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

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.

The Concept of «Peritumoral Zone» in Diffuse Low-Grade Gliomas: Oncological and Functional Implications for a Connectome-Guided Therapeutic Attitude

“…The longer OS achieved is related to a change in the natural history of the disease, surgery allowing us to significantly reduce the risk of malignant transformation, thanks to a decrease in the number of tumor cells. Additionally, taking into account PTZ knowledge, earlier treatments should be considered before a too wide extension of this tumor cell outskirts, making maximal resection impossible [20].…”

“…In fact, it has been evidenced that the extent of resection is a major prognostic factor, and hence, surgery is highly recommended in DLGG [17]. Furthermore, recent reports state that, when feasible, a "supratotal" resection (SpTR)-meaning a functional-guided resection beyond MRI signal abnormalities and therefore including the PTZ-may have an even greater impact on the natural history of the disease [12,[18][19][20][21][22]. In this case scenario, it is also likely that adjuvant treatment, namely, chemo-and/or radiotherapy, could be postponed and thus further extend not only survival but, moreover, patients' long-term quality of life (QoL) [23].…”

Intraoperative Ultrasound: Emerging Technology and Novel Applications in Brain Tumor Surgery

“…Navigated IOUS allows the fusion of preoperative MRI with IOUS imaging through the navigation of US probes. In this way, it is possible for the neurosurgeon to visualize IOUS imaging as overlay on brain MRI during real-time neuronavigation, thus improving the reliability of IOUS and the visualization of EOR against preoperative imaging (11,(17)(18)(19)(20)(21)(22).…”

Radiotherapy in Current Neuro-Oncology: There Is Still Much to Reveal

“…Considering that an increasing amount of new drugs is being launched, especially immuno-and molecular targeted therapies, neuro-oncologists need to be familiar with their possible interactions with concomitant RT, both in terms of improved clinical outcome and adverse events [22,23]. Even conceptually, new therapies, such as Tumor Treating Fields (TTFields), could be effectively integrated with RT for the treatment of highly aggressive brain tumors (e.g., glioblastoma) [24][25][26][27][28].…”