Management of malignant glioma: role of surgery in relation to multimodality therapy

Abstract

The goals of surgery for malignant glioma are to establish a histological diagnosis and to achieve mechanical cytoreduction to reduce intracranial pressure (ICP) and possibly alter tumor kinetics. There is controversy concerning the question whether the glioma is a focal or diffuse process; it appears that there may be variability between the two extremes in individual cases. The question of the value of surgery has also been controversial. Review of the literature suggests that both early and long-term postoperative outcome after radical surgical resection are better than the results of either partial resection or simple biopsy, in terms of neurological status and duration of survival. Similarly, reoperation for recurrence of glioma offers reasonable extension of quality survival. Despite the desirability of extensive cytoreductive surgery for malignant gliomas, the presence of viable in®ltrative cells beyond the margins of the resection necessitate that surgery be a part of an aggressive multimodality therapeutic approach. Adjunctive measures to control the in®ltrative component include newer forms of radiotherapy (such as stereotaxic radiosurgery) and newer delivery techniques for chemotherapy (agents impregnated in biodegradable polymers implanted in the tumor bed after surgical resection), and possibly immunotherapy and gene therapy as they may become feasible in the future. The strategy for management of malignant glioma thus consists of a combination of extensive surgical resection to reduce the accessible tumor burden, followed in rapid sequence by measures to control the in®ltrative portion of the tumor. It is recommended that these measures be offered`up front' rather than delaying treatment until there is clinical or radiographic evidence of tumor recurrence.

Operative Techniques for Gliomas and the Value of Extent of Resection

“…[53][54][55][56] However, there remains no general consensus in the literature regarding the efficacy of extent of resection in improving patient outcome. [57][58][59][60][61][62][63] With the exception of World Health Organization grade I tumors, gliomas are difficult to cure with surgery alone, and the majority of patients will experience some form of tumor recurrence.…”

Intraoperative stimulation techniques for functional pathway preservation and glioma resection

“…4 46 Low-grade gliomas carry a better prognosis, although the vast majority of patients eventually die of their disease and 5-year survival percentages range from 42 to 92% in the literature. 51,52,59,76,84,96,97,123 For all gliomas, the identification of universally applicable prognostic factors and treatment options remains a great challenge.…”

Multimodality Program Involving Stereotactic Surgery in Brain Tumor Management

“…It is a tenet of neurosurgery that the most efficient resection or cytoreduction may lead to the best eventual outcome or longest survival. Even with the best stereotactic-guided resection of all identifiable tumor tissue, it is recognized that gliomas always have viable infiltrative cells beyond the limit of resection [2], which requires therapy in addition to surgery.…”