Case Report: Beyond two years: a neurosurgical review of prolonged survival and late recurrence in IDH-wildtype GBM.

IDH-wildtype glioblastoma multiforme (GBM), the most lethal primary brain tumor in adults, has a median survival of 12-15 months despite maximal multimodal therapy, including resection, radiotherapy, and chemotherapy. However, a rare subset of patients, ranging from 1% to 5%, exhibits a prognosis that defies this expectation, demonstrating prolonged survival beyond two years or late recurrence after a recurrence-free interval exceeding two years. These exceptional outcomes are shaped by tumor biology and the extent of surgical resection, underscoring the pivotal role of neurosurgery in altering GBM's relentless course. This review synthesizes current evidence on the neurosurgical strategies driving such rare successes, illuminated by a striking case of a 67-year-old female who survived 42 months with methylated O6-methylguanine-DNA methyltransferase (MGMT) and telomerase reverse transcriptase (TERT) mutation positivity following gross total resection (GTR) without neuronavigation. Enhanced by intraoperative photographs and serial MRIs, we explore the technical nuances of resection, the impact of vascular complications such as an MCA infarct, and the diagnostic challenges posed by late recurrence, including pseudoprogression. By integrating insights from literature with clinical realities, this work advocates for refined surgical approaches, including optimized resection techniques and intraoperative imaging, to improve outcomes in IDH-wildtype GBM. This approach offers neurosurgeons actionable perspectives to confront this formidable disease.