Maximal safe resection

see Glioblastoma maximal safe resection.

Maximal surgical resection of high grade brain tumours is associated with improved overall survival (OS). It carries the risk of neurological deterioration leading to worsening performance status (PS), which may affect overall survival and preclude patients from adjuvant therapy 1).

Maximal safe resection is the “gold standard” with prolonged survival in patients with low grade glioma (LGG), aiming to achieve maximal survival benefit with minimal risk of functional deficit.

Although the strategy of maximum safe resection is widely accepted, the rates of complete resection of enhancing tumor (CRET) and the exact causes for motor deficits (mechanical vs vascular) are not always known.

Some patients would accept an increased risk of permanent neurological deficits in order to obtain a chance of increased survival. There was a significant variance in what constituted “quality of life” both between patients and for the individual patient over time.

In important life-changing decisions there is no “one size fits all”. We find that it is ethically acceptable to offer more extensive surgery than is possible within the concept of maximal safe surgery as a treatment option, when balancing the principles of beneficence, non-maleficience, autonomy and justice supports the decision. At the same time it must be remembered that even when the patients have made a well-informed decision, some will regret it. In that situation it will be our job as healthcare professionals to support them and help carry some of this burden 2).

Patel CK, Vemaraju R, Glasby J, Shires J, Northmore T, Zaben M, Hayhurst C. Trends in peri-operative performance status following resection of high grade glioma and brain metastases: The impact on survival. Clin Neurol Neurosurg. 2017 Nov 29;164:67-71. doi: 10.1016/j.clineuro.2017.11.016. [Epub ahead of print] PubMed PMID: 29197281.
Brennum J, Maier CM, Almdal K, Engelmann CM, Gjerris M. Primo non nocere or maximum survival in grade 2 gliomas? A medical ethical question. Acta Neurochir (Wien). 2015 Feb;157(2):155-64. doi: 10.1007/s00701-014-2304-5. Epub 2014 Dec 21. PubMed PMID: 25526721.
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