Abstract
The biggest challenge in neuro-oncology is the treatment of glioblastoma, which exhibits poor prognosis and is increasing in incidence in an increasing aging population. Diverse treatment strategies aim at maximum cytoreduction and ensuring good quality of life. We discuss multimodal neuronavigation, supra-maximum tumor resection, and the postoperative treatment gap. Multimodal neuronavigation allows the integration of preoperative anatomic and functional data with intraoperative information. This approach includes functional magnetic resonance imaging (MRI) and diffusion tensor imaging in preplanning and ultrasound, computed tomography (CT), MRI and direct (sub)cortical stimulation during surgery. The practice of awake craniotomy decreases postoperative neurologic deficits, and an extensive supra-maximum resection appears to be feasible, even in eloquent areas of the brain. Intraoperative MRI- and fluorescence-guided surgery assist in achieving this goal of supra-maximum resection and have been the subject of an increasing number of reports. Photodynamic therapy and local chemotherapy are properly positioned to bridge the gap between surgery and chemoradiotherapy. The photosensitizer used in fluorescence-guided surgery persists in the remaining peripheral tumor extensions. Additionally, blinded randomized clinical trials showed firm evidence of extra cytoreduction by local chemotherapy in the tumor cavity. The cutting-edge promise is gene therapy although both the delivery and efficacy of the numerous transgenes remain under investigation. Issues such as the choice of (cell) vector, the choice of therapeutic transgene, the optimal route of administration, and biosafety need to be addressed in a systematic way. In this selective review, we present various evidence and promises to improve survival of glioblastoma patients by supra-maximum cytoreduction via local procedures while minimizing the risk of new neurologic deficit.
Highlights
The biggest challenge in neuro-oncology is the treatment of glioblastoma, which exhibits poor prognosis and is increasing in incidence in an increasing aging population
The most illustrative example of these patient-related predictors is the silencing of the O-6-methylguanine-DNA methyltransferase gene (MGMT) through promoter methylation (MGMT-p, coding for a DNA repair protein)
The biggest challenge in neuro-oncology is the treatment of Glioblastoma multiforme (GBM) due to its continuing poor prognosis and its increasing incidence in an increasing aging population
Summary
A common setup for image-guided neurosurgery uses a tracked pointer on a preoperative magnetic resonance imaging (MRI) scan to visualize the tumor and its critical surroundings for guidance during the surgery. This approach includes the use of ultrasound, computed tomography (CT), MRI, and direct (sub)cortical stimulation The principle behind this approach is to use these modalities simultaneously and allow the intraoperative overlay of both anatomic and functional information to better handle the surgical approach and resection. In cases of parietal tumors, resection began from the anterior border (Figure 1) Even when these suggestions are followed, the risk of brain shift remains substantial, and the accuracy of the information provided by the neuronavigation system remains inadequate. In fluorescence-guided surgery using 5-ALA, the photosensitizer PpIX is still available in the remaining peripheral tumor extensions after the gross total resection; photodynamic therapy (PDT) is possible. Further novel intraoperative fluorescence imaging systems and probes, including fluorescein sodium, dye-containing nanoparticles, and targeted nano-probes, are being researched to improve the specificity and selectivity of intraoperative fluorescence[28]
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