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To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book. The Glioma Book Michael E. Sughrue, MD Associate Professor Department of Neurosurgery Prince of Wales Private Hospital Randwick, NSW, Australia 345 illustrations Thieme New York (cid:127) Stuttgart (cid:127) Delhi (cid:127) Rio de Janeiro LibraryofCongressCataloging-in-PublicationData Importantnote:Medicineisanever-changingscienceundergo- ingcontinualdevelopment.Researchandclinicalexperienceare Names:Sughrue,MichaelE.,author. continuallyexpandingourknowledge,inparticularourknowl- Title:Thegliomabook/MichaelE.Sughrue. edgeofpropertreatmentanddrugtherapy.Insofarasthisbook Description:NewYork:Thieme,[2020]|Includesbibliographical mentionsanydosageorapplication,readersmayrestassuredthat referencesandindex. the authors, editors, and publishers have made every effort to Identifiers:LCCN2019027673|ISBN9781626234444(hardback)| ensurethatsuchreferencesareinaccordancewiththestateof ISBN9781626234451(ebook) knowledgeatthetimeofproductionofthebook. Subjects:|MESH:Glioma–surgery|Cerebrum–surgery| Nevertheless, this does not involve, imply, or express any NeurosurgicalProcedures–methods guaranteeorresponsibilityonthepartofthepublishersinrespect Classification:LCCRD594|NLMWL307|DDC617.4/81–dc23 toanydosageinstructionsandformsofapplicationsstatedinthe LCrecordavailableathttps://lccn.loc.gov/2019027673 book.Everyuserisrequestedtoexaminecarefullythemanufac- turers’leafletsaccompanyingeachdrugandtocheck,ifnecessary inconsultationwithaphysicianorspecialist,whetherthedosage schedulesmentionedthereinorthecontraindicationsstatedbythe manufacturers differ from the statements made in the present book.Suchexaminationisparticularlyimportantwithdrugsthat areeitherrarelyusedorhavebeennewlyreleasedonthemarket. 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Contents Preface............................................................................................. vi ListofVideos...................................................................................... viii PartIFoundations 1. WhyBetterGliomaSurgeryMatters............................................................... 2 2. Sughrue’sThreeLawsofGliomaSurgery.......................................................... 6 3. SurfaceandGrossAnatomyoftheCerebrum.................................................... 19 4. AnIntroductiontoMacroconnectomicNetworksinCerebralSurgery ........................ 36 5. WhiteMatterAnatomyoftheCerebrum......................................................... 45 6. FunctionalNetworksof theHumanCerebrum................................................... 74 7. AwakeBrainMapping:Goals,Methods,andLogistics ........................................ 102 PartIIApplications 8. FunctionalTestingforBrainMapping........................................................... 112 9. GoingfromScantoPlaninaGliomaSurgery .................................................. 120 10. FrontalLobeGliomas............................................................................. 130 11. TemporalLobeGliomas.......................................................................... 158 12. InsularGliomas.................................................................................... 192 13. ParietalandOccipitalGliomas................................................................... 223 14. DifficultGliomas .................................................................................. 246 PartIIIIntegration 15. UniqueIssueswithRecurrentGliomas.......................................................... 306 16. LargeMultilobarGliomas ........................................................................ 316 17. CasesThatTaughtMeLessons .................................................................. 324 Index............................................................................................... 338 v Preface Itisuncommonthatanauthorspendstwoyearswritinga profound impact at the skull base than in the cerebrum. bookwiththeferventhopethatitwillberenderedobsolete Theexplanationisobvious:itiseasiertoexplainskullbase inshortorder,butthatisthegoalofthisbook.Inthisbook, anatomy with the naked eye than it is to explain the I summarize my current approach and experience with cerebrum. In other words, the visual appearance of the glioma surgery, which numbers about 1,000 surgeries at thirdnerveismorerepresentativeofitstruestructureand thetimeofwriting.However,unlikemostbooksinourfield function to the required level of detail for good decision whichaimtobea“HowIDoIt”tomefromthemaster,this making in surgery, than the visual appearance of the cut book aims moretobe provocative,with thehope ofgen- cerebral hemisphere. The cerebrum is made up of a stag- eratinganewfieldofthoughtingliomasurgery. geringcollectionofinterconnections,leadingtoindividual Thisbook isbuilt around theideathat wecanachieve uniqueness,complexityonamassivescale,andcrossingof betteroutcomesingliomapatientsbyupdatingourmodels connections, which makes the idea of sorting all this out of how the cerebrum works by thinking about glioma withthenakedeyeabsurd. surgery in terms of large-scale brain networks, and by Computersciencehascreatedthepossibilityofworking realizingthatregardlessofhowweperformagliomasur- outthebrainconnectionsonalevelofdetailneverbefore gery,wearecuttingaroundoracrossthepartsofnetworks possible, and it is obvious that this is the only way our whether we are aware of it or not. A few key principles/ surgeriesinthecerebrumwillbecomemorerational and biaseswhicharefundamentaltothisbookanditsphilos- safer.Thisbookdoublesdownonbigdataandbeginswhat ophyareoutlinedbelow. Ihopewillbealongprocessofworkingoutthedetailsof howtomakebetterdecisionsinsurgery. Concept 1: Our surgical models of the cerebrum are embarrassinglyoutdated Concept3:Gliomasurgeryisnotcurative,butitishelpful A quick look at images of the functional anatomy of the Itisimportanttobehonestwithpatientsaboutwhatweare brain with a critical eye reveals the limitations of the providing and not providing by taking out the tumor. anatomicmodelslocatingfunctioninthehumanbrainused Havingsaidthis,itishardtoarguethatwearedoingthe to teach people how to avoid problems in the cerebrum. patientafavorbyleavingalargeamountofnon-radiosen- BrocaandWernickehavebeendeadforoveracentury,yet sitivetumorintheirbrainandhopingitworks.Thedatalies we have not updated their language model very much. withcommonsenseandwiththeexperienceofthoseofus Wernicke’sareaisdefinedimpreciselyandcanspanapart who have been doing aggressive surgery on gliomas for oftheSTGormostofthelefttemporallobedependingon some time. In short, cytoreduction is helpful even if the the artist. Most of the brain is considered non-eloquent, patient isnotcured.Thereareseveralpointsinthisbook implying it doesn’t do anything. The subcortex is mostly whereIargueforthisprinciple,butitishardtoreadabook ignored. about glioma surgery without the basic idea that it is Mostsurgeonshavecausedaneurologicdeficitthatthey importantandworthimprovingon. couldn’t immediately explain. I would suggest that this Gliomasurgerycanbefrustratingasevenagreatoper- resultsfromusingbadmodelsofthebrain.Abettermodel ationcanleadtoclinicalfailure.Therehavebeenfewideas involves more specific localization of functions, acknowl- inneurosurgerywhichhavebeenaspersistentlyresistedas edgesthatfunctionallyconnectedareas areusuallyphys- theideathatitishelpfultocytoreduceaglioma.Thus,while icallyconnectedandthatthisisessentialforthemtowork itisimportanttobehonestwithourselvesandthepatients together, and incorporates the wholebrain into its world aboutourlimitations,itisequallyimportanttorecognize view:theso-callednon-eloquentareasarenottheretosoak howbadthisdiseasereallyis,acknowledgethelimitations upCSF. of just throwing chemotherapy and/or radiation at an A large part of this book is dedicated to making more unresected tumor, and appreciate the fact that many updatedmodelsofthebrainrelevanttoneurosurgeryand patientshaveatotallydifferentviewofriskthanwedo. explaininghowtoutilizethem. Concept 4: There is no such thing as an “inoperable” Concept2:Thebrainisabigdataproblem glioma Cadavericdissectionhasbeenahobbyofneurosurgeonsfor Itisworthaquickmentionthatnumerouspreviousstruc- decades,andithastakenusfar,particularlyatthebaseof turalbraindiseaseshavebeengiventhisterm,“inoperable,” theskull.Cerebraldissection,especiallywhitematterdis- including myelomeningoceles, petroclival meningiomas, section,hasalsoprovidedsomeusefulinsights.However,it foramen magnum meningiomas, basilar aneurysms and is clear that gross anatomic knowledge has had a more many more. The result in all these cases was gradual vi Preface improvement in surgical techniques due to technological ever,duringourtrainingtogether,heraisedsomeofthebest advances, refinement of surgical technique, questioning questionsaboutthediseasethatIhaveeverhadposedto andrethinking“conventionalwisdom,”bravery,andmost me,manyofwhichIamstilladdressing.Forexample,once importantlypersistenceandhumility.Inallthesecases,this when we were closing a glioma he noted to me, “Just termwasobviouslymisplacedinretrospect,andwhilenone becauseitisnotcurable,doesn’tmeanyouhavealicense ofthemaredesirablediagnoses,theyarenotuniformlyfatal todosloppywork.”Thisinfluenceisobvious. byanyone’scurrentmindset. Hughes Duffau never trained me, but I would be dis- Difficultgliomashavenotbeenaserioustopicofstudyas honestifIdidn’tacknowledgethesignificantinfluencehis manypeoplehavequitseriouslyconsideringwaystotryto ideashadonmyown.Theconceptthatweareoperatingon improvetheoutcomesforthesepatients.Asaresult,their networks and not cortical areas is obviously his, and his badoutcomebecomesaself-fulfillingprophesy,andprog- methods of subcortical dissection are also liberally ressstops. describedinthisbook.Clearly,muchofthisbookinvolves The key argument of this book is not that I have slain extensionoftheseideas(theuseofDTIsbeinganobvious thesemonsters—insomecases,farfromit.Itistheideathat difference).Nevertheless,Iwouldunlikelybeasinterested technology, especially connectomic imaging, provides inthesenetworkshadhenotpointedthisideaouttome. insightswhichcanhelpuscrackthesenutsandputthese Finally,probablynoonetaughtmemoreabouthowto tumors into play. In many ways, connectomics is to the operateongliomasthanCharlieTeo.Hewilllikelyrecognize cerebrum what the microscope was to the skull base: it thetechniquesectionsasmanyofthemareonesIlearned showsusthingswehadn’tknownweretherepreviously. from him. However, more importantly, I learned courage fromhim,asheshowedmetimeandagainthatthingswere Apreemptiveattributionofcredit achievablethatIhadneverthoughtwerepossible.Evenif It’s a bit impossible to outline a conceptual framework thesystemIproposeinthisbookisnothisidentically,his without unintentionally appropriating a concept that ideasthatweshouldbecontinuingtoimproveourtechni- another first brought to your mind. Certainly, that is the ques,andthatthepatientviewsthisasabattlefortheirlife case with this book: some of the ideas are my own, but asopposedtoanexerciseineventualfailure,areoneswhich withoutdoubtthisbookcontainstheideasofothers.Inlieu haveguidedmyowneversince. oftryingtoattributeallofthemtotheirauthorsonebyone, I think it might be best to describe three of the most MichaelE.Sughrue,MD influential. First is Eddie Chang, whowas myco-resident atUCSF. Eddiedoesn’tevenfocusongliomasurgeryanymore;how- vii List of Videos Video2.1Theneedtostopbleedingresponsibly Video2.2Packingoffareasofthetumor Video2.3Spotweldingarteries Video2.4Reducingtheriskofvasospasm Video2.5Gliomatissueboilswhencauterized Video2.6Identifyinganatomicboundaries Video10.1Resectionofmedialfrontalglioma Video10.2TheeffectofmanipulatingtheDMNandInitiationsystem Video10.3Lateralfrontaldisconnection Video11.1Temporaldisconnection Video12.1Largeright-sidedinsularglioma Video13.1Anterioroccipitaldisconnection Video13.2Medialparietaldisconnection Video13.3Posteriorcingulatetumor Video13.4Extensiveparietaloccipitaltumor Video14.1Anteriorbutterflyglioma Video14.2Splenialbutterflyglioma Video14.3Temporalparietaloccipitaljunctiontumor Video14.4Thalamicglioma viii
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