Optimising surgical resection strategy in high grade glioma: an evidence-informed, capability-aligned surgical framework for heterogeneous health systems.

BACKGROUND: Maximal safe surgical resection remains a major determinant of outcome in high grade glioma, with increasing resection and lower residual tumour volume associated with improved survival. However, the oncologic benefit of aggressive resection is conditional on preservation of neurological function and timely delivery of adjuvant therapy. Much of the evidence informing operative strategy derives from highly resourced healthcare systems and may not be directly applicable across heterogeneous practice environments. We therefore sought to synthesise contemporary evidence regarding extent of resection and develop a capability-aligned framework for context aware operative decision making.

METHODS: A structured narrative synthesis was undertaken examining literature relating to extent of resection, residual tumour burden, surgically acquired neurological deficits, operative adjuncts, tumour biology, and timing of adjuvant therapy in high grade glioma. This evidence was integrated with literature describing variability in neurosurgical and oncological capacity across diverse healthcare settings. Tumour complexity was stratified according to established anatomical and functional determinants of resectability and mapped to a four-level institutional capability classification to develop an evidence-informed conceptual framework.

RESULTS: Increasing extent of resection was consistently associated with improved survival; however, this benefit was strongly influenced by preservation of neurological function and access to timely adjuvant therapy. Operative adjuncts increased the likelihood of achieving safe maximal resection, while tumour biology and treatment context modified the relative contribution of surgery to overall outcome. Variability in institutional capability influenced both operative safety and the ability to realize meaningful oncological benefit. Integration of tumour complexity with institutional capacity provided a structured basis for calibrating operative ambition, aligning operative strategy with available infrastructure, and guiding referral across heterogeneous practice environments.

CONCLUSION: Extent of resection strategies derived from highly resourced settings cannot be uniformly extrapolated across heterogeneous healthcare systems. An evidence-informed, capability-aligned framework integrating tumour complexity, institutional capacity, and access to downstream neuro-oncology care provides a pragmatic conceptual model for context aware surgical decision making in high grade glioma.