The surgical management of diffuse gliomas: Current state of neurosurgical management and future directions

Abstract

After recent updates to the World Health Organization pathological criteria for diagnosing and grading diffuse gliomas, all major North American and European neuro-oncology societies recommend a maximal safe resection as the initial management of a diffuse glioma. For neurosurgeons to achieve this goal, the surgical plan for both low- and high-grade gliomas should be to perform a supramaximal resection when feasible based on preoperative imaging and the patient's performance status, utilizing every intraoperative adjunct to minimize postoperative neurological deficits. While the surgical approach and technique can vary, every effort must be taken to identify and preserve functional cortical and subcortical regions. In this summary statement on the current state of the field, we describe the tools and technologies that facilitate the safe removal of diffuse gliomas and highlight intraoperative and postoperative management strategies to minimize complications for these patients. Moreover, we discuss how surgical resections can go beyond cytoreduction by facilitating biological discoveries and improving the local delivery of adjuvant chemo- and radiotherapies.

Keywords: drug delivery; functional brain mapping; glioma; intraoperative tumor identification; maximal safe resection; supratotal resection.

Figure 1:

Schematic demonstrating techniques for disease monitoring, such as liquid biopsies, radiomics, repeat biopsies, traditional MRI images.

Figure 2.

Illustration showing supramaximal resection definitions for high-grade (a) and low-grade (b) gliomas.

Figure 3.

Illustration showing cortical and subcortical monopolar and bipolar mapping techniques.

Figure 4.

Methods for identification of tumor margins intraoperatively.

Figure 5.

Drug delivery strategies/adjuncts that involve neurosurgeons, such as convection-enhanced delivery, radiation implants, low frequency focused ultrasound.