From: <Salvato da Windows Internet Explorer 7>
Subject: The role of surgery in the management of intracranial gliomas: Current concepts Nunez OM, Seol HJ, Rutka JT - Indian J Cancer
Date: Sat, 9 May 2009 14:00:07 +0200
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Content-Location: http://www.indianjcancer.com/article.asp?issn=0019-509X;year=2009;volume=46;issue=2;spage=120;epage=126;aulast=Nunez

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" =
"http://www.w3c.org/TR/1999/REC-html401-19991224/loose.dtd">
<HTML><HEAD><TITLE>The role of surgery in the management of intracranial =
gliomas: Current concepts Nunez OM, Seol HJ, Rutka JT - Indian J =
Cancer</TITLE>
<META http-equiv=3DContent-Type content=3D"text/html; =
charset=3Dwindows-1252">
<META=20
content=3D"Indian J Cancer, full-text, online, electronic, e-journal, =
free access, open access, online submission"=20
name=3Dkeywords>
<META=20
content=3D"The Indian Journal of Cancer is an official publication of =
the Indian Cancer Society and Indian Society of Oncology."=20
name=3Ddescription><!--DC META DATA START-->
<META=20
content=3D"The role of surgery in the management of intracranial =
gliomas: Current concepts"=20
name=3DDC.Title><LINK =
href=3D"http://purl.org/metadata/dublin_core_elements#title"=20
rel=3DSCHEMA.dc>
<META content=3DNunez name=3DDC.Creator><LINK=20
href=3D"http://purl.org/metadata/dublin_core_elements#creator" =
rel=3DSCHEMA.dc>
<META=20
content=3D"Adjuvant therapies, advance in neurosurgery, extension of =
resection, glioma, surgery, survival"=20
name=3DDC.Subject>
<META=20
content=3D"The role of surgery in the management of human gliomas has =
been controversial. The results from numerous neurosurgical series are =
inconsistent. The current adjuvant therapies have facilitated treatment =
of patients, and have rendered neurosurgical removal without morbidity =
or mortality more commonplace than ever before. Here, we investigated =
the role of surgery in the management of adults with low- and high-grade =
gliomas. Even though there is substantial evidence which claims that =
surgery <i>per se</i> has a role to play in extending patient survival, =
there is a paucity of randomized clinical trials on this subject, and =
little in the way of Class II data to support these claims. However, =
this should not divert patients away from surgery, because there may be =
additional benefits from a concerted effort to remove a tumor =
completely. At the present time, it seems best that clinicians continue =
to individualize patient treatment based on a myriad of factors that =
relate to the patient, the patient's tumor, and the known biology of the =
disease." name=3DDC.Description><LINK=20
href=3D"http://purl.org/metadata/dublin_core_elements#description" =
rel=3DSCHEMA.dc>
<META content=3D"Medknow Publications" name=3DDC.Publisher><LINK=20
href=3D"http://purl.org/metadata/dublin_core_elements#publisher" =
rel=3DSCHEMA.dc>
<META content=3D"Nunez OM, Seol HJ, Rutka JT"=20
name=3DDC.Contributor.PersonalName><LINK=20
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<META scheme=3DISO8601 content=3D2009-4-1 name=3DDC.Date><LINK=20
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name=3DDC.Identifier><LINK=20
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href=3D"http://purl.org/metadata/dublin_core_elements#date" =
rel=3DSCHEMA.dc><!--DC META DATA END--><!-- Google Scholar tags start =
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<META content=3D"Indian Journal of Cancer" =
name=3Dcitation_journal_title>
<META content=3D"Medknow Publications" name=3Dcitation_publisher>
<META content=3D"Nunez OM; Seol HJ; Rutka JT" name=3Dcitation_authors>
<META=20
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gliomas: Current concepts"=20
name=3Dcitation_title>
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<META content=3D2 name=3Dcitation_issue>
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          onmouseout=3DnavleftMouseOut(this); colSpan=3D2=20
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            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#abstrac=
t">Abstract</A></TD></TR>
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          onmouseout=3DnavleftMouseOut(this); colSpan=3D2=20
            height=3D20>&nbsp;<B>=BB</B>&nbsp;&nbsp;<A =
title=3DIntroduction=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#Introdu=
ction">Introduction</A></TD></TR>
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          onmouseout=3DnavleftMouseOut(this); colSpan=3D2=20
            height=3D20>&nbsp;<B>=BB</B>&nbsp;&nbsp;<A title=3D"Low =
Grade Gliomas"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#Low =
Grade Gliomas">Low=20
            Grade Gliomas</A></TD></TR>
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          onmouseout=3DnavleftMouseOut(this); colSpan=3D2=20
            height=3D20>&nbsp;<B>=BB</B>&nbsp;&nbsp;<A title=3D"High =
Grade Gliomas"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#High =
Grade Gliomas">High=20
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            height=3D20>&nbsp;<B>=BB</B>&nbsp;&nbsp;<A=20
            title=3D"Neurosurgical Adjuncts to Overcome Morbidity"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#Neurosu=
rgical Adjuncts to Overcome Morbidity">Neurosurgical=20
            Ad...</A></TD></TR>
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          onmouseout=3DnavleftMouseOut(this); colSpan=3D2=20
            height=3D20>&nbsp;<B>=BB</B>&nbsp;&nbsp;<A title=3D"Adjuvant =
therapies"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#Adjuvan=
t therapies">Adjuvant=20
            therapies</A></TD></TR>
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        <TR>
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          onmouseout=3DnavleftMouseOut(this); colSpan=3D2=20
            height=3D20>&nbsp;<B>=BB</B>&nbsp;&nbsp;<A=20
            title=3D"Is Surgical Intervention Beneficial?"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#Is =
Surgical Intervention Beneficial?">Is=20
            Surgical Inte...</A></TD></TR>
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          onmouseout=3DnavleftMouseOut(this); colSpan=3D2=20
            height=3D20>&nbsp;<B>=BB</B>&nbsp;&nbsp;<A=20
            title=3D"The Extent of Surgical Resection"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#The =
Extent of Surgical Resection">The=20
            Extent of Su...</A></TD></TR>
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          onmouseout=3DnavleftMouseOut(this); colSpan=3D2=20
            height=3D20>&nbsp;<B>=BB</B>&nbsp;&nbsp;<A =
title=3DConclusions=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#Conclus=
ions">Conclusions</A></TD></TR>
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          onmouseout=3DnavleftMouseOut(this); colSpan=3D2=20
            height=3D20>&nbsp;<B>=BB</B>&nbsp;&nbsp;<A =
title=3DAcknowledgments=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#Acknowl=
edgments">Acknowledgments</A></TD></TR>
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            height=3D20>&nbsp;<B>=BB</B>&nbsp;&nbsp;<A=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#Referen=
ce">References</A></TD></TR>
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href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
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Article=20
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                <TD width=3D"100%" colSpan=3D3><FONT=20
                  class=3DtocAT><B>SYMPOSIUM</B></FONT></TD></TR>
              <TR>
                <TD width=3D"33%" height=3D5></TD>
                <TD width=3D"33%" height=3D5></TD>
                <TD width=3D"34%" height=3D5></TD></TR>
              <TR>
                <TD class=3Dother width=3D"100%" colSpan=3D3><B>Year =
</B>:=20
                  2009&nbsp; |&nbsp; <B>Volume</B> : 46&nbsp; |&nbsp;=20
                  <B>Issue</B> : 2&nbsp; |&nbsp; <B>Page</B> : =
120-126</TD></TR>
              <TR>
                <TD class=3Dother width=3D"100%"=20
            colSpan=3D3>&nbsp;</TD></TR></TBODY></TABLE>
            <P><FONT class=3DsTitle>The role of surgery in the =
management of=20
            intracranial gliomas: Current concepts</FONT><BR><BR><FONT=20
            class=3DarticleAuthor>OM Nunez<SUP>1</SUP>, HJ =
Seol<SUP>2</SUP>, JT=20
            Rutka<SUP>3</SUP></FONT><BR><FONT=20
            class=3DAuthorAff><SUP>1</SUP>&nbsp;Department of =
Neurosurgery,=20
            University Hospital "Abel Santamaria", Pinar del Rio, Cuba,=20
            <BR><SUP>2</SUP>&nbsp;Arthur and Sonia Labatt Brain Tumor =
Research=20
            Centre, Hospital for Sick Children, Toronto, Canada; =
Department of=20
            Neurosurgery, Kangwon National University College of =
Medicine,=20
            Chuncheon, Korea, <BR><SUP>3</SUP>&nbsp;Arthur and Sonia =
Labatt=20
            Brain Tumor Research Centre, Hospital for Sick Children, =
Toronto,=20
            Canada, <BR></FONT><BR></P>
            <P><FONT class=3DCorrsAdd><B>Correspondence =
Address</B>:<BR>J T=20
            Rutka<BR>Arthur and Sonia Labatt Brain Tumor Research =
Centre,=20
            Hospital for Sick Children, Toronto, Canada <BR><BR><A=20
            =
href=3D"http://www.indianjcancer.com/login.asp?rd=3Darticle.asp?issn=3D00=
19-509X;year=3D2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3D=
Nunez"><IMG=20
            alt=3D"Login to access the Email id"=20
            src=3D"http://www.medknow.com/images/email.gif" =
border=3D0></A>
            <P><B>Source of Support:</B> None, <B>Conflict of =
Interest:</B>=20
            None</P><B>DOI</B>:&nbsp;10.4103/0019-509X.49149<BR></FONT>
            <P></P>
            <TABLE cellSpacing=3D0 cellPadding=3D0 width=3D"100%" =
border=3D0>
              <TBODY>
              <TR>
                <TD class=3DinsideLine width=3D"100%"=20
height=3D1></TD></TR></TBODY></TABLE>
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub width=3D"85%" =
height=3D15>&nbsp;=BB<A=20
                  name=3Dabstract></A>&nbsp;Abstract</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD width=3D"15%" height=3D15></TD></TR></TBODY></TABLE>
            <P class=3Dabst>The role of surgery in the management of =
human gliomas=20
            has been controversial. The results from numerous =
neurosurgical=20
            series are inconsistent. The current adjuvant therapies have =

            facilitated treatment of patients, and have rendered =
neurosurgical=20
            removal without morbidity or mortality more commonplace than =
ever=20
            before. Here, we investigated the role of surgery in the =
management=20
            of adults with low- and high-grade gliomas. Even though =
there is=20
            substantial evidence which claims that surgery <I>per se</I> =
has a=20
            role to play in extending patient survival, there is a =
paucity of=20
            randomized clinical trials on this subject, and little in =
the way of=20
            Class II data to support these claims. However, this should =
not=20
            divert patients away from surgery, because there may be =
additional=20
            benefits from a concerted effort to remove a tumor =
completely. At=20
            the present time, it seems best that clinicians continue to=20
            individualize patient treatment based on a myriad of factors =
that=20
            relate to the patient, the patient's tumor, and the known =
biology of=20
            the disease.</P><BR>
            <P class=3Dkyds><B>Keywords:</B>&nbsp;Adjuvant therapies, =
advance in=20
            neurosurgery, extension of resection, glioma, surgery,=20
            survival</P><BR>
            <TABLE class=3Dsitethis width=3D"100%" border=3D0>
              <TBODY>
              <TR>
                <TD class=3Dother><B>How to cite this =
article:</B><BR>Nunez OM,=20
                  Seol HJ, Rutka JT. The role of surgery in the =
management of=20
                  intracranial gliomas: Current concepts. Indian J =
Cancer=20
                  2009;46:120-6</TD></TR></TBODY></TABLE><BR>
            <TABLE class=3Dsitethis width=3D"100%" border=3D0>
              <TBODY>
              <TR>
                <TD class=3Dother><B>How to cite this URL:</B><BR>Nunez =
OM, Seol=20
                  HJ, Rutka JT. The role of surgery in the management of =

                  intracranial gliomas: Current concepts. Indian J =
Cancer=20
                  [serial online] 2009 [cited&nbsp;2009 May 9];46:120-6. =

                  Available from:&nbsp;<A=20
                  =
href=3D"http://www.indianjcancer.com/text.asp?2009/46/2/120/49149">http:/=
/www.indianjcancer.com/text.asp?2009/46/2/120/49149</A></TD></TR></TBODY>=
</TABLE><BR><BR><BR>
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  =
name=3DIntroduction></A>&nbsp;=BB&nbsp;Introduction</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD align=3Dright width=3D"15%"><A=20
                  =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#top"><I=
MG=20
                  alt=3DTop=20
                  =
src=3D"http://www.indianjcancer.com/images/arrow_top.gif"=20
                  =
border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>Gliomas are the most=20
            common primary tumors of the central nervous system (CNS),=20
            representing approximately 50% of the newly diagnosed brain =
tumors.=20
            According to the 2007 World Health Organization (WHO)=20
            classification, there are many different types of gliomas:=20
            Astrocytic, oligodendroglial, mixed oligoastrocytic tumors,=20
            ependymomas, and choroid plexus tumors.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref1"=20
            name=3Dft1>[1]</A></SUP> Of these, astrocytomas, have the =
highest=20
            incidence.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref2"=20
            name=3Dft2>[2]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref3"=20
            name=3Dft3>[3]</A></SUP> <BR><BR>The classification of human =
gliomas=20
            includes both histological features such as nuclear atypia, =
mitotic=20
            figures, microvascular proliferation and focal =
pseudopalisading=20
            necrosis,<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref4"=20
            name=3Dft4>[4]</A></SUP> and the separation into four grades =
(I-IV),=20
            with low-grade tumors being grades I and II, and high-grades =
tumors,=20
            grades III (anaplastic tumors) and IV (glioblastoma). This =
grading=20
            system has proved most accurate in predicting the clinical =
outcome.=20
            <BR><BR>The goals of glioma surgery are: To obtain a tissue =
sample=20
            for diagnosis; to decrease tumor mass; to relieve =
neurological=20
            symptoms; and to provide time so that other treatments, such =
as,=20
            cranial irradiation and chemotherapy can be =
performed.<BR><BR>The=20
            biology, clinical , and outcome are different for low- and=20
            high-grade gliomas in adults, but the treatments for these =
neoplasms=20
            are somewhat similar. Cranial irradiation after surgical =
debulking=20
            has been a mainstay of therapy in a majority of cases. =
Despite the=20
            advances in the care of patients with gliomas these past 15 =
years,=20
            surgery still plays an important and decisive role in the =
management=20
            of these patients. Here we discuss the current concepts on =
gliomas=20
            in adults, including natural history studies, surgical =
intervention,=20
            biopsy versus resection, impact of the extent of resection, =
impact=20
            of adjuvant therapies, molecular tools, and some recent =
advanced=20
            techniques, with which surgery has become more safe and=20
            predictable.<BR><BR><BR>
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  name=3D"Low Grade Gliomas"></A>&nbsp;=BB&nbsp;Low =
Grade Gliomas</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD align=3Dright width=3D"15%"><A=20
                  =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#top"><I=
MG=20
                  alt=3DTop=20
                  =
src=3D"http://www.indianjcancer.com/images/arrow_top.gif"=20
                  =
border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>Low-grade gliomas=20
            (LGGs) are typically classified as WHO grade I and II =
neoplasms and=20
            include pilocytic astrocytomas, diffuse astrocytomas,=20
            oligodendrogliomas, ependymomas, and mixed gliomas. However, =
LGGs=20
            are understandably a heterogeneous group which is clinically =
and=20
            molecularly diverse. Therefore, we will limit our discussion =
here to=20
            WHO grade II diffuse astrocytomas, oligodendrogliomas, and =
mixed=20
            gliomas, which share similar characteristics of clinical=20
            manifestations, with invasive and malignant potential.<SUP> =
<A=20
            class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref5"=20
            name=3Dft5>[5]</A></SUP> <BR><BR>Low-grade gliomas are =
generally=20
            relatively slow-growing primary brain tumors. However, they =
may=20
            exhibit a diverse clinical behavior. Many patients present =
with only=20
            seizures and are neurologically stable for a prolonged =
period of=20
            time. However, others may show functional deficits or signs =
of=20
            increased intracranial pressure. The benefits of various=20
            interventions including radiotherapy, chemotherapy, and =
surgical=20
            resection, have been described, but the role of the extent =
of=20
            surgery remains unclear. At this time, there is no consensus =
on the=20
            policy of surgical treatment for LGG. Either biopsy, =
subtotal or=20
            total excision can be undertaken, given the tumor's =
location, the=20
            patient's age, and the safety of performing =
surgery.<BR><BR><BR>
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  name=3D"High Grade Gliomas"></A>&nbsp;=BB&nbsp;High =
Grade=20
                Gliomas</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD align=3Dright width=3D"15%"><A=20
                  =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#top"><I=
MG=20
                  alt=3DTop=20
                  =
src=3D"http://www.indianjcancer.com/images/arrow_top.gif"=20
                  border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>High =
Grade Gliomas=20
            (HGGs) are also called "malignant gliomas." These tumors =
represent=20
            the most common primary brain tumor in the adult population. =
For=20
            HGGs, the incidence is 5 to 10 per 100,000 persons, and the =
median=20
            survival is about two to three years for WHO grade III and =
ten 10 to=20
            twelve 12 months for grades IV.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref6"=20
            name=3Dft6>[6]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref7"=20
            name=3Dft7>[7]</A></SUP> The term glioblastoma multiforme =
(GBM), was=20
            introduced by Mallory in 1914, and is still used at the =
present time=20
            to depict the most malignant of intracranial glial =
tumors.<SUP> <A=20
            class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref8"=20
            name=3Dft8>[8]</A></SUP> <BR><BR>Some controversies still =
exist=20
            regarding the surgical treatment of HGGs. For the last 30 =
years, the=20
            neurosurgery community has debated the issue of the extent =
of=20
            resection. In actuality, aggressive resections began when =
Walter=20
            Dandy performed the first hemispherectomy in 1928, in order =
to=20
            achieve the "total" removal of an intracranial glioma.<SUP> =
<A=20
            class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref9"=20
            name=3Dft9>[9]</A></SUP> Despite this very aggressive =
approach, all=20
            patients succumbed from the disease retained in the =
hemisphere. This=20
            illustrates the highly invasive and infiltrative potential =
of GBMs.=20
            Total resection is impossible in most cases, especially when =
tumors=20
            are situated in eloquent areas.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref10" =

            name=3Dft10>[10]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref11" =

            name=3Dft11>[11]</A></SUP> Today, even with a near-total =
resection,=20
            the survival time of most patients hovers around 12 months. =
In some=20
            series, gross total resection of over 98% of the tumor, =
followed by=20
            chemotherapy and radiotherapy, may offer some improvement in =
the=20
            overall survival. <SUP><A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref12" =

            name=3Dft12>[12]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref13" =

            name=3Dft13>[13]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref14" =

            name=3Dft14>[14]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref15" =

            name=3Dft15>[15]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref16" =

            name=3Dft16>[16]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref17" =

            name=3Dft17>[17]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref18" =

            name=3Dft18>[18]</A></SUP><BR><BR><BR>
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  name=3D"Neurosurgical Adjuncts to Overcome =
Morbidity"></A>&nbsp;=BB&nbsp;Neurosurgical=20
                  Adjuncts to Overcome Morbidity</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD align=3Dright width=3D"15%"><A=20
                  =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#top"><I=
MG=20
                  alt=3DTop=20
                  =
src=3D"http://www.indianjcancer.com/images/arrow_top.gif"=20
                  =
border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>Historically,=20
            intraoperative electrocortical stimulation has proven to be =
the gold=20
            standard in glioma surgery for the avoidance of =
postoperative=20
            neurological deterioration. Advances in brain mapping =
techniques=20
            have gradually emerged and are part of the clinician's =
armamentarium=20
            to supplement clinical and radiological findings for =
preoperative=20
            planning. Preoperative functional magnetic resonance imaging =
(fMRI)=20
            enables the definition of the cortical functional areas and =
their=20
            proximity to the tumor tissue, and can provide global =
preoperative=20
            information about the resectability of the tumor without =
causing=20
            neurological deterioration.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref19" =

            name=3Dft19>[19]</A> </SUP>In addition, magnetic source =
imaging (MSI)=20
            with magnetoencephalography (MEG) provides a presurgical =
map, which=20
            clearly identifies the functional brain areas. As with fMRI, =
MSI=20
            correlates well with intraoperative cortical =
stimulation.<SUP> <A=20
            class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref20" =

            name=3Dft20>[20]</A></SUP> Diffusion tensor imaging (DTI) is =
a=20
            noninvasive method of studying the structure of human =
neuronal=20
            fibers and tracts. It captures the local water diffusion=20
            characteristics of tissues and models the 3D distribution of =
<FONT=20
            class=3Dspl>&nbsp;Brownian motion&nbsp;</FONT><A=20
            href=3D"javascript:openWin('speciallinks.asp?id=3D4606')" =
;><FONT=20
            class=3Dother><SUP>More Details</SUP></FONT></A> as the =
diffusion=20
            tensor.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref21" =

            name=3Dft21>[21]</A></SUP> It is beneficial to delineate =
margins of=20
            the glioma because DTI is sensitive to the directional =
diffusion of=20
            water along white matter tracks.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref22" =

            name=3Dft22>[22]</A></SUP> Kamada <I>et al,<SUP></I> <A =
class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref23" =

            name=3Dft23>[23]</A></SUP><I> </I>suggested that =
preoperative cortical=20
            and subcortical maps generated by a combination of =
functional MRI,=20
            MSI, and DTI are predictive and can be confirmed by =
intraoperative=20
            cortical and subcortical stimulation=20
            mapping.<BR><BR>Intraoperatively, cortical or subcortical=20
            stimulation can be used to aggressively remove gliomas and =
avoid=20
            injury to long tract fiber pathways such as the =
corticospinal tract.=20
            Several retrospective series have shown that these =
techniques allow=20
            for aggressive neurosurgery for LGGs, within eloquent areas, =
and are=20
            associated with a decrease in the risk of neurological =
sequelae=20
            after surgery, and to an improvement in the extent of =
resection,=20
            with an impact on survival.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref24" =

            name=3Dft24>[24]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref25" =

            name=3Dft25>[25]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref26" =

            name=3Dft26>[26]</A></SUP> <BR><BR>Currently, frameless =
stereotactic=20
            neuronavigation is very helpful in approaching deep seated =
tumors=20
            and voiding errors in trajectory during surgery. However,=20
            neuronavigation is known to be associated with =
intraoperative brain=20
            shifts, which render the device somewhat problematic.<SUP> =
<A=20
            class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref27" =

            name=3Dft27>[27]</A></SUP> To solve the problem of brain =
shifts,=20
            intraoperative MRI has been invented to allow for continuous =

            updating of imaging data, with compensation for the brain =
shift.=20
            Several retrospective articles have shown an increase in the =
extent=20
            of resection and survival time when intraoperative MRI is =
used.<SUP>=20
            <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref28" =

            name=3Dft28>[28]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref29" =

            name=3Dft29>[29]</A></SUP> As a result of advances in =
surgical=20
            techniques including pre- and intraoperative adjuncts and =
devices,=20
            more extensive surgery is now possible. In addition, greater =

            resection of a tumor leads to less chance of sampling error, =
which=20
            can be problematic when biopsies are performed.<BR><BR><BR>
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  name=3D"Adjuvant =
therapies"></A>&nbsp;=BB&nbsp;Adjuvant=20
                therapies</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD align=3Dright width=3D"15%"><A=20
                  =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#top"><I=
MG=20
                  alt=3DTop=20
                  =
src=3D"http://www.indianjcancer.com/images/arrow_top.gif"=20
                  border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>While =
surgery alone=20
            is often used to treat grade I gliomas, including pilocytic=20
            astrocytomas, all the other grades will require some form of =

            combination therapy including radiotherapy (RT), =
chemotherapy or=20
            both.<BR><BR>The identification of molecular markers, such =
as, the=20
            enzyme methylguanine methyltransferase (MGMT), =
epigenetically=20
            silenced in some tumors by methylation of the CpG island in =
the=20
            promoter region, has now been shown to be a predictive =
marker for=20
            treatment response to the chemotherapeutic agent, =
temozolomide=20
            (TMZ). Other molecular markers in clinical use today include =
the=20
            loss of heterozygosity on chromosomes 1p and 19q. If a =
patient with=20
            an anaplastic oligodendroglioma has this molecular =
phenotype, the=20
            overall survival is significantly better following treatment =
with=20
            chemotherapy. As more than 30% of GBM patients exhibit =
epidermal=20
            growth factor receptor (EGFR) amplification on their tumors, =

            treatment with EGFR inhibitors, such as, gefitinib and =
erlotinib has=20
            been introduced. Currently, there is a phase II study which =
uses=20
            Cilentigide, an integrin inhibitor, for GBM. Other molecular =

            treatments which are being examined are the use of an oral=20
            anti-vascular endothelial receptor (VEGF) tyrosine kinase =
inhibitor,=20
            and the use of wafers impregnated with chemotherapy, such as =

            carmustine, to treat some patients after neurosurgical =
resection=20
            (GLIADEL).<BR><BR><BR>
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  name=3D"Is Surgical Intervention =
Beneficial?"></A>&nbsp;=BB&nbsp;Is=20
                  Surgical Intervention Beneficial?</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD align=3Dright width=3D"15%"><A=20
                  =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#top"><I=
MG=20
                  alt=3DTop=20
                  =
src=3D"http://www.indianjcancer.com/images/arrow_top.gif"=20
                  border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>A =
'wait-and-see'=20
            policy has been considered for patients harboring typical =
LGG,=20
            especially with minimal symptoms or controllable seizures. =
This=20
            strategy may give some patients an overall improved quality =
of life=20
            (QOL) for some duration, because they are not exposed to the =

            possible morbidity and mortality related to surgery. =
However, Scott=20
            <I>et al,</I> has shown that grading gliomas on the basis of =
imaging=20
            characteristics alone underestimated the degree of =
malignancy in=20
            one-third of the cases.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref30" =

            name=3Dft30>[30]</A></SUP> They advocated procuring of =
tissue for=20
            diagnosis whenever it was deemed safe and =
possible.<BR><BR>Moreover,=20
            even though contrast enhancement on MRI has long been =
believed to be=20
            a sign of malignancy, recent studies have suggested that =
contrast=20
            enhancement may occur in up to 40-60% of LGGs.<SUP> <A =
class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref6"=20
            name=3Dft6>[6]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref31" =

            name=3Dft31>[31]</A></SUP> In the future, additional =
information may=20
            be gleaned through magnetic resonance spectroscopy and=20
            perfusion-weighted imaging, but at the moment, these =
techniques are=20
            still associated with significant error rates.<SUP> <A =
class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref32" =

            name=3Dft32>[32]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref33" =

            name=3Dft33>[33]</A></SUP> <BR><BR>As well as a possible =
error in=20
            diagnosis, the expectant management of patients with LGGs =
can bring=20
            on other risks, such as, malignant degeneration, subsequent =
tumor=20
            growth, and irreversible neurological deficit. However, =
despite=20
            these theoretical risks, several retrospective series =
revealed that=20
            the timing of surgical intervention did not affect the rates =
of=20
            malignant transformation, overall survival, or QOL.<SUP> <A=20
            class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref34" =

            name=3Dft34>[34]</A></SUP> While there is still some debate =
on this=20
            matter, procuring a tissue diagnosis by surgical =
intervention may be=20
            a reasonable first stem in the management of LGG patients,=20
            irrespective of their site of origin. Standard therapy for =
patients=20
            with progressive, symptomatic LGG remains fractionated =
radiotherapy=20
            (RT) after surgical intervention, although several clinical =
trials=20
            using chemotherapy, such as, TMZ before or after RT in LGG, =
have=20
            recently shown some effect.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref35" =

            name=3Dft35>[35]</A></SUP> <BR><BR>For HGGs the policy of=20
            'wait-and-see' has never been considered, even for tumors =
located in=20
            deep or eloquent areas. For GBM patients with multifocal =
disease,=20
            the use of biopsy-only has been reported with poor survival =
time in=20
            the pre-temozolomide era,<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref36" =

            name=3Dft36>[36]</A></SUP> with a series reporting around =
30% one-year=20
            survival, with biopsy alone.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref10" =

            name=3Dft10>[10]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref37" =

            name=3Dft37>[37]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref38" =

            name=3Dft38>[38]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref39" =

            name=3Dft39>[39]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref40" =

            name=3Dft40>[40]</A></SUP> <BR><BR>A small prospective =
series by=20
            Schneider <I>et al</I> ,<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref41" =

            name=3Dft41>[41]</A></SUP> <A class=3Dref=20
            =
onmouseover=3D"omovimg('viewimaget.asp?img=3DIndianJournalofCancer_2009_4=
6_2_120_49149_b1.jpg')"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#">[Tabl=
e=20
            1]</A> showed a correlation between resection and survival =
time.=20
            Nevertheless, physicians still considering aggressive =
surgical=20
            options for patients with HGGs need to take into account the =

            importance of relief of the symptoms and the need to get =
patients to=20
            their adjuvant therapies to improve survival and not be =
hindered by=20
            neurological morbidity. We summarize only three of the =
series=20
            reported after 2000, showing some significant improvement in =

            survival with aggressive resection of HGGs <A class=3Dref=20
            =
onmouseover=3D"omovimg('viewimaget.asp?img=3DIndianJournalofCancer_2009_4=
6_2_120_49149_b1.jpg')"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#">[Tabl=
e=20
            1]</A>.<BR><BR><BR>
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  name=3D"The Extent of Surgical =
Resection"></A>&nbsp;=BB&nbsp;The=20
                  Extent of Surgical Resection</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD align=3Dright width=3D"15%"><A=20
                  =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#top"><I=
MG=20
                  alt=3DTop=20
                  =
src=3D"http://www.indianjcancer.com/images/arrow_top.gif"=20
                  =
border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>Historically, biopsy=20
            has been used for tumors located adjacent to or deep within =
eloquent=20
            cortices. While stereotactic biopsy is chosen for patients =
with=20
            deep-seated lesions, resection is reserved for those with=20
            superficial lesions. Sometimes, brain mapping before surgery =
is=20
            useful, especially in the eloquent cortex. On the other =
hand,=20
            craniotomy and resection have an advantage for patients with =

            significant mass effect, which results in increased =
intracranial=20
            pressure or neurological deficit and for those with =
symptomatic=20
            refractory epilepsy.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref42" =

            name=3Dft42>[42]</A></SUP> However, several studies show the =

            possibility of misdiagnosis or bias of sampling. They even =
suggest=20
            that stereotactic biopsy may be an additional, even =
unnecessary=20
            procedure in the management of glioma, because it added an=20
            additional 0.9% and 4% risk of mortality and major =
morbidity, in=20
            each, and led to an inaccurate diagnosis in one-third to =
one-half of=20
            the cases.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref43" =

            name=3Dft43>[43]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref44" =

            name=3Dft44>[44]</A></SUP> Despite discrepancies between=20
            histopathology and clinical phenotype, some studies have =
shown that=20
            appropriate treatment was administered in more than 90% of =
the LGG=20
            cases.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref45" =

            name=3Dft45>[45]</A></SUP> From a pure risk taking vantage =
point,=20
            stereotactic biopsy may be more beneficial than craniotomy. =
In=20
            contrast to biopsy, surgical resection can minimize the =
likelihood=20
            of sampling error, but it exposes the patients to a higher=20
            risk.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref5"=20
            name=3Dft5>[5]</A></SUP> Although not curative, total =
resection=20
            provides multiple benefits, including reduction in cell =
number,=20
            increased efficacy of adjuvant therapies, and symptomatic =
relief.=20
            Interestingly, studies have shown that a large preoperative =
tumor=20
            size is a poor prognosis factor.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref46" =

            name=3Dft46>[46]</A></SUP> <BR><BR>Although there are many=20
            retrospective data <A class=3Dref=20
            =
onmouseover=3D"omovimg('viewimaget.asp?img=3DIndianJournalofCancer_2009_4=
6_2_120_49149_b2.jpg')"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#">[Tabl=
e=20
            2]</A> showing the benefit of extensive surgery for overall =
survival=20
            or QOL in LGG, <SUP><A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref47" =

            name=3Dft47>[47]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref48" =

            name=3Dft48>[48]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref49" =

            name=3Dft49>[49]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref50" =

            name=3Dft50>[50]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref51" =

            name=3Dft51>[51]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref52" =

            name=3Dft52>[52]</A></SUP> these are limited by the =
retrospective=20
            nature of these studies. There have been two prospective =
trials <A=20
            class=3Dref=20
            =
onmouseover=3D"omovimg('viewimaget.asp?img=3DIndianJournalofCancer_2009_4=
6_2_120_49149_b2.jpg')"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#">[Tabl=
e=20
            2]</A>, which showed the benefit of extensive surgery on =
overall=20
            survival or progression-free survival by univariate =
analysis.<SUP>=20
            <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref49" =

            name=3Dft49>[49]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref53" =

            name=3Dft53>[53]</A></SUP> Despite consistent findings on =
univariate=20
            analysis, on multivariate analysis, the benefits of =
extensive=20
            surgery were minimal in these studies.<BR><BR>To date there =
is no=20
            class I evidence supporting radical tumor removal in LGGs. =
In=20
            addition, several articles recently revealed that brain MRI =
has a=20
            serious limitation to delineating the true tumor extent when =

            methionine positron emission tomography (PET) or =
fluorodeoxyglucose=20
            (FDG) PET were used.<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref54" =

            name=3Dft54>[54]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref55" =

            name=3Dft55>[55]</A></SUP> Nonetheless, many neurosurgeons =
opt for=20
            extensive surgery in LGGs. The definition of the extent of =
resection=20
            has been evaluated on the basis of the surgeon's impressions =
alone=20
            (which frequently overestimate the extent of resection), =
while in=20
            others it has been assessed by CT or postoperative =
T2-weighted or=20
            fluid-attenuated inversion-recovery (FLAIR) MRI images.<SUP> =
<A=20
            class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref5"=20
            name=3Dft5>[5]</A></SUP> Obviously future trials should use =
MRI for=20
            evaluating the extent of resection rather than relying on =
the=20
            neurosurgeon's opinion.<BR><BR>Interestingly, recent studies =

            suggested neoadjuvant temozolomide chemotherapy before =
surgery could=20
            result in shrinkage of the unresectable tumor.<SUP> <A =
class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref56" =

            name=3Dft56>[56]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref57" =

            name=3Dft57>[57]</A></SUP> Even though a couple of =
nonrandomized=20
            studies showed even temozolomide chemotherapy alone shrank a =
tumor=20
            volume enough to consider further surgery,<SUP> <A =
class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref31" =

            name=3Dft31>[31]</A>,<A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref58" =

            name=3Dft58>[58]</A></SUP> the real effects, benefits, and =
risks are=20
            still being investigated by the European Organization for =
Research=20
            and Treatment of Cancer (EORTC) / National Cancer Institute =
of=20
            Canada (NCIC).<BR><BR>The impact of the extension of =
surgical=20
            resection on HGGs had been studied extensively. In 11 series =

            reported after 2000, seven of them showed statistics in =
favor of=20
            more extensive resections, whereas, in four this was not the =
case <A=20
            class=3Dref=20
            =
onmouseover=3D"omovimg('viewimaget.asp?img=3DIndianJournalofCancer_2009_4=
6_2_120_49149_b3.jpg')"=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#">[Tabl=
e=20
            3]</A>.<BR><BR>The key point here is related to the type of =
analyses=20
            used to determine the extent of resection. Six studies used=20
            nonvolumetric analyses, relying on the surgeon's estimation =
of the=20
            extent of resection. In the five that used volumetric =
analyses, they=20
            did show survival advantages with extensive resections. =
However,=20
            once again, these were mostly retrospective studies, =
influenced by=20
            biological factors, including age and Karnofsky performance =
scores,=20
            among other biases that were introduced. <BR><BR>In 2006 =
Stummer=20
            <I>et al</I> . performed a randomized controlled multicenter =
phase=20
            III trial with the use of 5-aminolevulinic acid (ALA) for=20
            Fluorescence-guided glioma surgery,<SUP> <A class=3Dref=20
            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref15" =

            name=3Dft15>[15]</A></SUP> showing 65% "complete resection" =
compared=20
            to 36% in the control group, showing an accurate estimation =
of the=20
            value of the extent of resection for HGG. How this technique =

            ultimately relates to overall patient survival remains to be =

            determined.<BR><BR><BR>
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  name=3DConclusions></A>&nbsp;=BB&nbsp;Conclusions</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD align=3Dright width=3D"15%"><A=20
                  =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#top"><I=
MG=20
                  alt=3DTop=20
                  =
src=3D"http://www.indianjcancer.com/images/arrow_top.gif"=20
                  border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>Our =
review=20
            investigated numerous reports in the literature supporting =
the=20
            importance of surgery for the treatment of low- and =
high-grade=20
            gliomas. Many articles showed the impact of more extensive =
and=20
            aggressive resections. However, most of the studies are=20
            retrospective or multivariate and nonrandomized in nature. =
Today,=20
            the management of these patients relies on combined =
therapies, which=20
            have been evolving over the last two decades. Concerning the =
role of=20
            surgery in patients with LGGs and HGGs, it is hoped that =
definitive=20
            trials lie just ahead. For the moment, clinicians should =
continue to=20
            individualize the management of their patients, taking into =
account=20
            the patient's age, tumor location, imaging studies, =
pathology of the=20
            tumor, and prognostic molecular markers. <SUP><A class=3Dref =

            =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ref68" =

            name=3Dft68>[68]</A></SUP><BR><BR><BR>
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  =
name=3DAcknowledgments></A>&nbsp;=BB&nbsp;Acknowledgments</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD align=3Dright width=3D"15%"><A=20
                  =
href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#top"><I=
MG=20
                  alt=3DTop=20
                  =
src=3D"http://www.indianjcancer.com/images/arrow_top.gif"=20
                  border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>This =
study was partly=20
            supported by the Kangwon National University (Ho Jun Seol), =
the=20
            Wiley Fund, and Brainchild, at the Hospital for Sick=20
            Children.<BR><BR>&nbsp;
            <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%"=20
            border=3D0>
              <TBODY>
              <TR>
                <TD class=3DpageSub height=3D15><A=20
                  name=3DReference></A>&nbsp;=BB&nbsp;References</TD>
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#top"><I=
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft4"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft5"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft5"><I=
MG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft6"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft6"><I=
MG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft7"=20
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MG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft8"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft8"><I=
MG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
                  border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft9"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft9"><I=
MG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
                  border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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href=3D"http://www.indianjcancer.com/article.asp?issn=3D0019-509X;year=3D=
2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft10"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft10"><=
IMG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft11"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft11"><=
IMG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft12"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft12"><=
IMG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
                  border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft18"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft18"><=
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft19"=20
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IMG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft20"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft20"><=
IMG=20
                  alt=3D"Back to cited text no. 20"=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
                  border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft21"=20
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IMG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft22"=20
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IMG=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft23"=20
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IMG=20
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2009;volume=3D46;issue=3D2;spage=3D120;epage=3D126;aulast=3DNunez#ft24"=20
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IMG=20
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IMG=20
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IMG=20
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src=3D"http://www.indianjcancer.com/images/ref_top.gif"=20
          
