In this review series, we address topics central to surgery for eloquent area intrinsic brain tumors in 3 phases. Tumor resection for eloquent area tumors must employ a nuanced understanding of both cognitive neuroscience (ie, managing neurological dysfunction associated with tumor network disruptions) and tumor biology (ie, understanding the benefits associated with extent of resection based on presumed molecular subtype). In the surgical management of eloquent area intrinsic brain tumors, neurosurgeons play a central role in treatment through tumor resection. This process is often called “onco-functional balance.” 9, 15 Within clinical neurosurgery, there must be a balance between the relative survival benefits associated with maximal resection against functional impairments established by tumor network integration as well as oncological therapies. 14 Brain tumor–associated neurological dysfunction is thought to occur in the setting of three situations: (1) infiltration of tumor into cortical and subcortical network structures, (2) lesions sustained following cytoreduction surgery, and (3) through oncological therapeutic interventions such as brain irradiation and chemotherapy. Eloquent cerebral structures are defined as areas of the brain with readily identifiable neurological function, in which injury results in disability. In describing this process, clinicians use the term “functional neural networks,” which leads to the idea of eloquent regions of brain. 13 There are, however, distinct brain regions in which intrinsic brain tumors and their associated perilesional edema disrupt network dynamics with neurological consequences. 11 - 13 Even in the era of molecular subclassification, glioma patients with poor prognostic molecular markers may experience survival periods similar to molecularly favorably subgroups when maximal extent of resection is achieved. For example, patients with both low- and high-grade gliomas experience a survival benefit with maximal extent of tumor resection. 9, 10 The surgical management of brain tumors has remained a central theme in management. 1 - 8 Therefore, interactions between intrinsic brain tumors such as gliomas and brain metastases with their neuron microenvironment are an important element for both tumor biology as well as cognitive, language, and sensorimotor processing. There are several preclinical models illustrating the nervous system's influence on tumor progression and tumors’ influence on nervous system functions. The adult brain is comprised of nearly 1 billion neurons and over 1 trillion network connections consequently, regardless of location, all intrinsic brain tumors interface with nervous system structures. Unlike cancers affecting other solid organs, brain tumors grow within the context of complex neural circuitry. Interconnecting Cognitive Neuroscience With Tumor Biology
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