University of CataniaSchool of Medicine

Department of NeurosciencesSection of Neurosurgery

State of the art in microsurgery ofBrain Gliomas

Vincenzo Albanese

Removal of right cerebral hemisphere for certain tumors with hemiplegia

Dandy WE JAMA 90: 823-825, 1928

“In the gradual evolution of resections of frontal, temporal and occipital lobes for the cure or attempted cure of invasive and otherwise incurable cerebral tumors, it has been found that the right temporal lobe, either frontal lobe or either occipital lobe (the left posterior to the supramarginal gyrus) could be completely removed without apparent mental impairment”.

Extent of MST 1-yr 2-yr 5-yrresection (months)

Gross total 17 72% 31% 12% Subtotal 11 47% 15% 2% Biopsy 7 23% 2% 0%

Barker et al. (UCSF), JNS 1996

Survival in GBM stratified by extent of resection

Goals of surgery for malignant gliomas

• 1. Providing diagnosis• 2. Relieving symptomatic mass effect• 3. Improving or manteining the KPS and QOL• 4. “Setting up” postoperative externally

delivered therapies• 5. Prolonging survival through

cytoreduction• 6. Applying locally-delivered therapies

Preoperative planning

DT - iMR Tractography

Surgery of Brain Gliomasis

Vascular Surgery

RM – PETFusion Image guided

Open Biopsyin non-enhancing glioma

Evaluation of results

Early post-op MRI< 48 h

Intraoperative control of resection

Evaluation of results

Be aware of Pseudo-progression

Preop 8/8/08 Postop 10/9/08 Postop 21/12/08 Postop 21/03/09

Evaluation of results

Be aware of Radionecrosis

65% GTR 5-ALAvs 36% GTR WL

Highly Integrated Glioma Surgery

Image and fluorescence guided and

cortical and subcortical mapped surgery

Laser assisted microsurgeryof Brain Gliomas

“Setting up” postoperative therapies

• Resection and TMZ – EORTC 26981 (Stupp)

• 2-year survival median survival• +TMZ -TMZ +TMZ -TMZ• GTR 37% 14% 18m 14m• STR 23% 9% 14m 12m• Bx 10% 5% 9m 8m

van den Bent et al., Eur J Cancer 2005 [abstr]

“A pessimist sees the difficulty

in every opportunity,

An optimist sees the opportunity

in every difficulty.”

Winston Churchill