Adult surgery

All referrals for de-novo potential primary brain tumour should be registered with the regional neurosurgical ‘on-call’ service linked to one of the 4 respective neurosurgical units and discussed within the regional neuro-oncology MDT.

GPs are requested to liaise for / refer suspected adult neuro-oncology cases via the locally agreed referral channels and / or discuss the case with the Neurosurgical and Oncologist middle-grade ‘on-call’ service.

All patients are to have an allocated key worker to facilitate the patient journey and collaboration between the various treatment teams.

Patients should have the opportunity to discuss the new diagnosis, targets of treatment and the range of available management options available across the national service.  Choice is important and needs to be reinforced in the shared decision making process to ensure that patients do not feel undue pressure with regards to any specific management option. Providing reassurance that the appropriate resources and support is available within national Adult Neuro Oncology Services is imperative in discussions with patients.

Patients with suspected malignant primary brain neoplasia should have the option of being treated surgically within 4 weeks of referral to Adult Neuro-oncology neurosurgery services.

Appropriate rehabilitation and supportive services must be resourced in order to facilitate the patient journey towards cancer treatment targets.

Fast track pathways for Neuropsychology and cognitive assessment should be available and resourced for patients with cognitive impairment undergoing brain tumour surgery.

It is encouraged that the neuro-oncology neurosurgeon should state and have their pre-operative surgical intention documented at the pre-operative neuro-oncology MDT – eg. ‘maximal safe resection and / or what is safely achievable’.

Patients should ideally have an early pre-operative consult with a designated neuro-oncology neurosurgeon associated with the dedicated neuro-oncology MDT, in order to discuss their diagnosis, to minimise patient transfers to acute clinical wards for assessments and be introduced to a named key worker.

A consensus across Scotland has not been achieved on appropriate caseload or level of subspecialisation for neuro-oncology surgery.  This remains under review with regard to service delivery challenges and will be a focus for prospective audit and further discussions at regional and national level.

Patients across the 4 neurosurgical units are expected to have access to approved neuro-oncology surgery trials (this may require referral to another of the units within the shared neurosurgical service network).

All cases with Radiologically suspected Low Grade Glioma should be discussed at the neuro-oncology MDT. The neuro-oncology MDT will discuss and confirm the best evidence based management option for each individual case and will direct the patient to the appropriate neuro-oncology clinic.

Patients should ideally be reviewed in a dedicated Low Grade Glioma clinic with joint neuro-oncology and sub-specialist neurosurgery presence.

At the first meeting with patients, the options of management, pros and cons of surgery, option of a surgical biopsy alone or further surveillance should be discussed. It is recommended that early surgery will provide accurate staging including molecular biomarker features of the suspected lesion. The advantages of early surgery, within 6 months of the initial radiological diagnosis should be recommended and discussed with the patient.

In individual cases where a patient has a component of small tumour residuum after primary surgery, the case should then be discussed at the Neuro-oncology MDT to consider further interventional options and early secondary surgery, especially in cases with accessible tumour residuum. This further discussion and the option of secondary surgery should be relayed to the patient.

An aspiration of the national pathway and service is that there will be a national low grade MDT once per month to discuss cases, provide shared expertise, facilitate collaborative decision-making and treatment planning and to ensure that care delivery is consistent with the best available evidence. This national low grade MDT would be attended by 1-2 subspecialist neuro-oncology surgeons from each of the 4 units.

The four Neurosurgical centres will have resources to allow for state-of the-art tumour surgery and DTI tracking systems to be available in a navigation setting; Optimally, this will allow for the four centres to provide surgery with access to DTI tractography real time navigation, 5ALA and IOM monitoring. It is a core aim to have intraoperative integration between DTI navigation and intraoperative ultrasound.

Unified Neuropsychology battery tests for patients requiring awake surgery brain tumour surgery is a core aim. This will facilitate audit and learning within the Low Grade Surgery Practice across the four centers and enhances multicentre cooperation of the neurosurgical units within a single service network, for low volume and complex cases.