Introduction: Gliomas arise within the brain, and surgical intervention is difficult to avoid during treatment. Fear of brain surgery is entirely understandable. However, in the vast majority of cases, bypassing surgery and proceeding directly to radiotherapy and chemotherapy is not a viable option.

Surgery addresses two major problems. The first is the mass effect caused by the tumor compressing surrounding brain tissue. Increased intracranial pressure can lead to symptoms such as headache, nausea, vomiting, and seizures. These symptoms can only be relieved through complete or partial tumor resection to decompress the intracranial space. Radiotherapy and chemotherapy act slowly, often taking weeks or even months to take effect, during which symptoms may continue to worsen.

The second issue is tumor burden. Both the dose and irradiation field of radiotherapy are inherently limited. When the tumor volume is excessively large, delivering a full therapeutic radiation dose may exceed the tolerance of normal brain tissue, whereas reducing the radiation dose may compromise tumor control. The same principle applies to chemotherapy. The cytotoxic efficacy of Temozolomide is closely related to the number of residual tumor cells. The larger the tumor cell population, the higher the likelihood of residual disease. Consequently, surgical debulking followed by chemotherapy generally produces significantly better outcomes.

Another critical consideration is pathological diagnosis. Without surgery, no adequate tumor tissue is available for comprehensive histopathological and molecular analysis. Key molecular markers—including IDH mutation status, MGMT promoter methylation, and 1p/19q codeletion status—are all determined through postoperative tissue specimens. These biomarkers are essential for establishing radiotherapy protocols and predicting chemotherapy sensitivity. Although stereotactic biopsy can obtain limited tissue samples, the quantity is often insufficient for complete molecular profiling.

Today, advances in technology have significantly improved the safety and precision of glioma surgery. Modern glioma surgery is no longer performed “blindly.” Intraoperative MRI can be used before cranial closure to assess for residual tumor; neuronavigation systems assist surgeons in planning surgical trajectories while avoiding eloquent brain regions; 5-Aminolevulinic Acid fluorescence guidance causes tumor tissue to emit red fluorescence under blue light, helping define tumor margins; intraoperative electrophysiological monitoring preserves the integrity of motor and language pathways; and during awake craniotomy, patients may speak continuously throughout tumor resection to confirm preservation of neurological function in real time. These technologies are not intended merely to make surgery appear more sophisticated—they exist to balance maximal safe resection with minimal neurological injury.

There are indeed a small number of situations in which surgery may not be appropriate, such as diffuse brainstem glioma, bilateral thalamic involvement, multifocal lesions that cannot feasibly be resected individually, or patients whose medical condition precludes surgery altogether. In such circumstances, clinicians may resort to biopsy followed by radiotherapy and chemotherapy. However, if surgery is refused solely out of fear, continued tumor growth and progressive compression of surrounding brain structures will only increase the complexity and risk of subsequent surgery rather than reduce it.

Reference: https://www.incsg.com/jiaozhiliu/8407.html