Radionuclide Therapy Integrated Multimodal Transsylvian Microneurosurgical Management of Type 5 Insular and Paralimbic Gliomas for Precision Oncology

BACKGROUND: Type 5 insular and paralimbic gliomas are surgically challenging because resection is limited by perforator-rich vascular anatomy and eloquent subcortical pathways, often leaving clinically relevant residual disease. We evaluated a precision-oncology workflow integrating multimodal preoperative planning, transsylvian microneurosurgical resection, and postoperative radionuclide-oriented stratification. METHODS: This retrospective study included 38 adults with type 5 insular and paralimbic gliomas treated through a transsylvian approach. Structural magnetic resonance imaging (MRI), T2/fluid-attenuated inversion recovery imaging, diffusion tensor tractography, and vascular mapping were integrated to define operative corridors and safety boundaries. Early postoperative MRI was used to assess extent of resection, neurologic outcome, and residual-disease category, which was then linked to standard follow-up, radionuclide-oriented reassessment, or targeted radionuclide therapy candidacy. RESULTS: Gross total resection was achieved in 72% of patients, subtotal resection in 21%, and partial resection in 7%. No new neurologic deficit occurred in 80% of patients, transient deficits in 15%, and permanent deficits in 5%, yielding a neurologic preservation rate of 95%. Residual disease was categorized as no significant residual in 55%, surgically constrained residual in 30%, and biologically high-risk residual in 15%. CONCLUSIONS: This integrated workflow achieved high rates of maximal safe resection and neurologic preservation while providing a structured postoperative framework for biologically informed residual-disease assessment, radionuclide-oriented reassessment, and targeted radionuclide therapy candidate selection in surgically complex gliomas.