Surgery of the brainstem and the diencephalic region in pediatric neuro-oncology: the right balance between "primum non nocere" and a "never give-up" philosophy

Despite gross total surgical removal has been demonstrated to play a major role in the majority of pediatric patients with tumors in or around the brainstem and the diencephalic region (substantially all except for intrapontine diffuse gliomas and germinomas), tumor location may limit both surgical indication and amount of surgical resection. The result is that surgery maybe denied because considered too dangerous or that resection may be limited and poorly effective. A wide range of different opinions regarding surgical indication and amount of resection that can be achieved creates confusion in families that must face these terrible diseases and may complicate the course of the disease with wrong decisions. In order to explore what can be offered by surgery within and around the brainstem and the diencephalic region we created a specific decision-making process were pediatric oncologic cases were always discussed in a multidisciplinary context including a surgical team that had devoted his activity and learning curve to those specific regions. Surgical indication resulted from an open debate where surgical risks (“Primum non nocere”) where weighted and compared to the possible advantages coming from resection (never give-up phylosophy). Results of surgery within and around the brainstem and the diencephalic region were reviewed by pediatric oncologists in 49 consecutive cases operated between 2009-2017 by using the most evolved technologies and techniques available. The issues of surgical indication, amount of resection, mortality-morbidity have been analysed with the specific aim to shed some light on the grey area of doing/undoing surgery in these tumors where the balance between surgical prudence and surgical aggressiveness is extremely delicate.