Optimizing Outcomes With Maximal Surgical Resection

Abstract and Introduction

Background: Aggressive surgical resection of malignant gliomas is a controversial issue in neurosurgery. Studies with rigorous methodology that fully address this issue have only recently become available.
Methods: The controversy regarding the role of maximal surgical resection of malignant gliomas is reviewed. The authors discuss surgical techniques and adjunctive technologies that can be utilized to assist in resection of these lesions.
Results: Using current microneurosurgical techniques, it is possible to resect malignant gliomas in gross total fashion. An aggressive approach in which 98% or more of the tumor mass is resected results in a statistically significant survival advantage.
Conclusions: An aggressive surgical procedure for malignant gliomas can result in increased survival duration for selected groups of patients.

A long-standing controversy in the neurosurgical literature involves the efficacy of maximally resecting malignant gliomas. In other fields of oncologic surgery, complete resection of the lesion, hopefully with wide margins, is key to controlling the disease, but malignant gliomas are invasive into the surrounding brain tissue, and thus wide resections are not possible due to nearby functionally critical areas. Properly designed, prospective studies have only recently become available that have shown a beneficial relationship between the extent of resection of malignant gliomas and survival. With continued refinements in microsurgical techniques and the use of adjunctive surgical technologies, major neurologic morbidity has been reduced to 8.5% and mortality to 1.7% for patients undergoing craniotomies for tumor.^[1] This article summarizes the controversy regarding maximal resection for malignant gliomas, clarifies the relationship between increased survival and the extent of resection, and discusses some of the techniques that can be employed to optimize the extent of resection of these tumors.