Adaptive Hybrid Surgery: Paradigm Shift for Patient-centered Neurosurgery

Abstract

The surgical management of cerebral and skull base lesions has evolved greatly in the last few decades. Still, a complete resection of lesions abutting critical neurovascular structures carries significant morbidity. Stereotactic radiosurgery (SRS) has emerged as an increasingly accepted treatment option. Minimally invasive, SRS results in excellent tumor control and low complication rates in patients with moderate-size tumors. The management of large cerebral and skull base tumors remains a formidable challenge. In such large tumors, radical surgical extirpation offers a significantly higher risk of neurological deficit, and SRS alone cannot be used because of the elevated incidence of radiation-induced complications known to be associated with large-volume tumors. With increasing treatment volumes, SRS-associated tumor control rates decrease and complication rates increase. Planned subtotal resection (STR) with adjuvant SRS (adaptive hybrid surgery [AHS]) has gained increasing interest in recent years as a multimodal approach. In AHS, a planned STR (aimed at decreasing surgical morbidity) followed by SRS to a preplanned residual tumor aids in harnessing advantages offered by both approaches. Although intuitive and reasonable, this paradigm shift from maximal resection at all cost has not been adopted widely. Combining open microsurgery with SRS requires a good understanding of both surgical and SRS modalities and their respective safety-efficacy features. We present a review and discussion on AHS as a modern, multidisciplinary treatment approach. Available data and views are discussed for vestibular schwannoma (VS) as a sample tumor. Other indications for AHS are mentioned in brief.

Figure 1. Changing Trends in the Clinical Management of Vestibular Schwannomas

AHS, adaptive hybrid surgery; GTR, gross total resection; STR, subtotal resection. Refer to text.

Figure 2. Adaptive Hybrid Surgery Software (with Permission, from Brainlab Inc.)

A) T1WI MRI showing a large right vestibular schwannoma abutting brainstem and adjacent structures. B) Planning STR, objective criteria for extent of STR. C) Simulation and optimization of residual tumor for SRS, radiation plan. D) Intraoperative update option for adjuvant SRS plan.