1. University of Catania School of Medicine Department of Neurosciences Section of Neurosurgery State of the art in microsurgery of Brain Gliomas Vincenzo Albanese

2. Removal of right cerebral hemisphere for certain tumors with hemiplegia Dandy WE JAMA 90: 823-825, 1928 “In the gradual evolution of resections of frontal, temporal and occipital lobes for the cure or attempted cure of invasive and otherwise incurable cerebral tumors, it has been found that the right temporal lobe, either frontal lobe or either occipital lobe (the left posterior to the supramarginal gyrus) could be completely removed without apparent mental impairment”.

3. Extent of MST 1-yr2-yr5-yr resection (months) Gross total 17 72%31%12% Subtotal 11 47%15% 2% Biopsy 7 23% 2% 0% Barker et al. (UCSF), JNS 1996 Survival in GBM stratified by extent of resection

4. Goals of surgery for malignant gliomas 1. Providing diagnosis 2. Relieving symptomatic mass effect 3. Improving or manteining the KPS and QOL 4. “Setting up” postoperative externally delivered therapies 5. Prolonging survival through cytoreduction 6. Applying locally-delivered therapies

5. Preoperative planning DT - iMR Tractography

6. Surgery of Brain Gliomas is Vascular Surgery

8. RM – PET Fusion Image guided Open Biopsy in non-enhancing glioma

9. Evaluation of results Early post-op MRI < 48 h

11. Intraoperative control of resection

12. Evaluation of results Be aware of Pseudo-progression Preop 8/8/08Postop 10/9/08Postop 21/12/08Postop 21/03/09

13. Evaluation of results Be aware of Radionecrosis

14. 65% GTR 5-ALA vs 36% GTR WL

15. Highly Integrated Glioma Surgery Image and fluorescence guided and cortical and subcortical mapped surgery

16. Laser assisted microsurgery of Brain Gliomas

17. “Setting up” postoperative therapies Resection and TMZ – EORTC 26981 (Stupp) 2-year survivalmedian survival +TMZ -TMZ +TMZ -TMZ GTR37% 14%18m 14m STR23% 9%14m 12m Bx10% 5% 9m 8m van den Bent et al., Eur J Cancer 2005 [abstr]

18. “A pessimist sees the difficulty in every opportunity, An optimist sees the opportunity in every difficulty.” Winston Churchill