Predicting survival in butterfly glioma: The role of molecular markers and surgical management

Introduction Butterfly gliomas are a rare subset of gliomas, accounting for 2.2–14% of the glioma population. Literature reports poor survival outcomes, which raises concerns among clinicians regarding the benefits of aggressive surgical and oncological treatment. In particular, data from low- and middle-income countries (LMICs) is sparse, calling into question evidence-based decisions in resource-constrained settings. Methodology A retrospective review of cases was conducted at an academic tertiary care hospital in Karachi, Pakistan. Patients over 18 years of age with a diagnosis of butterfly glioma, based on radiological features and histopathology, were included. Treatment patterns and survival outcomes (overall survival [OS] and progression-free survival [PFS]) were evaluated using Cox regression and Kaplan-Meier curve analysis. Results Fifty-one butterfly gliomas (5.9%) were identified from a total of 854 gliomas treated at our center. The majority were glioblastomas (58.8%), with Grade 3 astrocytoma representing the highest propensity among the overall glioma patients (40% of all Grade 3 astrocytomas). Ten patients underwent surgical resection via awake craniotomy. Maximum safe resection (near-total [NTR] and subtotal [STR]) was achieved in 60.8% (n = 31) of patients. Surgery followed by CCRT and adjuvant chemotherapy, age under 45 years, asymmetrical radiological patterns, awake resection, NTR, STR, and IDH mutation in butterfly gliomas were associated with significantly better OS and PFS. Pre-operative KPS was an additional predictor of survival in regression analysis. Conclusion Achieving maximum safe resection of butterfly gliomas followed by appropriate chemoradiotherapy can improve survival outcomes despite previously reported poor prognosis. Further molecular characterization of butterfly gliomas would help elucidate tumor biology and identify subgroups amenable to aggressive treatment.