J Neurol Neurosurg Psychiatry 75:ii24-ii30 doi:10.1136/jnnp.2004.040535

The present and future management of malignant brain tumours: surgery, radiotherapy, chemotherapy

  1. R Rampling1,
  2. A James1,
  3. V Papanastassiou2
  1. 1Western Infirmary, Glasgow, UK
  2. 2Southern General Hospital, Glasgow, UK
  1. Correspondence to:
 Professor R Rampling
 Western Infirmary, Dumbarton Road, Glasgow G11 6NT;

    While the majority of malignant brain tumours remain ultimately incurable, a variety of intermediate outcomes is nevertheless possible, depending on histological tumour type and grade. A common treatment strategy obtains for most malignant brain tumours. Surgery followed by radiotherapy are the major treatment modalities, while chemotherapy provides adjuvant and palliative support. The most exciting areas of advance lie in the genetic targeting of conventional treatments and in applying biotherapies and agents specifically directed at molecular targets within the cell. We describe the current status and future prospects for each of these modalities.


    Gliomas are the most frequently diagnosed class of primary malignant brain tumour. Since these tumours are incurable, the main emphasis is on symptom alleviation and prolongation of survival. In this context, neurosurgery has the distinct but interrelated aims of providing histological diagnosis, cytoreduction, symptomatic relief, and local delivery of adjuvant therapy.1,2 The surgical principles used in managing other malignant tumours are similar, though in some—for example, medulloblastoma—extensive cytoreduction may contribute to cure.

    Histological diagnosis

    In the great majority of cases of patients with newly diagnosed brain tumour it is imperative to obtain a precise histological diagnosis. Guidance on prognosis, decisions on further management and patient counselling will depend on the histological type and grade of the lesion. It is important to ensure that the tissue samples on which the final diagnosis is based are as representative as possible of the tumour as a whole. The diagnostic accuracy of various biopsy procedures depends on the amount of tissue obtained and the accurate targeting of areas of high diagnostic yield. This can be achieved from an open biopsy or by a radiologically guided, stereotactic procedure.

    To acquire a stereotactic biopsy a rigid frame is attached to the patient’s head as an external co-ordinate reference system. Various imaging modalities (mainly computed …

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