Surgery of low-grade gliomas: towards a 'functional neurooncology'

Purpose of review For a long time, surgery of diffuse low-grade glioma was debated because of the poor knowledge of the natural history, the lack of objective evaluation of the extent of resection, a too short follow-up and the functional risk. Recently, new technical and conceptual advances in surgery have dramatically changed the management. Recent findings Despite the lack of class I evidence, there is currently growing evidence that a more extensive surgical resection of low-grade glioma is associated with a more favorable life expectancy. The use of cortical and subcortical functional mapping allows us to tailor the resection according to individual functional boundaries, thus optimizing the extent of resection while minimizing the risk of permanent deficit less than 2%. The quality of life may also be improved, thanks to seizures control and functional rehabilitation. Summary Early surgery is currently the first treatment in low-grade glioma. Re-operation can also be considered, possibly more extensive than the first one, thanks to a functional remapping and/or a tumor shrink induced by neoadjuvant treatment, especially chemotherapy. The next step is to better evaluate the quality of life and to continue to improve it in addition to the survival to evolve towards a 'functional neurooncology'.