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Surgical resection in medulloblastoma: a crossroads in the molecular era
Joseph H McAbee1, David G Laird2, Amar Gajjar3
1Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD, USA.
Abstract:
Surgical resection for medulloblastoma has been a mainstay of treatment for decades due to the need for definitive diagnosis and known benefits on treatment efficacy and survival. While many pediatric neurosurgeons and neurooncologists agree that maximal safe surgical resection should be the goal of medulloblastoma surgery, actual practical application and benefits of maximal safe resection seem to vary. Early work on extent of resection provided a relatively arbitrary 1.5 cm2 threshold to distinguish subtotal resection (STR) from near total resection (NTR) and demonstrated a survival benefit if the residual was ≤ 1.5 cm2 (NTR or gross total resection (GTR)). However, recent evidence questions the validity of this threshold, with European researchers even suggesting that STR alone should not be considered a high-risk feature during adjuvant therapy planning. The question regarding extent of resection, therefore, is undeniably controversial and has become even more complex in recent years due to the seminal work done to identify medulloblastoma subgroups based on molecular characteristics. Adjuvant treatment approaches are being tailored to these molecular subgroups, and the impact of extent of resection on survival is being reconsidered within the context of subgroups. Certainly, the goal when treating children with medulloblastoma, or any form of brain cancer, should be to cure the disease while minimizing treatment-related toxicity, including surgical injury. In this article, we discuss the role of surgical resection for treating medulloblastoma and whether it is possible to maximize both surgical resection, to potentially improve survival and adjuvant treatment efficacy, while minimizing neurological morbidity.
Insights
Maximal safe surgical resection is key for medulloblastoma treatment, but its benefits and application vary. Recent research questions old thresholds, especially with new molecular subgroup data influencing adjuvant therapy.
Area of Science:
- Pediatric neurosurgery
- Neuro-oncology
- Brain cancer research
Background:
- Surgical resection is a primary treatment for medulloblastoma, crucial for diagnosis and improving outcomes.
- Maximal safe resection is widely accepted as the surgical goal, but its practical benefits and application vary.
- Historical thresholds for resection extent (e.g., 1.5 cm² residual) are being re-evaluated.
Purpose of the Study:
- To discuss the role of surgical resection in medulloblastoma treatment.
- To explore the controversy surrounding the extent of resection and its impact on survival.
- To examine the balance between maximizing resection and minimizing neurological morbidity in medulloblastoma patients.
Main Methods:
- Review of existing literature on surgical resection extent for medulloblastoma.
- Analysis of historical and recent evidence regarding resection thresholds.
- Consideration of molecular subgroup data in relation to surgical outcomes.
Main Results:
- The optimal extent of surgical resection for medulloblastoma remains controversial.
- Recent evidence challenges previously established thresholds for resection extent.
- Molecular subgroups of medulloblastoma may influence the impact of resection extent on survival and adjuvant therapy.
Conclusions:
- The goal of medulloblastoma treatment is to achieve cure while minimizing treatment toxicity.
- Extent of resection's impact is complex and influenced by molecular medulloblastoma subgroups.
- Balancing maximal resection with minimal neurological damage is essential for optimal patient outcomes.
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