Abstract
Supratentorial hemispheric diffuse low-grade gliomas (LGG), i.e., World Health Organization grade II gliomas, are generally revealed by seizures in young adults with no or only mild neurological deficits. These progressive tumors are characterized by a continuous growth, by tumor recurrences and by a progression into a higher grade of malignancy. Maximal safe resection preserving eloquent brain areas, when possible, is currently considered as the optimal primary treatment modality of LGG. Imaging determinations of the spatial extent of LGG are of paramount importance in evaluating the risk-to-benefit ratio of surgical resection. However, it is not yet clear how accurately MRI can delineate LGG. Indeed, LGG may recur postoperatively even after a MRI-based complete resection and recurrences generally occurred in the resection margins. The value of conventional MRI in determining the spatial extent of LGG is thus questionable. As demonstrated by multi-scale correlative approaches with histological and imaging data, conventional MRI underestimates the actual spatial extent of LGG, even when they are well delineated on T2-weigthed and FLAIR sequences. Cycling isolated tumor cells are present beyond MRI-defined abnormalities and permeate surrounding “normal” parenchyma at sites up to at least 15 mm outside MRI-defined tumor limits. Clear tumor boundaries do not actually exist as LGG are diffusely infiltrative tumors with a decrease of tumor cell density as a function of distance from MRI-defined abnormalities. This implies that a MRI-based complete resection of a LGG leaves isolated tumor cells beyond the surgical field. These results should be considered when planning a surgical resection of a LGG: (1) a maximal safe resection preserving eloquent brain area is recommended because of the infiltrative nature of LGG and the frequent juxtaposition close to and/or within critically eloquent brain areas; (2) surgical resection should be tailored according to cortico-subcortical functional boundaries rather than MRI-based limits; (3) an extended resection of a margin beyond MRI-defined abnormalities, whenever feasible in non-eloquent brain areas, might increase the survival of patients harboring a LGG; (4) an early surgical treatment while the LGG is smaller might delay tumor progression by decreasing the number of residual isolated tumor cells.
Keywords
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Acknowledgments
Johan Pallud wants to thank François-Xavier Roux, Edouard Dezamis and Bertrand Devaux of the department of Neurosurgery, Catherine Daumas-Duport and Pascale Varlet of the department of Neuropathology, Jean-François Meder and Catherine Oppenheim of the department of Neuroradiology of the Sainte-Anne Hospital Center in Paris, France. Johan Pallud wants to thanks all the members of the French Glioma Network (REG, Réseau d’Etude des Gliomes) and particularly Emmanuel Mandonnet, Laurent Capelle, Luc Taillandier and Hugues Duffau.
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Pallud, J. (2011). Diffuse Low-Grade Gliomas: What Does “Complete Resection” Mean?. In: Hayat, M. (eds) Tumors of the Central Nervous System, Volume 2. Tumors of the Central Nervous System, vol 2. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-0618-7_17
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