The emerging field of neurosurgical oncology: novel techniques to optimize outcomes and minimize mishaps.

Neurosurgical oncology is one of the most exciting areas of neurosurgery.7,11,14 It deals with an interesting range of pathologies—Figure 8.1 presents the breakdown of tumor types in 5230 brain tumor procedures performed by the senior author (PB) from 1987 to 2007. This paper will discuss three aspects of neurosurgical oncology—its justification as a subspecialty; the way in which new clinical technologies are creating increasingly safe manipulations to remove brain tumors; and the continuing importance of scientific discovery in this field. It will primarily discuss gliomas, because meningiomas are the topic for another paper in this volume. This subspecialty beautifully illustrates the themes of this meeting—transcendental leadership in clinical care, research, and education. In our reference list, we will primarily cite references from our own group and collaborators because of space restrictions; there are many hundreds of investigators working in these areas whose papers would have to be included to be a comprehensive account. We begin with an illustrative case, that of a 21-year-old woman from a European country who came to see the first author with intractable seizures and a left medial frontal mass in the leg area of the cerebral cortex (see Fig. 8.2). She had tried multiple medications to control her seizures and found them less and less useful. Her social and academic lives were being destroyed by these seizures, occurring many times a day, and involving the right arm and leg and speech. The challenge, of course, was how to identify and remove this lesion without leaving her with leg weakness. We approached this tumor with intraoperative magnetic resonance imaging (MRI) scanning with the General Electric (GE) Signa system, at the Brigham and Women’s Hospital (BWH). We have used this system for more than 1000 tumor craniotomies and it is a very accurate device to identify and resect intracranial masses (it is further discussed later in this paper). Placing her in a prone position, we were able to dissect along the falx, identify the tumor, resect it, and verify that it was completely removed (Fig. 8.3). She awoke without deficit, left the hospital in 3 days, returned to her home country in 10 days, and has been seizure-free since her return. This kind of result is now possible in neurosurgical oncology as we become increasingly able to use imaging and monitoring techniques for brain tumors of the cerebral cortex. It represents the most recent development in this important field.