Microsurgical outcomes and prognostic analysis of cerebellar gliomas; pathology, molecular biomarkers, and novel clinical insights: a retrospective study.
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INTRODUCTION: Cerebellar gliomas are a descriptive subset of posterior fossa gliomas which presents unique clinical challenges due to their proximity to critical structures. OBJECTIVE: To establish a location-stratified, molecularly integrated clinical benchmark for posterior fossa gliomas (cerebellar gliomas as a descriptive subset), and to define subtype-specific pathways that address the unique biological and anatomical characteristics of these tumors, distinct from supratentorial glioma paradigms. This study sets location-specific microsurgical outcome evaluation as primary objective and independent prognostic factor identification and subtype-specific adjuvant therapy definition as secondary objective. METHODS: This retrospective analysis of 450 patients with posterior fossa gliomas (cerebellar gliomas) who underwent microsurgical resection at a single institution was performed between 2014 and 2024. Anatomical localization such as cerebellar hemisphere, vermis, fourth ventricle, cerebellopontine angle (CPA) region, tumor volumetrics, extent of resection, and molecular profiling such as IDH1/2, 1p/19q, MGMT, TERT, and BRAF V600E, as well as perioperative morbidity, and long-term survival were systematically correlated. 1:1 propensity score matching (PSM) was used to disentangle the causal effect of gross total resection (GTR) from tumor biology/anatomical confounding. RESULTS: Gross total resection (GTR) was achieved in 74.9% of patients, with location emerging as the dominant surgical predictor: cerebellar hemisphere (80.7%) > vermis (78.0%) > fourth ventricle (58.2%) > CPA region (42.1%) (P < 0.001). In the subgroup of CPA region patients who received the modified retrosigmoid approach, GTR rate was significantly improved to 57.1% (8/14), yielding a 3-year overall survival of 67.3% to a ≥ 25% absolute improvement over historical controls. Molecular correlations in cerebellar gliomas diverged from supratentorial patterns: the canonical inverse IDH-TERT correlation was negligible (r = -0.09 vs. r ≈ -0.7 in supratentorial tumors), and IDH mutation showed only weak positive correlation with 1p/19q codeletion (r = 0.19, P < 0.001). CONCLUSION: Cerebellar gliomas follow the principle that location and molecular biomarkers are complementary core prognostic factors, with location as an independent determinant of surgical feasibility and long-term survival. Surgical tailoring to brainstem-adjacent anatomy and molecularly guided adjuvant strategies—including early irradiation for IDH-wildtype LGGs and intensified systemic therapy for TERT-mutant HGGs—deliver meaningful survival gains.