Brain Mapping: From Neural Basis of Cognition to Surgical Applications

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Patients with oligodendroglial tumors are more likely to respond, but those with mixed or astrocytic tumors may respond as well. Two phase III randomized trials have demonstrated no advantage for high versus low radiation doses and increased toxicity in higher doses. Because of its potentially delayed neurotoxicity and the equivalent results in terms of OS whatever the timing of treatment early or late , RT is being increasingly offered to high-risk patients 32 with unresectable tumors or tumor that cannot be reoperated and in cases of progression after CT but not as a first therapeutic option.

The first step for managing DLGG is to investigate the tumor's behavior and its possible consequences on brain functions. It is crucial i to calculate the volume of the tumor and its growth rate because it has been demonstrated that both parameters are prognostic factors correlated with survival; 5 , 34 ii to analyze the precise location of the glioma, both at the cortical and subcortical levels; and iii to perform extensive neuropsychological assessments even in DLGG discovered incidentally in order to adapt the intraoperative mapping, which has been demonstrated to increase the extent of resection while decreasing the morbidity.

In the series by Yordanova et al 4 of 15 patients experienced a recurrence, even if MT did not occur, with a mean delay of about 38 months because isolated tumoral cells were still present beyond the glioma visible on MRI. Indeed, honest information is very well accepted by patients and helps build trust that will last throughout the management of this chronic disease.

In practice, DLGG will likely recur several years after an initial maximal surgery, even after supracomplete or complete resection, and the growth rate of residual glioma after incomplete resection will be similar to its presurgical kinetics. Consequently, a second preventive treatment can be proposed just before this threshold is reached—but not too early— in order i to not use future therapies prematurely; and ii to preserve QoL by limiting the use of too much treatment s iii while controlling the tumor by avoiding MT Fig.

Proposal of dynamic therapeutic strategy in DLGG before malignant transformation, with special emphasis on the role of early and maximal surgical resection s as well as multistage therapies tailored to each patient over years modified from The impact of multiple surgeries on DLGG has been investigated. In 40 patients reoperated for recurrent DLGG, Schmidt et al showed that gross-total resection was associated with increased time before further surgery.

The median time between surgeries was 4. Thus, the authors suggested consideration of reoperation s in all recurrent DLGGs. Such a multistage surgical approach—beginning with initial function-guided resection, followed by a period of several years, and then a second surgery with optimization of EOR while preserving QoL—is possible, thanks to brain plasticity.

However, a significant oncological benefit of surgery was demonstrated only when the resection was or resections were at least subtotal. Otherwise, alternative treatment should be considered, without the need of biopsy. Again, the goal is to control the tumor volume, in order to delay AT while preserving QoL. TMZ is generally preferred because of fewer adverse effects.


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QoL does not seem to change over time while patients are receiving TMZ. Furthermore, CT has improved the QoL for patients with intractable seizures by controlling their seizures, thus leading us to give TMZ to these individuals sooner. When tumor shrinkage is important, especially with regression of the glioma invasion within eloquent structures, CT may open the door to a subsequent surgery.


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This strategy should not be guided by the molecular profile at the individual level. It has no negative impact on QoL and can even improve it Fig. B After 20 cycles of neo-adjuvant chemotherapy temozolomide a dramatic shrinkage was observed, and awake surgery with resection guided by functional mapping was achieved. When CT allows only stabilization of tumor volume, without opening the window to a re- operation, the duration of TMZ is still a matter of debate.

PCV is stopped after a maximum of 4—6 cycles. It is difficult to predict the behavior of DLGG after interrupting CT because distinct patterns have been described ie, continuation of shrinkage, prolonged stabilization, or rapid regrowth. First, with the aim of preserving QoL, CT should be interrupted if it is or if it becomes poorly tolerated.

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Second, radiologically, the tumor volume is one of the most important markers related to the risk of MT and OS. Third, the growth rate before administration of CT should be taken into account because this paramater is correlated with OS. Fifth, despite significant correlations between growth rate and 1p19q status, the decision to begin CT should not be based on molecular biology because of its poor predictive value of tumor response.

Prospective studies are needed to optimize the management of DLGG under CT, especially to evaluate the possible benefit-to-risk ratio of new protocols with alternating periods of several months of TMZ, broken by periods of single-treatment clinical and radiological follow-up. One prospective randomized trial demonstrated that early RT had no impact on OS.

Therefore, early RT should not be considered as a first option in strategies that aim to optimize the cumulative time with preserved QoL while preventing AT. Irradiation should be kept in reserve for progressive DLGG that has relapsed under chemotherapy and cannot be re- operated. The current philosophy for DLGG patients is to anticipate before neurological or even cognitive worsening a personalized, multimodal, and long-term management strategy, with online treatments adjusted over time on the basis of regular functional feedback and radiological monitoring.

This dynamic strategy challenges the traditional attitude, namely, i by proposing earlier therapy after the diagnosis, ii by repeating treatments eg. The ultimate aim is not yet curing this tumor but rather taking measures to delay AT as long as possible, while giving DLGG patients a real life that includes planning for their long-term future eg, such as deciding whether to have a baby.

This concept leads to individualized, functional, and prophylactic neurooncology. The next step is to envision a screening policy for silent DLGG, in order to achieve more frequent total and supratotal resections in smaller tumors. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.

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Neural Basis of Cognition

Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. Nonsurgical Therapies. Editor's Choice. New concepts in the management of diffuse low-grade glioma: Proposal of a multistage and individualized therapeutic approach Hugues Duffau. Department of Neurosurgery, Gui de Chauliac Hospital. Oxford Academic. Google Scholar. Luc Taillandier. See the editorial by Zadeh et al, on pages — Cite Citation.

Permissions Icon Permissions. Abstract Diffuse low-grade glioma grows, migrates along white matter tracts, and progresses to high-grade glioma.

Brain Mapping

Open in new tab Download slide. Google Preview. Histological Classification. Search ADS. Velocity of tumor spontaneous expansion predicts long-term outcomes for diffuse low-grade gliomas. Response assessment in neuro-oncology a report of the RANO group : assessment of outcome in trials of diffuse low-grade gliomas. The huge plastic potential of adult brain and the role of connectomics: New insights provided by serial mappings in glioma surgery.

The challenge to remove diffuse low grade gliomas while preserving brain functions. A randomized trial on dose-response in radiation therapy on low-grade cerebral glioma. Randomized trial on the efficacy of radiotherapy for cerebral low-grade glioma in the adult: European Organization for Research and Treatment of Cancer Study with the Medical Research Council study BRO4: an interim analysis. Prognostic factors for survival in adult patients with cerebral low-grade glioma. Long-term efficacy of early versus delayed radiotherapy for low-grade astrocytoma and oligodendroglioma in adults: the EORTC randomised trial.

Comparison of a strategy favoring early surgical resection vs a strategy favoring watchful waiting in low-grade gliomas. The effect of extent of resection on recurrence in patients with low-grade cerebral hemisphere gliomas. Proton magnetic resonance spectroscopy predicts proliferative activity in diffuse low-grade gliomas.

Lessons from brain mapping in surgery for low-grade glioma: insights into associations between tumour and brain plasticity. Cognition and resective surgery for diffuse infiltrative glioma: an overview.


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  • Role of extent of resection in the long-term outcome of low-grade hemispheric gliomas. Survival rates in patients with low-grade glioma after intraoperative magnetic resonance image guidance. Contribution of intraoperative electrical stimulations in surgery of low grade gliomas: a comparative study between two series without —96 and with — functional mapping in the same institution.

    Brain Mapping: From Neural Basis of Cognition to Surgical Applications

    Treatment outcomes and prognostic factors in patients with supratentorial low-grade gliomas. Extent of surgical resection is independently associated with survival in patients with hemispheric infiltrating low-grade gliomas. Recurrence and malignant degeneration after resection of adult hemispheric low-grade gliomas. Long-term outcome and survival of surgically treated supratentorial low-grade glioma in adult patients.

    Intracranial low-grade gliomas in adults: year experience with long-term follow-up at Mayo Clinic. Changes in presentation, treatment, and outcomes of adult low-grade gliomas over the past fifty years. Low-grade glioma surgery in eloquent areas: volumetric analysis of extent of resection and its impact on overall survival. A single-institution experience in patients.