Surgical resection of malignant brain tumors: who benefits?

While almost no malignant glial tumor can be cured by surgical resection alone, the oncologic benefits of radical tumor removal are clear. Mechanical cytoreduction is the only therapeutic modality by which a two-log cell kill can be achieved quickly. Surgery also "sets up" other therapies by facilitating the patient's survival during the acute treatment phase, by improving the patient's neurologic status, by potentiating the effect of other treatment agents, and through the removal of large numbers of inherently resistant cells. Recently, the value of reoperation also has been demonstrated, confirming its positive effect on survival. Nevertheless, there remain some patients for whom a radical resection is an inappropriate procedure, and reasonable alternatives should always be considered. Of course, glioblastoma multiforme and other intrinsic tumors of the brain are highly complex and heterogeneous lesions that require multimodal therapy, of which surgery is but one component.