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Incidental diffuse low-grade gliomas: from early detection to preventive neuro-oncological surgery

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Abstract

Although a large amount of data supports early surgical resection for symptomatic diffuse low-grade glioma, the therapeutic strategy is still a matter of debate regarding incidentally discovered diffuse low-grade glioma. Indeed, early and “preventive” surgery has recently been proposed in asymptomatic patients with silent diffuse low-grade glioma with better outcomes. The present review discusses the importance of an early diagnosis and of a preventive surgical treatment to improve the outcomes of incidental diffuse low-grade glioma and suggests the possible relevance of a tailored screening policy.

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Author contributions

All authors have participated in the writing of this manuscript, and all authors approve this final version. Conception and design was done by J. Pallud, H. Duffau. Acquisition of data was done by G. Lima. Analysis and interpretation of data were performed by G. Lima, J. Pallud, E. Mandonnet, L. Taillandier, and H. Duffau. Drafting the article was done by G. Lima and J. Pallud. Critically revising the article was made sure by G. Lima, M. Zanello, J. Pallud, E. Mandonnet, L. Taillandier, and H. Duffau.

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    Authors and Affiliations

    1. Department of Neurosurgery, Onofre Lopes University Hospital, Rio Grande do Norte Federal University, Natal, RN, Brazil

      Guilherme Lucas de Oliveira Lima

    2. Department of Neurosurgery, Sainte-Anne Hospital, Paris, France

      Guilherme Lucas de Oliveira Lima, Marc Zanello & Johan Pallud

    3. University Paris Descartes, Paris, France

      Guilherme Lucas de Oliveira Lima, Marc Zanello & Johan Pallud

    4. Réseau d’Etude des Gliomes (REG), Groland, France

      Emmanuel Mandonnet, Luc Taillandier, Johan Pallud & Hugues Duffau

    5. Department of Neurosurgery, Lariboisiere Hospital, Paris, France

      Emmanuel Mandonnet

    6. Department of Neuro-Oncology, Nancy Neurological Hospital, Nancy, France

      Luc Taillandier

    7. Histopathology and Animal Models, Institut Pasteur, Paris, France

      Johan Pallud

    8. Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 80 Avenue Augustin Fliche, 34295, Montpellier, France

      Hugues Duffau

    9. Institute for Neuroscience of Montpellier, INSERM U1051, Team “Plasticity of Central Nervous System, Human Stem Cells and Glial Tumors,” Saint Eloi Hospital, Montpellier University Medical Center, 80 Avenue Augustin Fliche, 34091, Montpellier, France

      Hugues Duffau

    10. Department of Neurosurgery, Hôpital Sainte-Anne, 1 Rue Cabanis, Cedex 14, 75674, Paris, France

      Johan Pallud

    Authors
    1. Guilherme Lucas de Oliveira Lima
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    2. Marc Zanello
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    3. Emmanuel Mandonnet
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    4. Luc Taillandier
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    5. Johan Pallud
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    6. Hugues Duffau
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    Corresponding author

    Correspondence to Johan Pallud.

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    Comments

    Michel Wager, Poitiers, France

    This is a very nice article, addressing various aspects of low-grade glioma management. Three main themes emerge from this text:

    The oncological rationale for early and aggressive surgical treatment of these tumors: this first aspect probably has become the most consensual today due to mounting evidence in literature during the last two decades. This paper brings an enriching view on what has now become the standard of care.

    The second point, raising the question of a screening policy, might get a more mixed reaction from readers because it goes far beyond neurosurgical care per se and might even be somewhat polemical, all the more so that it calls upon partly intangible arguments. But in any event, this would be in my view a sound and healthy controversy.

    Last but not least, the authors introduce the concept of centers «hyper-specialized in neuro-oncological care». This concept embodies the organizational aspects of the emerging concept of «functional neuro-oncology»1.

    Indeed, as any innovative therapeutic strategy, functional neuro-oncology requires a dedicated environment. Well-trained, dedicated surgeons—hyper-specialization is a well-illustrated cause of lower rates complications2—sustained and regular rate of procedures (awake brain surgeries on a minimum weekly basis would probably reach large agreement in the community); technical choices supporting the widest multidisciplinary management in the operating room3; committed, specialized anesthetists; mandatory presence, in the operating room, of speech therapists/neuropsychologist during awake procedures; detailed pre- and postoperative neuropsychological assessments; detailed neuro-oncological assessments—even standards of resection are now available for (not only) junior teams4, allowing comparison with colleagues and monitoring of learning curves; expert neuroradiological diagnosis and follow-up; perfect timing of pre- and/or postoperative chemotherapy in collaboration with dedicated board-certified neuro-oncologists. Functional neuro-oncology is by essence multidisciplinary, and networks have long illustrated this, up to the European level as exemplified by the European Low Grade Glioma (ELLG) network5.

    In this context, the concept of «hyper-specialized centers in neuro-oncology» might constitute an encouragement for committed teams in presenting the healthcare provision of their institutions, on dedicated websites, for example. This would be of great help both for referring physicians and for patients, in making their choice of who will treat brain tumors in the future—on sound evidences.

    This article, altogether expert and refreshing, should stimulate discussions and initiatives regarding these various aspects of that exciting growing field.

    References

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    2. Trinh VT, Davies Jm Fau–Berger MS, Berger MS. Surgery for primary supratentorial brain tumors in the United States, 2000–2009: effect of provider and hospital caseload on complication rates. 20150202 DCOM-20150331 (1933–0693 (Electronic)).

    3. Wager M, Rigoard P, Bataille B, et al. Designing an operating theater for awake procedures: a solution to improve multimodality information input. British journal of neurosurgery. Jun 17 2015:1–7.

    4. De Witt Hamer PC, Hendriks EJ, Mandonnet E, Barkhof F, Zwinderman AH, Duffau H. Resection probability maps for quality assessment of glioma surgery without brain location bias. PloS one. 2013;8(9):e73353.

    5. Beez T, Boge K, Wager M, et al. Tolerance of awake surgery for glioma: a prospective European Low Grade Glioma Network multicenter study. Acta neurochirurgica. Jul 2013;155(7):1301–1308.

    Krasimir Minkin, Sofia, Bulgaria

    Lima et al. try to defend the idea of preventive neuro-oncological surgery in cases of low-grade gliomas. The authors divide the clinical evolution of low-grade gliomas in occult, silent, symptomatic, and malignant transformation periods. Early surgery during the silent period (MRI visible but asymptomatic) was proposed based on the data of better tumor and symptom control in patients with possible gross total resection. This strategy could be also cost-effective after MRI protocols and target population adjustments. However, we have to keep in mind that cure of low-grade gliomas even treated in early stage remains an impossible mission because of the extensive tumor spread probably during the occult, MRI invisible stage1. Real total and supratotal resections remain unachievable because of the high functional price, but quality of live and overall survival gains seem sufficient prerequisites for preventive neurooncological surgery2,3,4.

    References

    1. Pallud J, Varlet P, Devaux B, Geha S, Badoual M, Deroulers C, Page P, Dezamis E, Daumas-Duport C, Roux FX. (2010) Diffuse low-grade oligodendrogliomas extend beyond MRI-defined abnormalities. Neurology 74:1724–1731

    2. Chang EF, Clark A, Smith JS, Polley MY, Chang SM, Barbaro NM, Parsa AT, McDermott MW, Berger MS (2011) Functional mapping-guided resection of low-grade gliomas in eloquent areas of the brain: improvement of long-term survival. Clinical article. J Neurosurg 114:566–573

    3. Yordanova YN, Moritz-Gasser S, Duffau H (2011) Awake surgery 468 for WHO Grade II gliomas within “noneloquent” areas in the left 469 dominant hemisphere: toward a “supratotal” resection. Clinical article. J Neurosurg 115:232–239

    4. Klein M, Duffau H, De Witt Hamer PC (2012) Cognition and resective surgery for diffuse infiltrative glioma: an overview. J Neurooncol 108:309–318

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    This study was not considered in any previous presentation.

    Johan Pallud and Hugues Duffau contributed equally to this work.

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    Lima, G.L.d.O., Zanello, M., Mandonnet, E. et al. Incidental diffuse low-grade gliomas: from early detection to preventive neuro-oncological surgery. Neurosurg Rev 39, 377–384 (2016). https://doi.org/10.1007/s10143-015-0675-6

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