Surgery is commonly the first therapeutic approach for tumour debulking and for obtaining tissue for diagnosis. All patients with presumed high-grade glioma should be considered for surgery and, at the discretion of the treating neurosurgeon, maximal safe resection is encouraged.

The volume of residual-enhancing disease is correlated with overall survival of patients newly diagnosed with high-grade glioma (Ellingson et al. 2018). Pre- and post-contrast MRIs should be conducted 48 hours after resection surgery to determine the volume of residual-enhancing disease.

Advanced surgical options to achieve maximal safe resection, such as fluorescence-assisted resection, intraoperative imaging and awake surgery, should be considered.

Timeframe for starting treatment

Surgery should occur immediately for most cases or within four weeks of diagnosis if not urgent (according to clinical need).

Training and experience required of the surgeon

Fellow of the Royal Australian College of Surgeons or equivalent, with adequate training and experience that enables institutional credentialing and agreed scope of practice within brain cancer.

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with high-grade glioma and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

• a full neurosurgical service for cranial neurosurgery, neuroradiology including MRI services and a post-operative high dependency unit
• appropriate nursing and theatre resources to manage complex neurosurgery
• critical care support
• 24-hour medical staff availability
• 24-hour operating room access and intensive care unit
• diagnostic imaging
• pathology
• nuclear medicine imaging.

High-volume centres generally have better clinical outcomes (Trinh et al. 2015). Centres that do not have sufficient caseloads should establish processes to routinely refer surgical cases to high-volume centres.