The Role of Advanced Neuroimaging to Guide Surgery in pLGGs

Advanced imaging techniques are playing an increasingly vital role in the surgical management of pLGGs, especially when tumors are located near eloquent areas of the brain. fMRI and DTI, or fiber tracking, help map essential neural pathways such as those related to vision, movement, or language. These tools allow surgeons to plan safer biopsies or resections, avoiding disruption of critical brain functions. Intraoperative strategies, including cortical stimulation and, in rare cases, awake surgeries, further enhance precision. These technologies ensure that even resectable tumors are approached with the goal of preserving long-term neurologic and cognitive outcomes.

Surgical decision-making is deeply informed by the nature of low-grade gliomas. Because many of these tumors are indolent and may enter a biologic state of dormancy in young adulthood, aggressive approaches are often unnecessary. Instead, treatment is guided by symptoms, location, and potential long-term effects. For many patients, a conservative approach is adopted—only intervening when the tumor grows or causes problems. When intervention is necessary, the use of advanced presurgical mapping helps strike a careful balance between tumor control and quality of life.

This strategic approach reflects a broader philosophy in pediatric neuro-oncology: the long view. Given the generally favorable prognosis of these tumors, the focus often shifts to maintaining a child’s developmental potential and minimizing cognitive or physical limitations. With the expectation that tumor progression may occur over time, clinicians are prepared with a wide range of treatment options and a mindset that welcomes multiple phases of care. Rather than aiming for a single curative moment, the goal becomes sustaining health, function, and opportunity for the patient across a lifetime, always mindful of the long-term implications of each clinical decision.