Should a gross total resection (GTR) of malignant gliomas be made? Although many around the world today believe in this practice, I have had some serious reservations about this principle given the underlying pathology of glioblastomamultiforme (GBM). Many cite the papers of Lacroix (Sawaya) (J Neurosurg 95:190-198, 2001) and Sanai (Berger) (Neurosurgery 62:753-766, 2008) that support the idea of GTR, which are based on survival rates and very short increases in survival with greater resection. As reported in Lancet Oncol 2006;7:392-401 by Stummer et al., who used 5-aminolevulinic acid (5ALA) fluorescence-guided resections in a randomized study, median survival and extent of resection was better than without this tumor edge marker: Yet, the ultimate survival was the same in both groups. Karnofsky scores postoperative had more deficits in the 5ALA group than in the controls. This difference became insignificant on long-term analysis, which makes sense. Kubben has written in SNI about the mistakes that can be made using tumor edge markers on imaging to determine residual tumor edges, which also can be applied to intraoperative marker usage. (Kubben et al. Surg. Neurol. Int, 2012, Volume 3, Issue 1 [p. 158]). Does the tumor end at the marker? The pathology studies would say no.

Read Shinouraetals paper (Surg. Neurol. Int. 2013; 4:149) analyzing the patients’ deficits after awake craniotomies in patients with different tumors in the premotor, motor, and sensory areas. They used Diffusion Tensor Imaging, Functional MR, neuronavigation, and brain mapping to determine the eloquent areas. Still they had 8% morbidity that lasted even under these ideal conditions. The factors producing the deficits were technical that occurred at the time of surgery. Is it reasonable to have a 10% morbidity for a rapidly advancing disease with a 100% mortality in a year's time?

Survival is not quality of life (QOL). And from my understanding, there is little information on the QOL of the people who undergo GTR with modern techniques. Also, it is inconceivable that GTR is sufficient to eliminate the diffuse infiltration of the brain by GBM. As of this moment we have still not changed the survival much in 50 years with surgery, radiation, and chemotherapy. That does not mean that research on curing GBMs should cease. In fact, proper organized studies should be done. Approaches such as immune and molecular therapies seem the most promising. Given that fact, should we offer a patient a deficit for their short life or QOL with surgery?

I remember a story of Dr Paul Bucy, a famous pioneer neurosurgeon and founder of Surgical Neurology, the print predecessor of SNI, who did a hemispherectomy in 1948 on a patient with a GBM to remove all the tumor he could find. When the tumor recurred on the opposite remaining hemisphere in the hemiplegic patient, Dr. Bucy wrote that the patient returned to curse him. Malignant tumors of the brain are not cured by surgery, or radiation, or chemotherapy as of this time. So, we need to ask, “What is our goal in doing this surgery?” What will be the QOL for the patient?

I remember treating a farmer from rural Minnesota in whom we resected a GBM. Then, he faced daily 6 h trips to get radiation therapy for 5 weeks that would have occurred during some of the best days of his remaining life. Does this additional treatment make sense? No, and so we agreed that he would not get the radiation therapy for the short time increase in his survival. That was time better spent with his loved ones. The real question is “Are we treating the doctor or the patient?” Are we technicians or are we thoughtful, caring physicians? What would you do if the patient were in your family? There may be a different answer for every patient. That is called Judgment. A technician would do the same operation on everyone. That makes no sense to me. What happened to Common Sense?