1.1 Introduction

In my experience as a trainee and as a practicing brain tumor surgeon, I have found that there are few topics about which more people have more strongly held views about than treating patients with gliomas, especially glioblastoma. I personally have met few neurosurgeons with a 100% spinal practice who hold strong views about whether aneurysms should be clipped or coiled, of whether craniopharyngiomas should be removed through the nose or a craniotomy. But many have an opinion (often negative) on whether or not a glioblastoma patient should get an operation.

Gliomas are unquestionably a bad disease, and the patients are often sympathetic victims, who in many cases slowly lose their battle despite our treatments. So it shouldn’t be surprising that people have come to strong conclusions about this disease. It can’t be cured, and surgery inevitably eventually fails in a large number of cases. Glioblastoma has an amazing ability to humble us by growing back a few weeks after the most technically excellent resection, which is a deflating experience even to a glioma surgeon.

1.2 Where has Nihilism Taken Us with this Disease?

My personal opinion is that by giving up on aggressively treating these patients that our field has collectively made the grim outcome a self-fulfilling prophecy. ¹ I have heard glioma surgery described as “easy” in comparison with skull base surgery, and it is often a case done occasionally by neurosurgeons who spend most of their time in the lab. A common method is to do the case with loupes and a headlight, the patient asleep, and the methodology is to suck the center of the “tumor” and not enter “eloquent” cortex. Basically, it is felt that because a cure cannot be obtained, that it is not as important to be technically excellent at doing it.

As a result, I regularly see many patients who have had no surgery or completely inadequate surgery. I see patients who have been told they have an “inoperable” tumor, when in reality; their tumor is located in a simple area and can be removed with minimal risk, provided the surgeon uses a good technique based on sound principles. Even worse, I often see patients where the surgical plan transgresses the worst possible trajectory in route to a subtotal resection, the worst of both worlds. Finally, I have seen all of the above occur at otherwise technically excellent neurosurgical centers (four examples of cases which were done at high quality academic neurosurgical programs are provided in Fig. 1.1), which can only occur from the view that it is not critical that we do glioma surgery at a technically excellent level.

This technical standard would never be accepted as the community standard for acoustic neuroma, which is a much less common disease and one where other treatments and repeat surgery are much more able to bail the patient out of a bad situation. The only conclusion is that we as a community do not believe that glioma surgery is important and that we should strive to refine our techniques until they are excellent, and that we should demand similar results from our peers.

1.3 My Own Contrary View

While glioma surgery cannot obtain a complete resection and cure, it does not necessarily follow that there aren’t good reasons to work towards excellence. Most notably is the repeated observation that improved resection improves overall survival for both low and high grade ^{1 ,​ 2 ,​ 3 ,​ 4 ,​ 5} glioma. Many studies demonstrate a survival advantage for aggressive resection of low-grade gliomas which can be as substantial as 10 years compared to doing only a minimal amount of resection or a biopsy. ^{1 ,​ 2 ,​ 3 ,​ 4 ,​ 5} By viewing outcomes with the binary view that our results are “cure or nothing,” we often deny patients a survival benefit that treating brain mets (a far less emotionally laden topic for most neurosurgeons) has never approached.

Further, even in the case of glioblastoma, when the survival benefit is less mathematically profound, logic and experience tell us that surgery provides these patients their best chance with a bad problem. I have yet to meet anyone alive and doing well 4 years after diagnosis with a biopsy and radiation but have met several individuals alive thanks to surgery. Cytoreduction probably improves the probability of efficacy of any radiation or chemotherapy, and it’s hard to expect a single drug to kill billions of cancer cells in a disease known for its ability to develop resistance and which hides behind the blood brain barrier. Thus, surgery gives the patient a chance, which is all most of these patients really ever ask from us.

Until a drug exists that can wipe the entire tumor out, permanently, without cytoreduction, this is the treatment paradigm most likely to end in a good result for them. I personally am skeptical that any of the present adjuvant treatments being studied will be able to tackle the entire disease without surgical cytoreduction and think the eventual treatment outcomes for GBM will be the result of incremental improvements gained by the statistical improbability of a cancer cell evading a series of effective treatments. Surgery’s role will be to drastically change that probability by providing a non-probabilistic treatment prior to exposing the cancer cells to your drug.

As well, the fear of surgery is usually grounded in the idea that you might make the patient worse, and that this risk is undertaken for an unclear benefit. I would answer that by pointing out that the belief in the idea that leaving a large cancer in the brain at initial diagnosis as a method for providing a good quality of life requires one to not remain in contact with these patients. Patients with tumors invading speech, motor, or other critical areas generally have a terrible quality of life, and controlling the tumor can preserve these functions. Many patients treated aggressively can remain neurologically normal with an excellent quality of life which lasts as long as tumor remains under control. Further, the worry about incurring neurologic risk has never slowed the development of skull base meningioma or acoustic neuroma surgery, two benign tumors for which the mandate to try to save the patient is nowhere near as acute. If we take glioma surgery as seriously as we take meningioma surgery, this risk inevitably falls, as any surgery done badly is dangerous and unwarranted. When you view the goal of surgery is the effort to save neurologic function that the tumor is trying to take, the justification for taking calculated risks is obvious.