table-II.
Comparison of surgery-related parameters between the two groups (χ̅±S), n = 60.
| Group | DoO (min)* | IBL (ml) | AT (d)* | IL (cm)* | Postoperative LoHS (d)* |
|---|---|---|---|---|---|
| Study group | 65.83±9.44 | 75.60±20.33 | 3.59±1.07 | 5.26±1.13 | 6.40±1.54 |
| Control group | 84.57±8.25 | 103.25±21.80 | 6.76±1.75 | 8.86±1.27 | 9.35±1.48 |
| t-value | 11.57 | 7.08 | 11.80 | 8.40 | 11.44 |
| p-value | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
p < 0.05.
Table-III.
Comparison of inflammatory marker and cytokine levels before and after treatment between the two groups (χ̅±S), n = 60.
| Inspection item | Time point | Study group | Control group | t-value | p-value |
|---|---|---|---|---|---|
| IL-6 (ng/L) | Preoperative | 15.75±6.43 | 15.46±6.18 | 0.25 | 0.80 |
| Postoperative* | 6.93±3.12 | 9.07±3.75 | 3.40 | 0.00 | |
| CRP (mg/L) | Preoperative | 97.35±20.31 | 96.84±19.50 | 0.14 | 0.89 |
| Postoperative* | 57.62±9.55 | 62.68±9.11 | 3.01 | 0.00 | |
| TNF-α (ng/L) | Preoperative | 47.63±13.52 | 46.87±12.80 | 0.32 | 0.75 |
| Postoperative* | 23.78±7.55 | 28.29±8.15 | 4.32 | 0.00 | |
| SAA (mg/L) | Preoperative | 134.07±22.42 | 132.84±23.06 | 0.40 | 0.69 |
| Postoperative* | 53.73±13.76 | 63.62±12.09 | 4.18 | 0.00 | |
| AVP (ng/L) | Preoperative | 23.37±5.60 | 23.48±6.07 | 0.14 | 0.92 |
| Postoperative* | 12.85±4.29 | 8.05±4.11 | 6.26 | 0.00 | |
| OT (ng//L) | Preoperative | 8.84±2.18 | 8.71±2.42 | 0.31 | 0.76 |
| Postoperative* | 3.76±0.71 | 2.83±0.46 | 8.52 | 0.00 | |
| β-EP (ng/L) | Preoperative | 96.59±10.44 | 97.23±9.87 | 0.34 | 0.73 |
| Postoperative* | 63.18±8.72 | 54.06±8.02 | 5.96 | 0.00 |
p < 0.05.
There were no significant differences between the two groups in AVP, OT, and β-EP levels before surgery (all p > 0.05). After surgery, these cytokine levels were significantly higher in the study group than in the control group (p = 0.00, respectively) (Table-III).
No significant differences were observed between the two groups in cognitive function, including language, memory, and orientation before surgery (all p > 0.05). At three months postoperative, the study group demonstrated significantly higher scores in these dimensions compared with the control group (p = 0.00, respectively) (Table-IV). No significant difference was observed in ADL scores between the two groups before surgery (all p > 0.05). At three and six months postoperative, the study group had significantly higher ADL scores than the control group (p = 0.00) (Table-V).
Table-IV.
Comparison of cognitive function before and after surgery between the two groups (χ̅±S), n = 60.
| Cognitive function | Time point | Study group | Control group | t-value | p-value |
|---|---|---|---|---|---|
| Language | Preoperative | 1.68±0.14 | 1.67±0.13 | 0.41 | 0.69 |
| Postoperative* | 3.74±0.70 | 3.21±0.53 | 4.68 | 0.00 | |
| Memory | Preoperative | 1.73±0.15 | 1.71±0.21 | 0.60 | 0.55 |
| Postoperative* | 3.58±0.62 | 3.19±0.57 | 3.59 | 0.00 | |
| Orientation | Preoperative | 1.85±0.27 | 1.84±0.16 | 0.25 | 0.81 |
| Postoperative* | 3.12±0.20 | 2.78±0.32 | 6.92 | 0.00 |
p < 0.05.
Table-V.
Comparison of ADL scores before and after surgery between the two groups (χ̅±S), n = 60.
| Group | Preoperative | At 3 months postoperative* | At 6 months postoperative* | F-value | p-value |
|---|---|---|---|---|---|
| Study group* | 60.75±5.63 | 70.53±6.19 | 78.27±6.82 | 9.05 | 0.00 |
| Control group* | 61.08±5.57 | 67.49±6.05 | 72.44±6.74 | 6.04 | 0.00 |
| t | 0.33 | 2.72 | 4.71 | ||
| p | 0.74 | 0.00 | 0.00 |
p < 0.05.
DISCUSSION
The results of this study demonstrate that microsurgery can effectively shorten surgery duration, hospital stay, and time to first postoperative ambulation, reduce intraoperative bleeding, and minimize incision size. These findings are consistent with previous studies.11 This effect may be attributed to the enhanced ability of microscopy to observe tumor characteristics, allowing for more accurate tumor localization. As the incision is smaller, patients also tend to experience faster postoperative recovery. A study reported the results of microsurgery on 20 cases of glioma, indicating that the final median resection rate was 92%, 60% of the patients were asymptomatic at discharge, and 45% of the patients were able to return to work after the operation.12 This also supports the conclusion of this study. OT, β-EP, and AVP are endogenous active substances found in neural tissues that can effectively promote the functional recovery of brain neurons.13 In this study, after surgery, the levels of OT, β-EP, and AVP in the study group were significantly higher than those in the control group. This suggests that microsurgery has a less damage to neural function. Sayyahmelli et al.14 also emphasized that microsurgery can provide safe and effective treatment for complex craniocerebral lesions. Inflammatory markers like IL-6, CRP, SAA, and TNF-α can induce M2 macrophage polarization, promoting glioma progression and playing an essential role in glioma development.15
Gliomas are primary intracranial tumors originating from glial cells, representing the most common type of primary brain tumor, accounting for approximately 80% of all malignant brain tumors.16 Its severely threaten patients’ lives, impact their quality of life, and impose heavy burdens on patients, their families, and society.17 Currently, surgery remains the mainstay of treatment for gliomas. However, craniotomy incisions are typically large, leading to excessive damage and resection of brain tissue in functional areas, which contributes to neurological dysfunction in patients. This affects postoperative outcomes, prolongs recovery time, leads to poor prognosis, and negatively impacts postoperative quality of life. Recently, microsurgery has gradually been applied to the treatment of patients with glioma. The microsurgical approach, which emphasizes precise operation, protection of blood vessels and nerves, preservation of normal tissue, and atraumatic suturing, is a key factor in surgical success.18
This study found that after the operation, the levels of the above inflammatory markers in the study group decreased more significantly than those in the control group. This confirms that microsurgery is safer than conventional open surgery and has a smaller impact on neural tissue. Studies suggested that circulating IL-6 and CRP may serve as powerful biomarkers for a poor prognosis in glioma patients.19,20 Further results showed that microsurgical treatment for glioma can improve cognitive function and ADL. This may be explained by the reduced damage to normal brain tissue during microsurgery, which allows for complete tumor resection with minimal impact on neural function, contributing to faster postoperative recovery for patients. This study systematically explored for the first time the combined effect of AVP, OT, β-EP and serum inflammatory factors (TNF-α, IL-6, CRP) in postoperative nerve injury and prognosis of patients with glioma, filling the research gap in this field.
Limitations:
It include a small patient sample size and a short follow-up period. Future studies should increase the sample size and extend the follow-up duration to provide a more objective assessment of the long-term benefits and stronger clinical evidence of this treatment approach for patients with glioma.
CONCLUSION
Microsurgery demonstrates a more favorable clinical efficacy for patients with glioma compared with traditional craniotomy. This treatment approach proves to be both safe and effective as it can facilitate better recovery of serum biomarkers such as AVP, OT, and β-EP, exert a minimal impact on inflammatory markers, and effectively improve patients’ cognitive function and ADL.
Authors’ Contributions:
YC and ZM: Conceived and designed the study.
DZ and LM: Collected the data and performed the analysis.
XS: Was involved in the writing of the manuscript and is responsible for the integrity of the study.
All authors have read and approved the final manuscript.
Footnotes
Conflicts of interest: None.
Source of funding: None.
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