University of Catania School of Medicine Department of

University of Catania School of Medicine Department of Neurosciences Section of Neurosurgery State of the art in microsurgery of Brain 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”.

Survival in GBM stratified by extent of resection Extent of resection MST (months) 1 -yr 2 -yr 5 -yr Gross total 17 72% 31% 12% Subtotal 11 47% 15% 2% Biopsy 7 23% 2% 0% Barker et al. (UCSF), JNS 1996

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 - i. MR Tractography

Surgery of Brain Gliomas is Vascular Surgery

RM – PET Fusion Image guided Open Biopsy in 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 -ALA vs 36% GTR WL

Highly Integrated Glioma Surgery Image and fluorescence guided and cortical and subcortical mapped surgery

Laser assisted microsurgery of Brain Gliomas

“Setting up” postoperative therapies • Resection and TMZ – EORTC 26981 (Stupp) • 2 -year survival • +TMZ -TMZ • GTR 37% 14% • STR 23% 9% • Bx 10% 5% median survival +TMZ -TMZ 18 m 14 m 12 m 9 m 8 m 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