Neuro-oncology

Lynne P. Taylor, MD, FAAN

Tresa M. McGranahan, MD, PhD

Vyshak Alva Venur, MD

Modern neurosurgery, as we know it, was born with the specialty in 1920 as a direct result of the understanding that patients could live through the operation if increased intracranial pressure could be controlled. Harvey Cushing, through his groundbreaking animal experiments, described the Cushing reflex in 1901 as widened pulse pressure with an increase in systolic and decrease in diastolic pressures accompanied by bradycardia and irregular respirations. In 1905, he expanded this to his concept of the classical clinical triad of elevated intracranial pressure that is so familiar to us today: headache, vomiting, and papilledema. By 1915 his operative mortality rate for craniotomies on 130 patients was 7.4% at a time when surgical mortality rates elsewhere were 30 to 50%.[1]

Since that time, the care of patients with brain tumors has developed into a true multidisciplinary undertaking. With the birth of the subspecialty of neurology by the establishment of the American Academy of Neurology (AAN) in 1948 and of neuro-oncology as a formal discipline with the establishment of the Society for Neuro-oncology (SNO) in 1996, and more recently the development of the International Neuropalliative Care Society (INPCS) in 2021,[2] we have further deepened the expertise that can be applied to continue to improve the quality of life and survival of our patients for the future.

It is fitting, then, that we begin this issue of Seminars in Neurology devoted to neuro-oncology with an article about updates in neurosurgical techniques focusing on the importance of the extent of tumor resection, intraoperative mapping, magnetic resonance imaging (MRI) and ultrasound, and fluorescence-guided surgery; all of which I am sure Dr. Cushing would have found astonishing. Next, we describe a review of conventional and advanced techniques in imaging such as diffusion restriction, MRI spectroscopy, and perfusion to help us understand how to distinguish true tumor growth from treatment-related inflammatory changes or “pseudoprogression,” a very common clinical conundrum. Moving into the world of neuro-oncology with treatment strategies for patients with primary glial tumors, we also tackle the important concept of prognostication and how some of the newly described mutations in tumors help inform our predictions for the likelihood of our treatments to be successful. Less common, but very important, central nervous system (CNS) tumor subtypes are discussed both in the article on brain tumors in adolescents and young adults and the article on germ cell tumors with the latter being more prevalent in East Asia and for which we are grateful for the contribution from our colleague at the National University Cancer Institute in Singapore.

Neuro-oncologists are also frequently involved in the care of patients with secondary complications of hematologic and solid tumors on the nervous system and the article on management of brain metastases stresses the growing importance of treatment with systemic chemotherapy and targeted agents that can cross the blood–brain barrier and help avoid the focused toxicity that often arises from surgical resection or stereotactic radiosurgery. Likewise, as another late manifestation of cancer, the difficulties of diagnosing and treating leptomeningeal carcinomatosis is addressed with a discussion of the role of craniospinal radiation therapy as an attractive therapeutic strategy for the future.

Lastly, we discuss a potentially curable CNS tumor: primary CNS lymphoma and its cousin, secondary CNS lymphoma, which are brain metastases from a primary systemic lymphoma. Both of these can be extremely hard to diagnose and are sometimes mimics of more common neurologic disorders such as multiple sclerosis or neuromyelitis optica.

We chose the authors of these articles to represent the great diversity in our field with different perspectives from institutions across the United States and the world. We are very grateful for their time and expertise and hope that you learn as much reading their contributions as we did. We are very appreciative of the guidance and support of Drs. David Greer and Ariane Lewis, the editor-in-chief and deputy editor of Seminars in Neurology.

Our field has come a long way in the last one hundred years. The therapeutic nihilism of the past is being eroded as we make slow, but certain, progress. As a testimony to that progress, the upcoming volume of Seminars in Neurology will be devoted to palliative care, neurologic rehabilitation, and long-term survivorship issues.

Publication History

Article published online:
14 December 2023

• References

• 1 Greenblatt SH. Harvey Cushing's paradigmatic contribution to neurosurgery and the evolution of his thoughts about specialization. Bull Hist Med 2003; 77 (04) 789-822
• 2 Taylor LP, Besbris JM, Graf WD, Rubin MA, Cruz-Flores S, Epstein LG. Ethics, Law, and Humanities Committee, a joint committee of the American Academy of Neurology, American Neurological Association, and Child Neurology Society. Clinical guidance in neuropalliative care: an AAN position statement. Neurology 2022; 98 (10) 409-416