Conclusions

Deciding on whether to operate on patients with low-grade gliomas is a particularly difficult area of neurosurgery although, from the purely technical point of view, the surgery itself is often relatively straightforward. It is easy to conclude that small, easily accessible tumors should be removed and that large, infiltrating tumors are best left alone unless they are causing raised intracranial pressure. The problems arise with the great majority of patients whose tumors fall between these two extremes. Using modern neurosurgical techniques, there can be no doubt that more tumors can now be totally excised than was the case in the past. Such patients, however, remain in a small minority. The majority of patients have tumors where there is little prospect of total removal and where is no clear evidence that partial removal improves outcome. It can be very difficult for both the surgeon and the patient to accept that nothing is to be done. Careful and sympathetic explanation is essential whatever treatment is recommended. If surgery is to be undertaken in those cases where total resection is clearly not going to be achieved, it is essential that surgical morbidity should be extremely low. On the other hand, the operation will become a meaningless charade if the morbidity is kept low by merely carrying out a limited biopsy, if it is already known from the pre-operative scan appearances that adjuvant treatment will not be recommended. There is no science in making decisions of this kind: instead the neurosurgeon must be guided by his experience (and, if necessary, by the greater experience of surgical colleagues), by discussion with his oncological colleagues and, above all, by honest and open discussion with the patients and their families.

Finally, it must be stressed that the neurosurgeon's responsibility to his patient does not end once an operation has been carried out, or if a decision has been made to defer treatment of a low-grade tumor, or if a tumor has been deemed inoperable. It is tempting for the surgeon to try to avoid the immense stress and anxiety that many people suffer when a diagnosis of this kind has been made, especially when they will have to live with the knowledge of the tumor, and the patient's probably impending death, for many years. Careful and sympathetic follow-up and explanation will often be just as important as the surgical or oncological treatment in determining the quality of the patient's life.

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