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Table of Contents
EDITORIAL
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 87-88

Adjuncts in glial tumor management: Optimizing strategy


Department of Neurosurgery, Seth G. S. Medical College and King Edward VII Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication10-Jan-2020

Correspondence Address:
Dr. Dattatraya Muzumdar
Department of Neurosurgery, Seth G. S. Medical College and King Edward VII Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2590-2652.275537

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How to cite this article:
Muzumdar D. Adjuncts in glial tumor management: Optimizing strategy. Int J Neurooncol 2019;2:87-8

How to cite this URL:
Muzumdar D. Adjuncts in glial tumor management: Optimizing strategy. Int J Neurooncol [serial online] 2019 [cited 2020 Apr 5];2:87-8. Available from: http://www.Internationaljneurooncology.com/text.asp?2019/2/2/87/275537



Surgery for low- and high-grade gliomas has evolved over the last two to three decades and is still in evolution to achieve maximum resection rate. With the advances in radiation oncology, medical oncology, and the biology of the disease, the management of this complex disease entity has become comprehensive. There are different treatment protocols as per the geography and population characteristics. These have resulted in comprehensive study groups, which have been published, in the form of guidelines. Currently, there are American, European, and regional guidelines which are being quoted and followed in practice. However, these guidelines can be followed in totality if the infrastructure and practice paradigms are uniform in a specified population.

Techniques, technology, and tools in neuro-oncology are legitimate arms of diagnostic and therapeutic advancement in management of gliomas. These advances have helped in improving the diagnostic accuracy of glioma and its subtypes as per the WHO 2016 classification and maximizing the extent of resection (EOR) close to 95%–98% in appropriate cases, molecular typing, tailored adjuvant therapy, and even in recurrent glioma. However, its judicious use is paramount. Indiscriminate use will be a major source of rising health-care costs and may limit its further use. In a diverse country like ours, there is a marked variation in the affordability of the patient as well as level of training among neurosurgeons, radiation oncologists, neuropathologists, and medical oncologists to effectively use these advanced technologies and tools. Appropriate financial and insurance regulations for the patient and uniform training methodology for neurosurgeons, radiation oncologists, neuropathologists, radiologists, and medical oncologists are the need of the hour to maximize the utility of these tools and outcome.

The emerging recognition of health economics is an important consideration. The various preoperative and intraoperative adjuncts for resection of glioma in eloquent and noneloquent areas include functional magnetic resonance imaging (MRI) for motor and language, diffuse tensor imaging, neuronavigation, intraoperative tools such as ultrasound, computed tomography (CT), MRI, dyes such as 5-aminolevulinic acid (5-ALA), indocyanine green, and intraoperative neuromonitoring. It would also include anesthesia-monitoring equipment such as bispectral index monitoring, awake craniotomy, and anesthesia drugs. In addition to the advanced neuropathology techniques including molecular typing as well as advanced radiation and medical oncology, the total cost of therapy of glioma can be prohibitively expensive. It may be within the reach of few affluent patients but may be an additional burden on the finances of the large section of patient population in our country or the institution where the patient belongs. This may need to be taken into account while recommending the treatment as per the prevailing situation.

Intraoperative ultrasound is a relatively cheap and affordable tool, which can be easily available, reliable, user-friendly, reproducible, and used in medium and tertiary hospitals alike in contradistinction to intraoperative CT or MRI. As per the data available on clinical use of 5-ALA, it certainly enhances glioma surgery by improving the surgeon's ability to maximize EOR, possibly surgical comfort, and safety. Despite its well-accepted impact on maximizing EOR in Europe and Japan, there remains a need for a multicentric study in the Indian subcontinent with definitive data to augment its use. Furthermore, simply relying on thresholds for determining the acceptability of a new intervention can lead to ever-increasing health-care costs. The true overall impact of the intervention also must be considered in the context of other available options.

The use of adjuncts and technology in improving the EOR and outcomes as well as advances in radiation techniques and technology and chemotherapy should be measured in light of the diverse economic strata in our country. The primary measure should be that the patient should be least burdened for the financial implications regarding its implementation. The recommendations should come from academic neuro-oncological forums and societies. In our country, the practice paradigms are vastly different even in the same city or town due to variability in the economic and logistic support for treatment of such complex problem. Various nongovernmental and philanthropic agencies should help create awareness and come forward in support so that rational treatment can be delivered to the most deprived section of our society who need treatment for brain tumors. The governmental agencies could issue an advisory endorsing and authenticating the same.

Finally, for the young neurosurgeons, basic tools of surface navigation such as the anatomy, subarachnoid space, and the surface measurements for planning a craniotomy as well as accurate localization of the tumor should never be forgotten. Even while resecting a glioma, careful consideration should be given to functional landmarks of eloquent and noneloquent cortex as per the motor homunculus as well as physiologic lobar divisions. The surface of the brain, color, consistency, and texture should be judged critically and may give important information about the underlying glial tumor. The appropriate use of technology and tools in neuro-oncology for maximizing outcome measures should be supplementary to the application of existing basic knowledge and tools, which are time-tested over many years of hard work by our predecessors in their respective fields of neuro-oncology.






 

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