A new concept of diffuse (low-grade) glioma surgery
Preservation and even improvement of the quality of life is currently a priority in surgery for gliomas, in addition to the optimization of the extent of resection with significant increase of the overall survival. In this setting, the goal of the present review is to revisit technical aspects of glioma surgery in the lights of new concepts both in the fields of neurooncology and cognitive neurosciences, which recently emerged from translational researches — with special emphasis on diffuse low grade gliomas.
Firstly, the vascularisation (arteries and veins) has to be more systematically spared, by performing subpial dissection and by limiting the use of coagulation within the brain. Secondly, individual cortical as well as subcortical mapping must be more regularly considered, with the aim of better understanding and preserving the white matter pathways underlying the functional connectivity — even in presumed “non-eloquent areas”, to perform “supra-complete” resection.
Therefore, brain surgeons should change their state of mind, in order to operate the nervous system involved by a chronic tumoral disease (and no more by operating a tumor mass within the brain). In other words, the neurosurgeon should see first the brain, and not the glioma, to adapt his surgical procedure to the three-dimensional anatomo-functional organization of each patient. It implies that brain surgeon must change his technique within the central nervous system, which has to be different from the surgical technique outside the brain. This perspective seems to represent the best way to build a modern and personalized “functional surgical neurooncology”.
KeywordsIntraoperative electrical stimulation glioma surgery subpial dissection subcortical mapping functional connectivity
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- Duffau H, Capelle L, Denvil D, Sichez N, Gatignol P, Taillandier L, Lopes M, Mitchell MC, Roche S, Muller JC, Bitar A, Sichez JP, van Effenterre R (2003) Usefulness of intraoperative electrical subcortical mapping during surgery for low-grade gliomas located within eloquent brain regions: functional results in a consecutive series of 103 patients. J Neurosurg 98: 764–78PubMedCrossRefGoogle Scholar
- Duffau H, Velut S, Mitchell MC, Gatignol P, Capelle L (2004) Intra-operative mapping of the subcortical visual pathways using direct electrical stimulations. Acta Neurochir (Wien) Acta Neurochir (Wien): 265–69Google Scholar
- Duffau H, Lopes M, Arthuis F, Bitar A, Sichez JP, Van Effenterre R, Capelle L (2005) Contribution of intraoperative electrical stimulations in surgery of low-grade gliomas: a comparative study between two series without (1985–96) and with (1996–2003) functional mapping in the same institution. J Neurol Neurosurg Psychiatry 76: 845–51PubMedCrossRefGoogle Scholar
- Duffau H (2010) Surgery of gliomas in eloquent areas: from brain hodotopy and plasticity to functional neurooncology. Neurosurg Focus 28: IntroGoogle Scholar
- Duffau H (2011) Brain mapping: from neural basis of cognition to surgical applications. Springer, Wien New YorkGoogle Scholar
- Gil Robles S, Gatignol P, Lehéricy S, Duffau H (2008) Long-term brain plasticity allowing multiple-stages surgical approach for WHO grade II gliomas in eloquent areas: a combined study using longitudinal functional MRI and intraoperative electrical stimulation. J Neurosurg 109: 615–24CrossRefGoogle Scholar
- Giussani C, Roux FE, Ojemman J, Sganzerla EP, Pirillo D, Papagno C (2010) Is preoperative functional magnetic resonance imaging reliable for language areas mapping in brain tumor surgery? Review of language functional magnetic resonance imaging and direct cortical stimulation correlation studies. Neurosurgery 66: 113–20PubMedCrossRefGoogle Scholar
- Martino J, Vergani F, Gil Robles S, Duffau H (2010) New insights into the anatomic dissection of the temporal stem with special emphasis on the inferior fronto-occipital fasciculus: implications in surgical approach to left mesiotemporal and temporoinsular structures. Neurosurgery 66: 4–12PubMedCrossRefGoogle Scholar
- Soffietti R, Baumert BG, Bello L, von Deimling A, Duffau H, Frénay M, Grisold W, Grant R, Graus F, Hoang-Xuan K, Klein M, Melin B, Rees J, Siegal T, Smits A, Stupp R, Wick W (2010) Guidelines on management of low-grade gliomas: report of an EFNS-EANO* Task Force. Eur J Neurol 17: 1124–33PubMedCrossRefGoogle Scholar