Supratotal Resection of Gliomas With Awake Brain Mapping: Maximal Tumor Resection Preserving Motor, Language, and Neurocognitive Functions

Abstract

Gliomas are a category of infiltrating glial neoplasms that are often located within or near the eloquent areas involved in motor, language, and neurocognitive functions. Surgical resection being the first-line treatment for gliomas, plays a crucial role in patient outcome. The role of the extent of resection (EOR) was evaluated, and we reported significant correlations between a higher EOR and better clinical prognosis of gliomas. However, recurrence is inevitable, even after aggressive tumor removal. Thus, efforts have been made to achieve extended tumor resection beyond contrast-enhanced mass lesions in magnetic resonance imaging (MRI)-defined areas, a process known as supratotal resection. Since it has been reported that tumor cells invade beyond regions visible as abnormal areas on MRI, imaging underestimates the true spatial extent of tumors. Furthermore, tumor cells have the potential to spread 10–20 mm away from the MRI-verified tumor boundary. The primary goal of supratotal resection is to maximize EOR and prolong the progression-free and overall survival of patients with gliomas. The available data, as well as our own work, clearly show that supratotal resection of gliomas is a feasible technique that has improved with the aid of awake functional mapping using intraoperative direct electrical stimulation. Awake brain mapping has enabled neurosurgeons achieve supratotal resection with favorable motor, language, and neurocognitive outcomes, ensuring a better quality of life in patients with gliomas.

The clinical and neurocognitive functional changes with awake brain mapping for gliomas invading eloquent areas: Institutional experience and the utility of The Montreal Cognitive Assessment

“…Generally, resection beyond 1-2 cm for contrast-enhanced tumors or 1-2 cm beyond the boundary in Flair images for non-enhanced tumors could be considered acceptable supratotal resection (33). Evidence indicated that supratotal resection might improve EOR and prolong the progression-free as well as OS in glioma patients (34). Our findings also suggested that awake brain mapping enabled surgeons to achieve supratotal resection with favorable neurological and clinical outcomes while preserving the neurocognitive function.…”

Self‐Disassembling and Oxygen‐Generating Porphyrin‐Lipoprotein Nanoparticle for Targeted Glioblastoma Resection and Enhanced Photodynamic Therapy

“…Although gross total resection is generally recommended to improve the prognosis, [ 31 ] striking a balance between tumor clearance and functional preservation remains a major concern, since determining the optimal resection margin is difficult. [ 32 ] Therefore, the extent of healthy tissue co‐resected during this process was evaluated through the Ki‐67 staining. Figure S16c (Supporting Information) illustrates examples of tumor resections guided by saline, indocyanine green (ICG), PLNP, and PLCNP.…”

A Personalized Longitudinal Strategy in Low-Grade Glioma Patients: Predicting Oncological and Neural Interindividual Variability and Its Changes over Years to Think One Step Ahead

“…One step forward is to achieve a “supra-complete” resection, to remove the PTZ which contains ITC exposing patients to a high risk of recurrence [ 49 , 66 ]. Long-term follow-up after supra-marginal LGG excision has shown a stronger impact on the natural course of the disease [ 27 , 48 , 81 , 82 ]. As a consequence, it has been proposed to consider LGG as remaining “high-risk” even in young patients (<40 years) who have had only a subtotal resection [ 83 ].…”