Management of glial tumors: Viewpoint—surgery and intracavitary radiopharmaceutical therapy

Glial tumors are primary tumors of the central nervous system and can be divided into low and high-grade tumors. Even though there are no randomized control studies on extent of resection, there is a growing body of evidence supporting maximal, safe resection when surgery is pursued for patients with these tumors. The management of low-grade gliomas (World Health Organization grade II tumors) consists of maximal surgical resection without causing deficits for tumors that are growing or causing mass effect. Incidentally discovered, small low-grade gliomas can be considered for routine surveillance with frequent imaging. High-grade gliomas (World Health Organization grade III and IV tumors) should undergo maximal surgical resection while avoiding iatrogenic deficits. Despite maximal surgical resection, the majority of patients with both low and high-grade tumors will inevitably have recurrence and eventually die from progressive disease. The majority of this recurrence occurs in close proximity to the tumor margins. One type of adjuvant therapy that has been developed to increase radiation to the tumor margins while minimizing toxicity to surrounding normal brain parenchyma is intra-cavitary radiopharmaceutical therapy, also known as brachytherapy. This therapy involves placement of radioisotopes in the tumor bed either peri- or postoperatively and shows promise in that patients with both low and grade gliomas can undergo local radiation therapy, and therefore are not subjected to the neurocognitive problems associated with external brain radiation and the systemic toxicity of chemotherapy. However, clinical trials have yet to show a significant survival benefit for patients undergoing brachytherapy.​