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Review
. 2020 May 29;15(2):266-271.
doi: 10.4103/ajns.AJNS_296_19. eCollection 2020 Apr-Jun.

The Ethical Dilemma in the Surgical Management of Low Grade Gliomas According to the Variable Availability of Resources and Surgeon Experience

Marshall Norman Lahiff  1   2 , Michael George Zaki Ghali  3   4
Affiliations
Review

The Ethical Dilemma in the Surgical Management of Low Grade Gliomas According to the Variable Availability of Resources and Surgeon Experience

Marshall Norman Lahiff et al. Asian J Neurosurg. .

Abstract

Low grade gliomas (LGGs) affect young individuals in the prime of life. Management may alternatively include biopsy and observation or surgical resection. Recent evidence strongly favors maximal and supramaximal resection of LGGs in optimizing survival metrics. Awake craniotomy with cortical mapping and electrical stimulation along with other preoperative and intraoperative surgical adjuncts, including intraoperative magnetic resonance and diffusion tensor imaging, facilitates maximization of resection and eschews precipitating neurological deficits. Intraoperative imaging permits additional resection of identified residual to be completed within the same surgical session, improving extent of resection and consequently progression free and overall survival. These resources are available in only a few centers throughout the United States, raising an ethical dilemma as to where patients harboring LGGs should most appropriately be treated.

Keywords: Gliomas; intraoperative; magnetic resonance imaging; neuronavigation; supratotal resection; surgeon experience; survival; technology.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
Diffusion tensor tractography of a patient with left frontal oligodendroglioma. (a) The tumor infiltrates the left corticospinal tract (magenta) throughout its precentral gyral and centrum semiovale extents. Upper panel: Axial T1 weighted magnetic resonance imaging (MRI) sequences demonstrate left frontal oligodendroglioma. The location of the corticospinal spinal tracts (magenta) is determined by diffusion tensor tractography and superimposed on the axial T1 weighted MRI. Middle panels: Color maps demonstrate decreases in fractional anisotropy resulting from left frontal oligoglioma. Lower panels: Axial fluid attenuated inversion recovery MRI sequences indicate the location of the left frontal oligodendroglioma. Volumetric analysis determines the oligodendroglioma occupies a space of 29 cm3. (b) Axial fluid attenuated inversion recovery magnetic resonance imaging sequences performed postoperatively evidence residual within the area of deep fascicular infiltration. Corticospinal tract involvement precludes safely achieving a supratotal resection and predicts worse outcomes following operative intervention. Modified with permission from of Figure 1 of Castellano et al.[27]
See this image and copyright information in PMC

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