Commentary

For several decades, the role of surgery for patients with glioblastoma has been a major controversy in neurosurgery. The literature abounds with contrasting opinions from neuroscientists across the globe with arguments ranging from biopsy alone or no surgery, to those who would aim for nothing less than gross total resection. In spite of several noteworthy scientific and technological advances in an attempt to tackle the disease, glioblastoma remains incurable. Five-year survivals are almost unheard of, yet most of us optimistically continue to operate on these formidable lesions, often uncertain whether our surgical intervention is making any significant positive impact on patient's longevity and quality of life.

In the current issue, Amirjamshidi et al venture into the controversy of the role of radical surgical resection in glioblastoma with particular relevance to the operating conditions and technological limitations in less developed and developing countries. They rue the unavailability of more sophisticated technology such as intraoperative MRI in their facility and consider it a significant limiting factor in the optimal resection of these lesions. They conclude that sufficient surgical experience may partially compensate for the lack of sophisticated technology in achieving optimal resections in less developed parts of the world. Having worked in the neurosurgical settings of developing and developed parts of the world for over a decade each, I find their conclusion interesting. I think it reflects a common notion among many in the developing world that perhaps access to sophisticated technology provides all the answers we are looking for.

Most neurosurgeons practicing in the developed world and having access to all the perioperative technological assets have by now come to terms with the fact that most of these surgical advances have not altered the eventual prognosis in patients with glioblastoma. On the other hand, the neurosurgeons in relatively less developed part of the world perhaps do not seem to share the same nihilism. They often seem to believe that further technological surgical adjuncts such as intraoperative MRI would help them achieve better results in these patients, comparable to the outcomes in developed countries. I believe it is a myth prevalent in some of the less developed parts of the world that the disparity in technological advances is directly translated into the (perceived) differences in the surgical outcomes in the patients with glioblastoma. There is no doubt that scientific developments have enabled us to better understand many neurological diseases and to find effectives remedies with minimum morbidities. Nevertheless, I remain unconvinced that we have gained any significant grounds in the management of glioblastomas. We ourselves do not have facilities for intraoperative MRI at our institution. I have encountered many neurosurgeons working in similar setups who believe that intraoperative MRI would have definitely helped them accomplish total macroscopic resections. Sometimes I wonder whether in the pursuit of technological advances we allow ourselves to remain immune to the fact that the availability of latest neuronavigation tools, preoperative ultrasound, mapping devices, or an intraoperative MRI imaging does not obviate the necessity of the surgery to be performed by a competent and experienced surgeon. Even if surgery is a technical success, the disease has usually spread well beyond the margins depicted by the intraoperative imaging devices, making total resection a surgical illusion in most cases anyway. I am sure that most neurosurgeons will concur that there is nothing so humbling as to find a macroscopically totally resected lesion, substantiated by an immediate postoperative MRI, to be of the same size or even larger than its original size in a 6-month follow-up MRI scan.

There is little doubt that latest imaging advances and intraoperative tools enable us to locate most brain tumors precisely. They also facilitate relatively less invasive approaches necessitating minimal exposure of normal parenchyma and better definition of tumor boundaries. These in turn permit radical tumor resection with minimal handling of surrounding structures resulting in expeditious recovery. I am however anxious that we may unknowingly err toward placing an overemphasis on the technological gadgets in estimating treatment outcomes. Even if a surgeon has all the latest technology at hand, the tumor resection itself depends on the hands that carry it out and the brains behind it. From my experience of working long enough in extreme settings, I am not sure whether various intraoperative technological advances, by themselves, are independent predictors of surgical outcome in patients with glioblastoma.

These advances in technology have their own downside as well. With increasing use of sophisticated preoperative as well as intraoperative imaging to aid the surgeon, our successors are finding it difficult to master the skills of preoperative neurologic examination of patients and topographical localization of the lesions during surgery. I am not a technophobe by any means, yet I believe, overreliance on technology is one of the most common errors in modern neurosurgery. For example, do we not miss a few heartbeats when the neuronavigation system that was perfect in the planning room fails during surgery? Is it not annoying when due to the inevitable brain shift during a procedure the neuronavigation tool takes one astray? I am often impressed by the ability of trainee surgeons to beautifully delineate the tumor on the computer screen, contemplate the smallest possible craniotomy with the shortest and least invasive trajectory, but only to be disheartened when he or she is unable to translate all that planning into effecting a gross macroscopic resection preoperatively. I make no attempt to hide my unease when I notice trainees spending more time on computer in planning of the surgery than in performing the surgery itself. Acceptable surgical results can still be achieved by adhering to fundamental principles of neurosurgery using basic preoperative imaging such as CT/MRI and standard neurosurgical equipments without access to newfangled gadgets; however, the converse cannot be true.

In less developed parts of the world where there are only basic imaging modalities and routine surgical equipments at hand, surgeon's attention is more likely to remain focused on deploying basic principles of microneurosurgery in executing operations, which I believe is the most valuable tool in our armamentarium. I have often wondered whether this itself might negate any disadvantages posed by the lack of preoperative technological gadgets? This probably explains why some of the gifted neurological surgeons I have come across are based in relatively improvised parts of the world where facilities are less than optimal. I agree that intraoperative imaging and sophisticated gadgets allow us to be more minimalist yet effective in tumor resections. However, I do not think they can convert a poorly planned and improperly executed neurosurgical procedure into a surgical success. The technique of microsurgical dissection, the skill of defining and maintaining tumor-brain planes, the discipline of applying minimal retraction to the brain with least possible handling of normal parenchyma and accomplishing tumor resections with minimal neurovascular sacrifice all these I believe are the most important requirements in neurosurgery and are fortunately not technology-dependent. I am concerned that influence of several market-driven forces may make our successors lose their focus and get the priorities wrong in planning and execution of neurosurgical procedures. The basic principles of neurosurgery including detailed knowledge of neuroanatomy and the art of microsurgical dissection are invaluable requisites for performing neurological surgery and cannot be reduced to being mere surgical adjuncts to the modern-day technology-driven surgical endeavors, a common and worrying trend that I find hard to ignore.

It is widely accepted that surgery alone is unlikely to offer a definitive cure for glioblastomas. However, it is possible that surgery, perhaps radical excision, may continue to play an important role in future, whereas the adjuvant modalities of treatment address the disease at a molecular level. With the recent progress in other modalities of treatment including gene, chemo-, and immunotherapy, one can be hopeful that the current debate regarding role of surgery and perceived differences in the surgical outcomes related to the availability (or the lack) of latest perioperative technological gadgets will remain only of academic and historical importance in years to come.