Brain Mapping-Aided SupraTotal Resection (SpTR) of Brain Tumors: The Role of Brain Connectivity.

Giuseppe Roberto Giammalva,Cesare Gagliardo,Carlo Gulì,Maria Angela Pino,Luigi Basile,Massimo Midiri,Domenico Messina,Silvana Tumbiolo,Federica Paolini,Paola Feraco,Roberta Costanzo,Giuseppe Emmanuele Umana,Rosario Maugeri,Francesca Graziano,Lara Brunasso,Domenico Gerardo Iacopino,Rosa Maria Gerardi,Gianluca Scalia

doi:10.3389/fonc.2021.645854

Abstract

Brain gliomas require a deep knowledge of their effects on brain connectivity. Understanding the complex relationship between tumor and functional brain is the preliminary and fundamental step for the subsequent surgery. The extent of resection (EOR) is an independent variable of surgical effectiveness and it correlates with the overall survival. Until now, great efforts have been made to achieve gross total resection (GTR) as the standard of care of brain tumor patients. However, high and low-grade gliomas have an infiltrative behavior and peritumoral white matter is often infiltrated by tumoral cells. According to these evidences, many efforts have been made to push the boundary of the resection beyond the contrast-enhanced lesion core on T1w MRI, in the so called supratotal resection (SpTR). SpTR is aimed to maximize the extent of resection and thus the overall survival. SpTR of primary brain tumors is a feasible technique and its safety is improved by intraoperative neuromonitoring and advanced neuroimaging. Only transient cognitive impairments have been reported in SpTR patients compared to GTR patients. Moreover, SpTR is related to a longer overall and progression-free survival along with preserving neuro-cognitive functions and quality of life.

Highlights

Gliomas constitute a common type of primary brain tumor
Contrast-enhancement on brain MRI is commonly considered a consequence of the blood-brain barrier (BBB) permeabilization because of the tumor infiltrative behaviour; the boundaries of contrast-enhancement on brain MRI are considered to reflect the margins of the tumoral lesion [10]
extent of resection (EOR) has been assumed as a metric to judge the success of tumor resection and to predict improved long-term outcomes, such as progression-free survival (PFS) and overall survival (OS) [13]: in particular, lesser residual tumor volume is directly correlated to longer OS [10]

Summary

Introduction

Gliomas constitute a common type of primary brain tumor. Malignant histological subtypes (highgrade gliomas, HGGs), are classified by the World Health Organization (WHO) as either grade III or IV tumors. Glioblastoma (GBM) is the most common and aggressive malignant primary brain tumor [1,2,3,4,5,6,7] It carries an unfavorable prognosis with a median overall survival of 12–18 months and early death after diagnosis in case of no intervention [8,9,10]. Contrast-enhancement on brain MRI is commonly considered a consequence of the blood-brain barrier (BBB) permeabilization because of the tumor infiltrative behaviour; the boundaries of contrast-enhancement on brain MRI are considered to reflect the margins of the tumoral lesion [10] In support of this assumption, the extent of resection (EOR) of the tumoral lesion is independently correlated to survival time. EOR has been assumed as a metric to judge the success of tumor resection and to predict improved long-term outcomes, such as progression-free survival (PFS) and OS [13]: in particular, lesser residual tumor volume is directly correlated to longer OS [10]

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Discussion

Conclusion