Neurosurgical approach

Glioblastoma multiforme is a highly infiltrative tumor that typically has a central region of necrosis surrounded by contrast-enhancing proliferative tumor cells surrounded by diffuse isolated tumor cells that migrate into the brain. The goal of surgery is often directed toward the central necrotic region and the imaging-defined enhancing margin. To limit morbidity from removing functional brain tissue, the infiltrative tumor cells found in surrounding brain are generally not considered part of the surgical target. This is also the site where tumors recur after treatment. It is well accepted by most surgeons and neuro-oncologists that, when possible, aggressive resection of malignant gliomas is the preferred initial step in management. Although there are limited randomized prospective studies that address extent of resection and survival, the benefit of aggressive surgical resection will not be debated in this report. Tumor resection to the maximum extent that is safely possible can decrease tumor burden and thereby enhance the effects of adjuvant therapies, improve symptoms from mass effect, reduce the frequency of seizures, and provide tissue for pathological and genomic studies to better identify and test novel therapy.Surgery for glioblastoma is highly dependent on imaging. Magnetic resonance imaging can provide an anatomic definition of the lesion and functional capacity of critical cortical regions and allow for precise localization within the brain. The common use of stereotactic guidance, intraoperative imaging, functional magnetic resonance imaging, and physiologic monitoring have enhanced the surgeon's ability to achieve aggressive tumor removal while protecting the patient from neurologic impairment. This review will address the use of these techniques as an important first step in managing patients with glioblastoma.