Surgery for Brain Cancer: Essential Information

Surgery for Brain Cancer: What Patients Need to Know

Surgery for Brain Cancer: What Patients Need to Know. Brain cancer surgery is different from surgery for most other cancers. The surgeon is not simply trying to remove as much cancer as possible. The goal is to remove as much tumor as can be safely removed while protecting the brain functions that control movement, speech, memory, vision, sensation, and other essential abilities.

Brain cancer is a unique type of cancer. Brain cancer surgery is often only the first step in treatment. Learn more about Radiation for Cancer – What Patients Need to Know and how radiation may be incorporated into treatment after surgery.

If chemotherapy becomes part of your treatment plan, see Chemotherapy for Cancer – What Patients Need to Know for an overview of how chemotherapy works, common side effects, and questions to ask your oncology team.

For some patients, surgery can be the first and most important step in treatment. For others, a biopsy may be safer than attempting to remove the entire tumor. And for some brain tumors—particularly certain metastatic tumors—radiation, systemic therapy, or a combination of treatments may be more appropriate.

This article explains what patients and families should know before agreeing to brain tumor surgery, including the different types of surgery, how surgeons decide how much tumor to remove, potential risks, recovery, and questions to ask a neurosurgeon.

PeopleBeatingCancer perspective: A brain cancer diagnosis is one of the situations where getting a second opinion from a multidisciplinary neuro-oncology team can be particularly valuable. The location and biology of a brain tumor can make the difference between a tumor that is safely resectable and one where attempting complete removal could cause permanent neurological damage.

I am a long-term survivor of an incurable blood cancer called multiple myeloma. My research and experience with evidence-based non-conventional therapies are the reason why I have lived in complete remission from my incurable blood cancer since achieving complete remission in early 1999. I have learned that the best way to manage cancer is to combine the best of conventional and evidence-based non-conventional therapies.

I have come to believe that therapy-induced side effects can be life-threatening while ruining quality of life. Consider therapies shown to reduce possible side effects.

Scroll down the page and post a question or a comment if there’s anything you’d like to know about radiation for cancer.

Good luck,

David Emerson

Learn more about Brain Cancer-

Concepts Central to Managing Your Cancer-

Why Brain Cancer is SO Dangerous

What Is Brain Cancer Surgery?

Brain cancer surgery is an operation performed to remove a brain tumor, obtain tissue for diagnosis, relieve pressure inside the skull, or improve symptoms caused by the tumor.

The two broad categories are:

Surgical biopsy — removing a small amount of tumor tissue for diagnosis.
Surgical resection — removing some or as much of the tumor as can be safely removed.

The National Cancer Institute identifies two major goals of brain tumor surgery: establishing a diagnosis and reducing pressure caused by the tumor while preserving neurological function.

Importantly, “complete removal” does not always mean that every cancer cell has been eliminated.

Many malignant brain tumors infiltrate surrounding brain tissue. Cancer cells may extend beyond what can be seen on an MRI or what the surgeon can distinguish visually during an operation.

Consequently, surgery is often followed by radiation therapy, chemotherapy, targeted therapy, or another treatment.

Why Is Brain Surgery Different From Other Cancer Surgery?

Consider the difference between removing a tumor from the colon and removing one from the brain.

A surgeon can sometimes remove a section of the colon containing a tumor and reconnect the remaining bowel.

The brain is different.

A tumor may be located next to the areas responsible for:

Speech
Movement
Balance
Vision
Hearing
Memory
Sensation
Personality
Swallowing
Coordination

Removing additional tumor tissue may potentially improve cancer control—but if that tissue is part of functioning brain, the operation could cause permanent neurological disability.

That creates the central question in brain tumor surgery:

How much tumor can be removed without causing unacceptable damage to normal brain function?

Current neuro-oncology guidance emphasizes that preventing a new permanent neurological deficit takes priority over maximizing the percentage of tumor removed.

What Are the Goals of Brain Tumor Surgery?

The purpose of surgery depends on the type, size, location, and biology of the tumor.

1. Obtain a diagnosis

Sometimes imaging strongly suggests that a person has a brain tumor but cannot establish exactly what type it is.

A biopsy provides tissue that can be examined by a pathologist.

Modern brain tumor diagnosis may involve much more than looking at cells under a microscope. Molecular testing can help determine the tumor’s classification and may influence treatment and prognosis.

2. Remove as much tumor as safely possible

When a tumor can be safely accessed, the neurosurgeon may attempt a resection.

The objective is generally not simply “maximum removal.”

It is better described as:

Maximum safe resection.

3. Reduce pressure on the brain

A growing tumor can occupy space inside the skull and compress surrounding brain tissue.

Removing tumor tissue can relieve this pressure and potentially improve neurological symptoms.

4. Improve symptoms

Surgery can sometimes improve symptoms caused by the tumor, including:

Headaches
Seizures
Weakness
Problems with speech
Problems with balance
Vision problems
Nausea related to increased intracranial pressure

Seizures are among the common symptoms associated with brain tumors, and in selected patients, tumor surgery may also help control tumor-related seizures.

5. Make additional treatment more effective

Reducing the amount of tumor remaining can make subsequent radiation or systemic treatment part of a broader treatment strategy.

Brain Tumor Biopsy vs. Brain Tumor Resection

These procedures are not the same.

Biopsy

A biopsy removes a small amount of tumor tissue.

A stereotactic biopsy uses imaging and specialized equipment to guide the surgeon to the tumor.

Biopsy may be preferred when:

The tumor is located deep within the brain.
The tumor is near critical neurological structures.
Removing the tumor would pose excessive risk.
The diagnosis can be established from a small tissue sample.

The NCI notes that stereotactic biopsy can be used for lesions that are difficult to reach and resect.

Resection

Resection means surgically removing tumor tissue.

Depending on the circumstances, the surgeon may perform:

Gross total resection
Near-total resection
Subtotal resection
Partial debulking

The terminology can vary between studies and medical centers, so patients should ask their surgeon exactly what percentage or volume of tumor they expect to remove.

What Is a Craniotomy?

A craniotomy is one of the most common approaches used for brain tumor surgery.

During a craniotomy:

The patient is placed under anesthesia, although some procedures may use an awake technique.
The surgeon makes an incision in the scalp.
A section of skull bone is temporarily removed.
The surgeon accesses the brain and tumor.
The tumor is removed or biopsied.
The bone is replaced.

The NCI provides an overview of craniotomy as an operation in which a section of the skull is temporarily removed to provide access to the brain.

What Is an Awake Craniotomy?

The phrase “awake brain surgery” can sound frightening.

In reality, awake craniotomy is a specialized technique used for selected tumors located near areas of the brain responsible for important functions such as speech and movement.

The patient may be awake for part of the operation, so the surgical team can test neurological functions while the tumor is being removed.

The patient might be asked to:

Speak
Name objects
Read
Move a hand or foot
Perform simple tasks

This allows the surgical team to identify important functional brain regions and avoid damaging them.

The NCI notes that cooperative patients can undergo awake craniotomy with real-time neurological assessment during tumor removal.

Not every patient or tumor is appropriate for an awake craniotomy.

How Do Surgeons Know What to Remove?

Brain tumor surgery increasingly relies on technology designed to distinguish tumor from healthy brain and to identify important neurological pathways.

Depending on the tumor and medical center, surgeons may use:

Preoperative MRI
Functional MRI
Diffusion imaging
Neuronavigation
Intraoperative MRI
Intraoperative ultrasound
Fluorescence-guided surgery
Electrical brain mapping
Neurophysiological monitoring
Awake language or motor mapping

The purpose is not simply to remove more tissue.

The purpose is to remove more tumor while protecting functioning brain.

Does Removing More Brain Tumor Improve Survival?

This is one of the most important—and complicated—questions patients should ask.

Research in glioblastoma has repeatedly found an association between greater extent of tumor resection and improved survival.

For example, a large systematic review and meta-analysis involving more than 41,000 patients found lower mortality among patients undergoing gross total resection compared with subtotal resection. However, the authors also rated the quality of the evidence as moderate to low.

A later meta-analysis focused on modern WHO-defined IDH-wild-type glioblastoma similarly found longer overall and progression-free survival associated with gross total resection, although the researchers emphasized limitations caused by differences among the studies.

There is an important caveat.

Association does not necessarily prove that removing more tumor itself causes longer survival.

Tumors that are easier and safer to remove may also have more favorable biological characteristics. Patients who are healthier may also be more likely to undergo extensive surgery.

The EANO guidelines therefore make an important distinction: efforts to achieve complete resection are justified, but preventing permanent neurological deficits takes priority.

The practical takeaway

Don’t ask only:

“Can you remove the whole tumor?”

Also ask:

“What is the maximum safe resection for my particular tumor, and what neurological functions are at risk if you try to remove more?”

That is a much more useful question.

What Happens If the Surgeon Cannot Remove the Entire Tumor?

Leaving tumor behind does not necessarily mean that surgery was unsuccessful.

Sometimes the safest operation is to deliberately leave tumor tissue behind because removing it would risk permanent neurological damage.

The remaining tumor may then be treated with:

Radiation therapy
Chemotherapy
Targeted therapy
Tumor-specific therapies
Clinical trials
Additional surgery in selected circumstances

The treatment plan depends heavily on the tumor’s pathology and molecular characteristics.

The NCI notes that patients with adult CNS tumors may receive surgery followed by radiation, chemotherapy, targeted therapy, or clinical-trial approaches depending on tumor type and circumstances.

What About Brain Metastases?

Not every brain tumor began in the brain.

Cancer from another part of the body can spread to the brain. These are called brain metastases.

Common primary cancers that can metastasize to the brain include:

Surgery can be particularly useful for selected patients with a large or symptomatic brain metastasis, especially when it is causing pressure on surrounding brain tissue.

Current multidisciplinary guidelines emphasize that surgery is most useful in selected patients, with factors such as tumor size, number of metastases, symptoms, overall health, and control of cancer elsewhere in the body influencing the decision.

For some patients, stereotactic radiosurgery may be used instead of surgery or after surgery.

Therefore:

A brain metastasis does not automatically mean that surgery is required—or that surgery is inappropriate.

The decision should be individualized.

What Are the Risks of Brain Tumor Surgery?

Brain surgery is major surgery.

Potential complications include:

Bleeding
Infection
Seizures
Brain swelling
Blood clots
Stroke or vascular injury
Cerebrospinal fluid leakage
Problems related to anesthesia
Neurological deficits
Problems with speech or language
Weakness or paralysis
Changes in vision
Memory or cognitive problems
Balance or coordination problems
Personality or behavioral changes
Need for additional surgery

The exact risks depend heavily on the tumor’s location.

A tumor located near the motor cortex may carry different risks than a tumor located near language centers or deep structures of the brain.

NCI notes that surgery can cause complications including infection, bleeding, damage to nearby tissues, and anesthesia-related problems.

One question deserves special attention:

“What is the risk that I will have a permanent neurological deficit after surgery?”

Ask the surgeon to explain this in plain language.

What Happens Immediately After Brain Surgery?

After surgery, patients are closely monitored.

Depending on the procedure, you may spend time in:

A post-anesthesia recovery unit
A neurological intensive care unit
A regular hospital room

The medical team may monitor:

Consciousness
Speech
Strength
Sensation
Pupillary responses
Blood pressure
Seizures
Brain swelling
Surgical-site complications

An MRI or CT scan may be performed soon after surgery to determine how much tumor remains and to evaluate the brain following the procedure.

EANO guidance recommends postoperative imaging within approximately 24–48 hours for diffuse gliomas, including sequences that can help distinguish residual tumor from postoperative changes.

Brain Surgery Recovery

Recovery varies enormously.

Some patients experience relatively rapid recovery.

Others need weeks or months of rehabilitation.

Recovery may involve:

Physical therapy

For weakness, balance problems, walking difficulties, or coordination problems.

Occupational therapy

To help patients regain the ability to perform everyday activities.

Speech-language therapy

For problems involving speech, language, swallowing, or cognitive communication.

Cognitive rehabilitation

For problems involving:

Memory
Attention
Processing speed
Executive function
Organization

Rehabilitation is not an admission of failure.

It is part of brain cancer treatment for many patients.

NCI describes physical and rehabilitation specialists working with brain tumor patients to restore abilities affected by the tumor or its treatment.

How Long Does Recovery Take?

There is no single recovery timetable.

Recovery depends on:

Tumor location
Tumor size
Type of surgery
Amount of tumor removed
Preoperative neurological function
Postoperative complications
Age and general health
Need for additional cancer treatment
Rehabilitation needs

Some patients may return home within several days.

Others may require inpatient rehabilitation or substantial assistance at home.

Patients should plan for the possibility that they will need help with:

Transportation
Meals
Medication
Showering
Dressing
Household chores
Childcare
Work
Medical appointments

A strong caregiver and family support system can be extremely valuable during recovery.

Will I Need Radiation or Chemotherapy After Brain Surgery?

Possibly.

Surgery is often only the first part of treatment for malignant brain tumors.

For example, the NCI lists surgery followed by radiation and chemotherapy among standard treatment approaches for glioblastoma.

The need for additional treatment depends on:

Tumor type
Tumor grade
Molecular characteristics
Amount of tumor remaining
Patient age
Overall health
Previous treatments
Whether the tumor is primary or metastatic

This is why the pathology and molecular report following surgery is so important.

What Should You Ask Your Neurosurgeon?

Before surgery, consider taking a written list of questions.

About the tumor

What type of brain tumor do you suspect?
Where exactly is the tumor located?
Is it near an area responsible for speech, movement, memory, vision, or other critical functions?
Is the tumor considered surgically accessible?

About the operation

Is the goal biopsy, partial removal, or maximum safe resection?
What percentage or volume of the tumor do you realistically expect to remove?
Would an awake craniotomy be appropriate?
Will brain mapping or neuro-monitoring be used?
What happens if the tumor is more invasive than expected?

About risks

What are the most likely complications?
What is the risk of permanent neurological damage?
What functions are most at risk?
What is the risk of seizures, bleeding, infection, or stroke?

About recovery

How long will I probably remain hospitalized?
Will I need rehabilitation?
Will I be able to drive?
How soon could I return to work?
What help should my family arrange at home?

About treatment after surgery

When will the pathology and molecular testing be available?
Will I need radiation?
Will I need chemotherapy?
Are targeted therapies available?
Should I consider a clinical trial?
Should I obtain a second opinion before beginning additional treatment?

Should You Get a Second Opinion?

For a major brain operation, a second opinion can be particularly valuable.

Consider seeking consultation at a comprehensive neuro-oncology center where neurosurgeons, neuro-oncologists, radiation oncologists, neuroradiologists, neuropathologists, rehabilitation specialists, and other experts regularly work together.

A second opinion may answer questions such as:

Is surgery really necessary?
Is biopsy safer?
Is the tumor resectable?
How much tumor can safely be removed?
Would an awake craniotomy help?
Are there alternative treatments?
Is a clinical trial appropriate?

A second opinion does not necessarily mean changing doctors.

It can simply mean obtaining more information before making an irreversible decision.

Surgery Is Only One Part of Brain Cancer Treatment

For most patients with malignant brain cancer, the long-term treatment plan involves more than surgery.

Depending on the tumor, treatment may include:

Diagnosis → Surgery/Biopsy → Pathology & Molecular Testing → Radiation and/or Drug Therapy → Rehabilitation → Surveillance

For metastatic brain tumors, the pathway may be different:

Primary Cancer → Brain Imaging → Multidisciplinary Evaluation → Surgery and/or Stereotactic Radiation → Systemic Therapy → Follow-up

The important point is that brain cancer treatment should be individualized.

There is no universal “best” brain cancer surgery.

PeopleBeatingCancer Evidence Rating

Evidence Rating: Moderate

What is well established: Surgery can provide tissue for diagnosis, relieve pressure, improve symptoms, and remove the tumor in appropriately selected patients.

What is supported but more complicated: Greater extent of resection is associated with improved outcomes in glioblastoma and other gliomas. Multiple systematic reviews support this association, but much of the evidence is observational and therefore cannot completely establish cause and effect.

Most important clinical limitation: Removing more tumor is not automatically better if doing so causes permanent neurological damage. Current guidelines emphasize maximum safe resection rather than tumor removal at any cost.

For brain metastases: The role of surgery depends strongly on tumor size, number, symptoms, location, overall health, systemic disease, and available radiation/systemic therapies.

Research & Evidence

National Cancer Institute

Adult Central Nervous System Tumors Treatment (PDQ)
NCI: Adult Central Nervous System Tumors Treatment

Central Nervous System Tumors Treatment – Health Professional Version
NCI: CNS Tumors Treatment (Health Professional)

Surgical Resection & Glioblastoma

Brown et al., JAMA Oncology — Association of the Extent of Resection With Survival in Glioblastoma: Systematic Review and Meta-analysis
PubMed research article

Jusue-Torres et al. — Effect of Extent of Resection on Survival in IDH-Wild-Type Glioblastoma
PubMed research article

Revilla-Pacheco et al. — Extent of Resection and Survival in Glioblastoma
PubMed research article

Glioma Surgery Guidelines

EANO Guidelines on Diagnosis and Treatment of Diffuse Gliomas of Adulthood
EANO guideline — full text on PubMed Central

Brain Metastases

ASCO-SNO-ASTRO Guideline: Treatment for Brain Metastases
PubMed — Treatment for Brain Metastases Guideline

ASTRO Clinical Practice Guideline: Radiation Therapy for Brain Metastases
PubMed — ASTRO Brain Metastases Guideline

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