The Principles Behind Every Brain Tumour Operation

This applies mainly at the extremes of age: very large tumours in infants, or very large tumours in elderly patients involving critical areas of the brain. For brain stem and deep-seated thalamic gliomas presumed to be malignant, a biopsy may not even be taken, since these are treated directly with radiotherapy. Glioblastomas (grade 4 gliomas) carry a poor prognosis, though chemotherapy and radiotherapy can still extend survival and quality of life for that shorter span of time.

Four things are essential. MRI is mandatory, brain tumour surgery should not be performed without it. An operating microscope is needed for magnification, even a basic one without fluorescence or navigation add-ons. The anaesthetist needs to be equipped and experienced in controlling brain swelling and blood pressure during surgery, ideally with a year or two of experience at a neuro centre. And a post-operative ICU with ventilator support is needed, since some patients require ventilation for a day or two. Good post-operative ICU care alone can reduce complications by 25 to 30 percent. With these four in place, superficial tumours such as meningiomas, surface gliomas and straightforward intraventricular tumours can be safely removed; difficult tumours should still be referred to a better-equipped centre.

Metastasis used to be the most common brain tumour, but with better radiotherapy and chemotherapy most metastatic cases are now managed by radiation and medical oncology rather than surgery, except when a solitary large metastasis is causing a symptomatic mass effect. The tumours operated on most often today are gliomas and meningiomas. Gliomas run from grade 1 to grade 4, and grade 4 glioblastomas have the worst prognosis. Meningiomas usually have a good prognosis, though some are atypical or malignant and located at difficult skull-base sites near major vessels; those can be treated with modern radiotherapy such as gamma knife or cyberknife after a subtotal resection. Pituitary tumours are third most common and are usually benign, approached endoscopically through the nose.

Yes. All patients need post-operative care from a team of physiotherapists and rehabilitative support. About 90 percent of patients who arrive without deficits leave hospital without one, but even they need psychological support, and patients with malignant tumours need considerably more of it given the chemotherapy and radiotherapy ahead. Patients need to see the neurosurgeon and physiotherapist regularly for at least 3 to 6 months, and continue lifelong follow-up MRIs.

The full presentation covered the range of techniques used, from neuronavigation and awake craniotomy to fluorescence-guided resection and endoscopic approaches, depending on the tumour's location and type.

In 99.9 percent of cases, yes, to obtain a histopathological diagnosis. The exception is a presumed diffuse brain stem or deep-seated thalamic glioma, which may go directly to radiotherapy or chemotherapy without a biopsy.

A histopathological diagnosis, maximal safe tumour removal, complete removal where a benign tumour allows it, and minimum morbidity with minimum recurrence.

Robotic neurosurgery and robotic stereotactic biopsy are already available in some centres, alongside research into tumour biology and gamma knife radiotherapy for small or metastatic tumours.