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Neurosurgery Notes
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Photomicrograph of GBM |
How do you decide whether a patient should
have a surgical removal of the tumor or just a biopsy?
Many malignant gliomas are single tumors that can be completely or partially
removed. Removing the tumor mass, particularly if it has created pressure on the
normal brain, may bring about an improvement in the patient's symptoms. However,
malignant cells often penetrate deep into the surrounding brain and these
residual cells or "tentacles" will begin to grow and spread into the same area
and beyond. For this reason, surgery alone is rarely if ever effective in
controlling the disease for more than a few months.
A "sampling" of the tumor, or biopsy, may be performed safely in most patients. Elderly patients, patients with severe illness, or patients with very deep tumors may be at higher risk for complications for an attempted complete removal of the tumor. Removal of even a small portion of the tumor is often enough to confirm the diagnosis of a malignant tumor, but a biopsy would not be expected to relieve symptoms. A biopsy may be done with three-dimensional calculation of its location (a stereotactic procedure) or with a limited removal of the tumor under direct vision (an open procedure).
Compete surgical removal or resection of malignant gliomas may be considered by the neurosurgeon if he or she determines that it is safe to do so. The size and location of the tumor, as well as the general health of the patient, are important considerations in planning extensive surgery.
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| Progression of malignant glioma over an eight-week period. | |
Does surgical removal alone ever cure
malignant glioma?
Malignant gliomas, as a rule, reappear after treatment, usually within
months. This is often thought to be a result of the small number of tumor cells
that cannot be entirely removed at the time of surgery. Despite therapy, the
vast majority of malignant gliomas return at or near the site of the original
surgery.
If the tumor returns, is another surgery
recommended?
Re-resection of a malignant glioma may be indicated in certain patients.
Sometimes the patient has had radiation therapy and cannot have more radiation
to this area, but nevertheless has tumor regrowth. If the patient is
symptomatic, removal of the tumor a second time or even a third time can be
considered. However, further therapy with chemotherapy or another modality is
then recommended because the tumor will rapidly grow again.
A few years ago, a wafer containing chemotherapy (Gliadel) was approved by the Food and Drug Administration for implantation at the site of the surgery for recurrent malignant glioma. Not all patients can or should be considered for Gliadel treatment; although it has shown a survival benefit in some patients, its use must be weighed carefully by the neurosurgeon.
How has neurosurgery advanced the treatment
of malignant glioma?
Several new technological advances have made neurosurgery for brain tumors
safer. The use of intraoperative navigational equipment to better visualize the
tumor during surgery is available in several area hospitals. Monitoring
equipment before and during surgery to assess the function of the normal brain
near the tumor may also be helpful. Finally, postoperative evaluation of the
extent of resection by CT or MRI may guide further therapy and provide a
baseline for determining the response to subsequent treatment with radiation
therapy or chemotherapy.
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