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SNI, Surgical Neurology International,
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and Internet Information, Journal and Neurosurgery with Nancy Epstein as the Senator-in-Chief, and SNI Digital, a new multimedia interactive digital resource for medical information and video,
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audio, print, and podcast with James Aspen as the Senator-in-Chief,
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is to please to present another in the series of interviews and neuroscience leaders, and this leader is Professor Hugus DeFoe who is going to talk in nine lectures about brain surgery in the future
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redefining unco-functional outcomes and quality of life.
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This lecture will be on long-term unco-functional results. Connectome-based surgical resection.
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SNI, Surgical Neurology International, is read in 239 countries and territories. Over the past 16 years, it has the third largest circulation and readership in neurosurgery, has over 650, 000
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readers a year.
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SNI digital is multimedia information. It's now seen in 158 countries in the last 24 months It's new. It's a video of neurosurgery journal of the future
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and a resource. It has 22, 800 viewers and over 24, 000 podcast listeners a year. Both provide information you can believe They're free to everyone on the Internet 247365.
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Web address of surgical neurology international and SI digitalorg, so Web address and SI digital, both will be available in the next week or two with an app.
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The goal of the foundation supporting these information resources is to help people throughout the world
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Dr. Defoe is at
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the degree to show The Act Hospital and Montpier University Medical Center, Montpier, France. He can be reached at the phone numbers and email as listed.
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This is a list of the first five of the nine lectures Dr. Defoe is giving. The first four are including the talk today on session for long-term on co-functional results. Connect-on-base surgical
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resection are all available at snidigitalorg.
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Other talks you can see in the subsequent slides the topic study covers about glioma in the insula, corpus colosum glioma, pitfalls
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of neuroimaging, and what beyond low-grade glioma can this be applied to
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Actually, those lectures are available on SNI digitalorg. In-video, audio printout, formants, and podcasts, also on Apple Amazon and Spotify. And although the lectures can be downloaded to your
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computer for free.
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Moderator is James Ousman. Creator and founder, CEO of SNI, SNI Digital. Former professor of the universities in Minnesota, Michigan, Illinois, and UCLA. former head of neurosurgery at Henry
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Ford and Detroit and UIC in Chicago and a futurist, entrepreneur in healthcare consultant.
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The other moderator is Estrada Bernard, who was on the faculty of the Duke University and neurosurgery, he was former head of neurosurgery at the University of North Carolina. His specialties are a
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neurosurgery, spine, brain, and pain. He's on the board of directors of SNI, a digital head of SNI Digital's Grand Rounds programs. Now, it held in Sub-Saharan Africa over the past two years in
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Latin America with the last five months.
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Our Chief Technical Officer is Michael Chile.
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He's the principal and graph attacker company he's formed. Thank you, very happy to give this fourth lecture.
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And most important for me, because after almost 30 years of experience in this
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field of glioma surgery, and especially for low-grade glioma, I think that the most important is to show the long-term functional and oncological outcomes and not only to have some conceptual and or
5:22
technical consideration. But really, to ask to me the question, to know if I was helpful for my patient during three decades. And I will start, as usual, by a case illustration 41-year-old a
5:36
have We.
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man working in the marketing with a previous medical history of disease and a first portion seizure, normal clinical examination, allowing the discovery and this preoperative a
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mirror of an imagined typical. again for a low grade glioma, it was 16 years ago, and the location was in the left palletal lube just in front of
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the pallet of chipton solus.
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So I will not insist, of course, about the fact that I did an awake surgery with intraoperative corticone and bibatotract mapping inhibition guiding me thanks to a better understanding of his brain
6:29
processing and thanks to real-time cognitive monitoring.
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I will show you the prosperity of MRI six months after the surgery. So it was 15 years ago with so-called complete precision according to the flare imaging and also the T2 and the side return slide.
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And because it was a logarithmic gamma without any sign of mackling non-transformation, in the patient will recover perfectly and they want to return to a normal life. We decided not to give any
7:08
adjuvant treatment, no chemotherapy, no rate of therapy, non-typalyptic drug. And in fact, you can see now the MRI did recently, this year in the patient know any modification. So that means
7:26
that with the possibility to regain the samples, because of course it was a 16 years ago, and the absolute certitude that it was
7:38
IDH-meditated low-grade glioma. It's a little bit to be honest, strange for me too, but I have more and more patients like this with perfect stability for complete restrictions, More than 15 years
7:55
later, without any adjourning treatment, we've never relapsed, no re-operation, no seizures, non-tapeptic growth, and perfect normal life. We've, of course, no more cognitive scores working
8:09
full-time and taking care of this family.
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So, based on that, I would like just to remind what we have seen during the three previous tubes, very, very shortly, but most important for me. I mean, to understand the relationships between
8:29
the natural story of this is before to go to the operating theater and the brain reorganization in order, as you said, Jim, to see the brain and not the tumor when you do an extensive recession,
8:43
according to the corticone and subcorticone, restriction according to the functional boundaries at the individual level.
8:54
connectomic neuro-oncology. And of course, to play with these dynamics, not only between the tumor and the central nervous system and its dynamic, but also to play with surgery now. And to have
9:07
the interactions between this is the brain and us, your surgeons. And eventually without any chemotherapy. And to try to find a good balance between what we can change in these interactions by
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doing, if possible, a complete or even a separate authorization. Once again, according to the critical cortical and why matter tracked, and not according to what we think we know about the tumor,
9:41
namely, what we can see on the pre-operative MRI.
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And according to this concept, you will see, of course, the results now with long term for that, speaking about Cipart et al. But not only because in many cases, I was obliged to stop a little
9:58
bit earlier, because the brain was not a bunch for the organization completely, especially at the level of the way matter tracked, the limitation of your plasticity. And definitely, this is
10:11
possible only if we change our mind, localization does not exist, but associationism is not enough Connectomics is good, but a little bit rigid. We have to go toward this concept of meta
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networking brain dynamic interaction with over changing relationships withing and between networks And this is
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the reason why we started 30 years ago by being objective. It will be critical for the reasons I will show you. I mean, old patients benefited from pre and prosperity cognitive assessment, and not
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just my subjective view as a neurosurgeon and all patients have been operated on under weight mapping according to these individual critical boundaries as we have seen in previous talks. So based on
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this connectomic based surgical resection and without using any technology which is a limitation of thought as we will see in the next talk, what are the results? When I started, so 30 years ago,
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the natural story of the Le Greg Leoma was not so good and even if this tumor were called benign, in fact, as you know, in the vast majority of cases, they became a clique note, spontaneously,
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more or less within the five years following the first, some tumor. and the median survival was six years. It's not my opinion, it has been published in a randomized trial at this period and of
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course the quality of life was more or less never evaluated.
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So now I did more than 1, 000 patients
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and I did more than 14 hundred awake surgeries Why? Because I did a lot of reapposition as we have seen in the previous talk by playing on the dynamics of network but also allowing to come back and
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to remove more tumor, more brain invaded by chronic disease, with so-called illoquent areas. You can see broken area, varnicus area, behind the
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labivane, sontrol area, the insular the, corpus callism and so on and so on So the first.
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important reason is that with almost 30 years of life, this is a very reliable, reproducible technique beyond the philosophy, because the mortality is zero. Of course, I have a good team, but
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it's not forbidden to have good anesthesiologists, knowing that it's not the same anesthesiologist in 30 years. I have seen more or less four different teams, just because I was not in Montpellier
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initially, but in Paris, and after that, because I became older, getting older now, so I have seen three generations in my department. Nonetheless, that means that for the vast majority of your
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surgeons who came to Montpellier telling me, I would like to develop this kind of surgery, but one of the main limitations could be honesty issues. In
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fact, you see that it's not dangerous. less than 05 of severe pronging deficit, and I will detail a little bit more in another talk dedicated to insular surgery, because I made a mistake when I
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was younger by pushing too much of the restriction to the anterior perforating substance and using too stroke in the depth and of course a too permanent emiperisis. But it was when I was younger,
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because I didn't know very well at that time, the functionality of the right inferior frontoxedcton fasciculus. 86
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of cognitive preservation plus 10 of cognitive improvement, definitely with pre and perspective, systematic cognitive assessment, objectively, which is unique in the literature. Why? Because in
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99
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of series, you have no cognitive assessment. So to say, if the clinician was preserved or even improved, it's impossible if you did not perform your cycle, the general examination.
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94 to 95 of return to work, according to subgroup, I will detail a little bit more later. And 93 of positive impact on epilepsy, and especially on chronic epilepsy, when patient had intractable
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seizures
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before surgery, which is not so good for me, because you will see that finally, I continue to have six to seven percent of patients with chronic seizures, and then preventing to have an optimal
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quality of life, especially speaking about driving.
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This is why if I can do spread authorization, I need to remove more than the flare-iprocygnal visible in pre-operative, right? It's good of course for oncological issues, you will see that. But
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it's good on so far, I believe, because we demonstrated more than 10 years ago that
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especially in the Grey Gaima, seizures is related to not the core of the tumor, but the periphery, the cortex around the tumor. And of course, a parking invaded by the tumor, even if not visible
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in the prior part of the MRI So that means that if you can remove more according to the limitation of plasticity at the individual living, and according to the preoperative reorganization induced by
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the tumor, then you will increase both the quality of oncological outcomes and also the functional outcomes by preventing chronic seizures in the vast majority of cases So once again, there is no
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dilemma. You can improve both by adapting. to the individual corticone and why matter track mapping.
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In order now to focus a little bit more on the oncological outcomes, we were obliged to select a support of my experience. Why? Because I did surgery so 30 years ago and it was not possible at the
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time to obtain even aposteriority,
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IDH pattern in all cases. So I selected the last 600 patients regarding oncological outcomes in order to be sure to apply the last classification, even if we know that it will change again in a few
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months. And what happened? For the first time in the full detraiture, you can see that the median of all survival is more than 20 years, not reached and we published this paper two years ago and I
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can tell you that it's not yet reached with two more years of fall-out today.
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Of course, from surgery, but if you use the first santoom, I'm not speaking about incidental discovery, we start to reach the medians of Haigong, but you'll see more than 23 years, which is, of
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course, not enough, never, but much more than the full series reported in the literature. And the secret was, of course, to avoid to use. To early adjuvant treatment, and especially to early
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regular therapy, we speak about that. Less than 2 of regular therapy. So finally, against the recommendations, because if you have more than 40, You know that you should do write your therapy
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for long by chemotherapy and of course This results with a prospective collection of data demonstrated that this dogma is not adapted to better results with long-term flow.
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Of course, it's better to have a newly-gotten Roguela Yomardan and astrocytoma, at least statistically speaking But even if, in astrocytoma, the median survival is more than 15 years. And I will
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not tell in Roguela Yomard, because I did recently the Kapan Major just for me. And it's more than 26 years, and the median survival is not yet reached, because still 60 of my patients still live
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So I think that in
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Oligon and Roguela Yomard, reasonably, I should go beyond - 30 years, but I have to wait three to four more years before to publish these unique results. But in all cases, and this is the main
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point, if you do at least a subtletor restriction, an aforcio-tutor-resiction, an aforcio-tutor-resiction, you
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will have a survival benefit of tumorization across all molecularly defined subtypes. Even if, of course, is valid,
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astrocytum, more or less, I would say, to simplify that, you can triple the median survival.
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And this is particularly true. So, in agreement with the case report, I show you in introduction, if you can do support authorization according to the reorganization of the brain before surgery.
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So, if you can push, please go beyond. the intraoperative MRI, the preoperative flare MRI, the hyperecogenicity
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if you use intraoperative ultrasound beyond the navigator information and so on and so on. Because in this subgroup, the rate of death, not regrowth, but death is zero.
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You can tell me, yes, but to remove the brain and part of the brain nonetheless, even if we know the answer to more sounds could be disabling, at least at the cognitive level. No, we published
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the song series in brain, I don't know why to solve it. With 400 logarithmic patients benefiting from post-operative cognitive assessment, by comparing total to super total rosization. No
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significant difference.
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And you can, if you push the realization beyond the flare, you do not induce any cognitive disorders, further cognitive disorders in comparison with totalization. Of course, because it's a
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selection of patients, according to their particular free organization before surgery. So you understand why the previous talks were critical to understand these results, because sometimes I have
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to stop earlier But as you remember, I hate to lose, then I will come back five to 10 years later by inducing mechanisms of neuroplasticity in the meantime, and add that time to do total or even
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through practicalization without inducing any severe oxidative deaths. So we have to play not only with the brain or the patient now, but the potential result from neuroplasticity after your surgery
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And this is especially true.
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in cellular logarithmic logarithoma, even if I will not insist too much because we will dedicate one other lecture specifically to this challenging location. But to make a long history short, about
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more than 300 awake surgeries in this specific location for logarithoma. What is very exciting is to see that not only the patient can continue to live longer, but also with a 96 of return to work,
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but also with a better control of intractable epilepsy, which is very frequent before surgery in Paralympic system. So you can help not only patients, allowing them to live longer, but also
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functionally, not only by preserving the function, but also by improving their quality of life, thanks to relief of chronic serious.
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especially true if you do wake surgery.
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Indeed, I compared myself to myself. When I was younger, I did some surgery specifically in this location, Paralympic location, in the right, so-called non-dominant hemisphere, to be honest, I
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have noticed knowledge of the meta network 30 years ago, because in fact, I described the meta network just a few years ago, and I did some surgery under general anesthesia, and then I induced,
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as I told you, to permanent me paralysis, because I pushed the restriction to match in the depth, because I was not protected by the right iPhone, because the vision was a sleep.
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You can see that the return to work was 82. With more or less in this location, 90, I will not insist too much once again, we will see that on now. and next talk. But now, by doing this past 20
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years, systematically wake-sager in the right Paralympic system, and you have the same externalization, the right of super-chromological deficits is zero, and the return to work jumped to 96. So,
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do wake-sager
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Indeed, you remember that the right non-dominant hemisphere does not exist, we have seen that previously. But now, it's a perfect illustration with results
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obtained thanks to the application of this dogma in the operating field, and to demonstrate that it was true, not only in Montpellier, but everywhere in the world, and not only for low-grade lemma,
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but onto an high grade game. We will have a session also dedicated to other indications than the great lemma. We did the meta-analysis of the literature demonstrating very clearly that for all
25:59
gliomas, the great high grade, located within the right circle non-dominant hemisphere. If you compare a weight surgery, versus a sleep surgery, everywhere in the world, it's exactly like a
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membrane, patients with a weight-based mapping recession improved their quality of life and their cognitive function. Strong surgery in comparison with patients operated on under generalized vision.
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And not against the externalization. So the question is, Hi, it's not done systematically.
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So I will continue the long term outcomes Speaking a little bit more about the functional arc, because you can tell me, okay, you increase medium survival beyond 20 years, but maybe at the expense
26:52
of quality of life. It's the reverse. My patients, not only are able to return to work in 94 to 95 places, but they can continue to enjoy a negative life for at least 15 years. After that, it
27:08
depends, of course, on the recurrence of the tumor, especially in some astrocytoma, as we have seen previously.
27:18
And typically, this is true. What are the location of the tumor if you apply the concept of meta-plasticity? I will not insist too much, because we will have also a tool dedicated to the
27:32
restriction of logarithmic involving the corpus callosome. But just one slide to show you that even in this very. challenging location,
27:46
you can apply the concept and to have exactly the same results with more than 96 of return to work and a mid-gen survival of 20 years if you removed also the part of the tumor invading the corpus
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callism. So we will see that in more detail in a few months.
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The scoop, which should be published in a journal near surgery in one to two months. I reviewed the proof very recently about a unique series of more than 500 patients. So, IDH meditated, awake
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surgery, long term for up, and so on and so on. And what is the scoop is that if patients return to work, not only by preserving the quality of life, meaning avoiding any
28:40
pleasure, capias at least 80, and so on. and so on and so on, and are specifically written to work, which is very high, as you know, in my series because more than 95.
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But you can have patients not able to return to work, especially because of seizures, or because some cognitive issues, or able to return to work, but to be obliged to stop in a few years and so
29:06
on and so.
29:08
If they were able to return to work and to continue to work, it's very, very, very significant, as you can see, p0005, they will live longer. So
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that means that if you enjoy a negative life, not by Italy, I will avoid permanent deficit, but I'm really active as a human being, four, 10, 15, 20 years, I will live longer There is no
29:40
dilemma.
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in the gray glioma. By pushing the residual according to functional boundaries, you will improve both quality of life and survival because both are linked.
29:53
So now I decided to examine specifically patients with more than 15 years of fallout. So by forgetting a little bit the oncological issues because they have a lot of patients still alive. And this
30:09
is the sole series in the full literature Not only speaking about surgery, but also young clergy in general,
30:18
which was interested by the long term quality of life of patients living more than 15 years. And as you can see, more than 90 of them were able to continue to work and to have so very good quality
30:32
of life.
30:34
Except if they were irradiated in the meantime at some point of the natural history Sometimes, of course, because of the growth of the tumor, but sometimes also because of management, I'd wear 10
30:49
years after my surgery, for instance, against my recommendation. And at that time, what happened? The quality of life declined. They were not able to continue to work and the survival is less.
31:07
I specifically dedicated a study Now, almost a submitted in patient,
31:17
not selected for surgery. Because with a low grade layer malgated within so-called eloquent areas, according to the classical
31:28
localization is view. Procluseria, because there are a Roland D system like your understood. And in this specific sub-series, you can see that the mean extent of position is also an ID person with
31:39
a mean. of all survival of 22 years since the biopsy, because they did surgery of course, while this patient were not selected for that, the goal was to do biopsy, it was done before in another
31:54
department, and just to give Kimo an array of repair today was I didn't him, and that's it. You imagine a major survival on 22 years, and why they were not pretty done, because your surgeons
32:08
continue to believe on localizationism, they did not understand that the brain plasticity is much more
32:19
is beyond our imagination, except if you start to be involved in this concept of metallic work.
32:27
You can tell me, yes, but if you look at tumors just in between right two and three, because they are very voluminous. I did a specific series with patients also, and long-term
32:41
with more than
32:45
100 Cc, which is the answer is in the literature about that.
32:48
And in fact, the results are exactly the same because they did the surgery according to the functional boundaries. And it's very exciting to see that considering a young survival. No significant
32:59
difference between U-grade two and U-grade three. Why? Because it's not really a grade three. It's a U-grade two with some foot size of grade three. And I will speak a little bit later about that.
33:12
On the other hand, the other extreme is that you can write patients for smaller tumor because incidentally discovered. And of course, we demonstrated that in one per year. But also, we did a
33:26
multi-son tric series with UCSF, a mid-burger, a calgary, who did the answer. And you can see the results, of course, with a median externalization of more than 95 of resization but also more
33:41
than.
33:43
61 of total R-super-taturization. Why preserving the quality of life? Because we did systematically a cognitive assessment after this recession of so-called normal patient before. And in fact,
33:57
they had in more than 50 of them, some fragility in some domains of cognition, 97 of them were able to return to work.
34:12
And this is the reason why my question is now, is it possible to cure the gray layer man? Of course, it's just a question, I have to be cautious. Nonetheless, I have more and more patients with
34:22
no recurrence after more than 15 years.
34:28
As you know, if you have a recurrence, which is nonetheless in the vast majority
34:38
of cases, unfortunately, then please re-operate a patient as we have seen previously. by playing with mechanism for neuroplasticity. Not only a second time, but also a third time, fourth time,
34:47
a fifth time, 20 years later. And of course, if the patient continues once again to enjoy their own life, they will continue to live in a sense. So you will increase both the quality of life and
34:57
the medium survival. You see, everything is full of common sense. And once again, speaking about long-term results, this is true also If you mix grade two and three. So if you can re-operate
35:15
patients within ill-quantity areas, by playing with mechanisms of network reconfiguration every five to 10 years, then the medium survival of so-called low-work grade lemma two and three is 18 years.
35:34
Why preserving the quality
35:37
of life? Even after signal third, fourth, fifth surgery, we are doing systematically an objective, cognitive evaluation. And you can see that the return to work is similar, 94
35:53
of patients able to resume their employment. In other words, the mechanisms of neuroplasticity are efficient, similarly after reappointment And so to reapprate and to extend the resynction is not
36:12
at the expense of the quality of life, even 20 years later. This is really critical. The brain is magic.
36:22
Once again, the brain has some limitation. And you remember the first two. We have two at this time. And by italing, careful do not cut the connectivity in the depth, the limitation of
36:35
neuroplasticity, Otherwise, of course, your patient will keep permanent deficit. and all neurologically speaking, but if it's true for your surgeon, it's true for your therapist, if they
36:50
irradiate the connectivity after no wake, connect to base the surgical physician, in a sense we have to understand that the ages of the surgical cavity,
37:05
the functions,
37:07
the way matter tracks connectivity, the limitation of neuroplasticity. So even if you do a beautiful radiotherapy just at the level of this connectivity, one centimeter or two of margin without
37:22
irradiating of course the full brain, you will irradiate the minimal common brain and then what will happen, a decline of cognitive function.
37:33
This is the point. If you have 20 years of life,
37:39
mean when you are for that. Because of course, if you are looking at you, you are watching just the reasons in the five years following radiotherapy, you inside the patients are not so bad, but
37:53
they are living more than 20 years. But if you are objective, even within the five years regarding radiotherapy, by doing now objective, cognitive, andor behavioral assessment, and I used
38:08
voluntary
38:10
paper, not from Montpellier, to demonstrate that I am objective by telling that. And the paper published just three years ago, not 10 years ago when the brain was irradiated. You can see that in
38:24
about 50 of patients you have already cognitive andor emotional disturbances within the five years. You imagine after 20 years, is it possible to imagine? I will tell you. 30 percent of late
38:41
dementia. We are not speaking about cognitive disturbances. We are speaking about demand patients. You have seen many reasons by postponing radiotherapy and the quality of life for patients after
38:56
15 years. Here
38:59
with radiotherapy, not only they are not working anymore, but they will finish with dementia. That's crazy. And we continue to originate.
39:10
I will not use a paper for Montpellier to be objective also, and published in neurology, so
39:18
the photojournal of clinical neurology. And just one year ago, you can see by yourself the conclusion of our colleagues.
39:28
They compared early array of therapy, so according to the classical protocol, published in New England, bla bla bla, to the failed array of therapy.
39:39
And they did not too much insist about functional issues, but just oncological issues. And you can read by yourself. By doing all your array of therapy, you are living shorter. The median
39:52
survival are shorter. That's crazy. So by doing early array of therapy, not only the patients have cognitive deficits,
40:04
but they have a reduced survival That's crazy.
40:10
We have full four patients.
40:16
And we will reproduce exactly the same mistake. Why? Because everything was based on progression free survival. When they said you have to irradiate earlier. It's exactly what we are doing with
40:29
Vrazi they need today. I'm not against. I would like to have a longer full up, not just three years, Because I have 30 years of flapping.
40:39
in the great lemma match crunch. And what I did is to compare it to Muslim mind, according to the classical trial, especially done by Rajishto, in high risk, look like lemma, and you can see the
40:55
BFS 39
40:58
months with the BFS published in New England recently using war 27 months, I do not speak about the cost. As crazy, I will not replace
41:17
surgery, reapposition, deferring Rajishto at the end, eventually using the Muslim mind when you have an invasion of the connectivity by Warazi didn't even. And sometimes it was done. You see what
41:32
happened? The patient I followed for 15 years and finally I was not able to reapply him.
41:40
two months of vorazidini, you see what happened in two months,
41:47
not the PFS, it's just better than possible, so we have to stop everything and to give vorazidini to everyone. Are we reasonable? This
42:02
is the reason why we decided definitely to postpone adjuvant treatment as I said before Especially, by your therapy, you have understood why, but also when you have for sale of manly
42:13
non-transformation, because in the work classification, it was not yet incorporated. The most important parameter in the great layer map, except the diffusion, the fact that this
42:30
tumor arehate heterogeneous. So it's totally different, of course, if you have one focus of manly non-transformation in the middle and you did a superb part of the resolution, we are serious to
42:38
have. Fusai, Magdalene transformation everywhere. And when Fusai were just in the middle of the tumor by doing a lobectomy, we decided not to give adjuvant treatment. And you can see the
42:56
five-year survival rate in this specific subgroup, more than 95.
43:03
I tried to publish that in Genomeo Sanctuary to explain that it's just full of common sense. If you have just this focus of so-called grade four in the middle and you do this pre-totalization,
43:16
please do not refrigerate. Otherwise, you will in your decline of cognitive function reduce mid-and survival, because you will not be able to reuse riotherapy a few years to decades later. If you
43:30
have for site-magnant transformation everywhere, this is a high-grade lemma It should be critical for the new classification.
43:40
of the WHL, but they do not care because only molecular biology, that's crazy.
43:52
An example, but there are many, of course, announcements. I decided to read the first one in
44:03
2002, 24 years ago. It was, including, at that time, with the old, old, old classification, grade three. And I said, No, I just brought the translation. Please follow the patient. Of
44:18
course, initially, we've memorized every three months and finally, every six months And I did not sure. But there was a regrowth leading to a reappration 15 years later, without Timor, I am so
44:33
happy about that.
44:35
And at that time, it was a great tool according to the new classification. That's crazy. No, it's not crazy because I removed one focus of way three during the first century, full of common sense,
44:48
and I did super totalization. And finally, to be honest, the patient had more and rather for a P past year, so 23 years after a long life.
45:01
It's not new But you can see that in your oncology, the first journal in your oncology, blah, blah. 11 years ago, we proposed with my colleague, Luca Young jie, a famous oncologist in France to
45:14
avoid to do to early radiotherapy. And if possible, to postpone also a German treatment. Of course, why? To keep them in reserve for the next next next future, because I was sure that I was not
45:29
going to cure patients. And finally, in the meantime, the patient in general in my life, so they increased their major survival and as we've seen, I was able to re-operate more or less half of
45:40
them. And finally, we gave her chemotherapy when there was a diffusion at the level of the connectivity and limitation of neuroplasticity without irrigation of the Wi-Fi to track. And finally,
45:52
some of them were irrigated 15 to 10 years later. Everything is clear. They are living longer and better Because we know the limitation of neuroplasticity and when I showed this kind of slide during
46:07
the first talk, probably many colleagues said, I do not see the real relationships with the clinical implication. Now, you know, I am certain allowing patients to live longer and better beyond 20
46:20
years because I understood the brain plastic mechanisms but most of all the limitation. And then I adapt to each patient, see the brain, not the tumor you understood. Everything is clear. And
46:33
definitely you can be a neuroscientist and proposing new models of cognition in nature for geologists and neuroscientists. You can propose this model of interaction between and
46:50
within networks. And you can apply this concept to the management of patients with gliomas, especially the great glioma And to brag with the same view, even if the protocols change, but static
47:08
protocol based on instantaneous photography. Without taking into account the past and without trying to anticipate the future, just based on the molecular pattern, it's crazy
47:27
So my conclusion is my patients are living longer and better.
47:33
Because
47:36
I changed the concept of evidence-med medicine just by publishing this paper almost 10 years ago by Italian, we changed the definition of evidence-med medicine, which was initially to compare one
47:55
treatment to another one, that's it.
47:59
Second, because I do not use quotation-free survival, which is a wrong sugar rate to elongate and point. As we have seen, we have the paper published in Lancet in 2005 by Italian earlier for this
48:15
because we were able to postpone the PFS two years. And finally, the survival was worse. And finally, the quality of life was worse. And we continue to use sorrogate. That's crazy We do not.
48:33
learn from our mistake. For me, it's very clear. I try to be just a little bit unpathetic. And I know that since 30 years, my patients want just two things to live longer and better. That's it.
48:50
PFS is just the psychotherapy of new oncologists External conversation, just psychotherapy of new such. I want to see survival and quality of life. But now, for the first time with more than 20
49:09
years, I showed you objective reason based on prospective collection of data and of course, not randomized. Because I believe on Hippocrates You can see the statue just behind me.
49:27
So, you have again the choice now.
49:32
just to apply the nucleus vacation based on molecular, butterm, and metilum, or to treat a patient based on better understanding of the typical modification of the brain, of the interaction
49:45
between the brain and the tumor, and the interaction between the brain, the tumor, and your treatments. And first of all, the surgical physician performed like according to the functional mapping
49:59
Everything is clear, at least in my mind, but with objective facts. And I regret that in the literature, so many colleagues are they around the field, can just talk without objective results.
50:16
Ask them, first of all, the long-term functional and in oncological issues, of course, oncological results Now we can discuss and
50:28
I'm waiting for your patience. Thank you so much once again for your attention and for giving me this opportunity to transmit the message, not based on my view, but based on facts. I am very
50:42
Cartesian. I believe on Hippocrates and Descartes and French.
50:50
I'm standing, so can we stop sharing a sharing screen so we can see all the audience I use,
50:58
that's terrific, we have almost 24 people here now in Strata. Let's have some questions from the audience. I have a whole bunch of them written down. You should have police protection after this
51:11
lecture. When you go home, you need police protection because you are bringing up many controversial subjects which are going to antagonize neurosurgeons and doctors for long held beliefs. So I'm
51:27
just warning you, OK?
51:30
Okay, he's good to Philippines. They would like to kill me. They have a chance in Manila next week. So we will see. Okay. Well, anyway, okay. So let's open it up for some questions. Please
51:45
anybody have some questions
51:50
they want to ask.
52:03
Andrés, what's your second question? I know an excellent lecture. I always said the same.
52:12
I know the work of Professor DuFois. It's an incredible, where you see the picture of the slides, pre-operative and post-operative, the Lyoma resectionist unbelievable.
52:25
But we were trying to copy his masterclass My question is, I know his answer to my
52:33
question. But you know, there is a little bit pressure of the market trying to, there is this new dragon in the market for low grade Lyoma. They are saying that maybe it's a possibility for the
52:48
recurrence. I am a little bit afraid because neurocologist always have a friend of the surgery, the regular surgery, not like we as another surgeon the complications, the consequences, the
53:04
undecided ends, is completely different from the perspective from the neurocologist and the neurosurgeons, but many patients are managed by neurocologist. So I have a little bit of friend of some
53:18
people which will lose the possibility to rehabilitate it on because of the new drugs. In my country, it's not so easy because it's not a cheap drug, but I don't know if in the United States or
53:33
maybe in Europe. I think as a neurosurgeon, we have to put all of our energy trying to offer surgery. Of course, if the patient is in good condition, but many times, logarithm glioma belongs to
53:46
young people. Under recurrence is still in young and good condition patients. So I think research is a very good opportunity for them Professor Dufour always showing his letter this. this topic.
54:00
But I think in the next year, this new drug, because of the market, we'll produce a little bit controversy in this issue.
54:14
Do you have seen the results? 50 of recurrence after three years, using false identity? I would like, of course. I am more or less at the end of my career a year It's not an issue. If I'm not
54:30
continuing to do a very extensive lead to me, I can play piano. But in fact, it does not work. After three years, 50 of recurrence, and 10 of them with maximum transformation. So you have done
54:45
so. When patients are asking me what I think about, I'm telling, I do nothing. I show you. And they are telling, but how? They decided to replace surgeries. with your reasons, by just a drug
55:03
with three years of flab. And I say, I don't know, you can ask them, but be careful because today it's just an illusion. To my opinion, I answer, I think that we will have one third, I don't
55:20
know, maybe 25, maybe 40 of patients who will really benefit from longer benefit from anti-IDH.
55:32
But we have to define the good subgroup based on individual and productive factor and it's totally against evidence-med medicine and ethics today. To forget the
55:46
reasons we're obtained with this long flat just because a new drug not compared to other treatments, even regular therapy if they won't.
55:59
a specific combination, but just to possible, that's crazy. And when I explain that to patients, 95 of them will tell me, Ooh, I will wait. And if that works, I will benefit from it in 10
56:16
years. So in the meantime, you will continue to follow me. And if needed to reopen me. And this is the reason why I continue to manage the patient by myself. But not only because I have also the
56:32
chance to work with a very clever young ecologist in Monpere, in France, and in the world. And 10 of them, at least, can understand that we have to be careful. And then we can continue to manage
56:46
all together these patients. But they are the first, in case of recurrence, to ask me if I did not meet the patient because 10, 000 kilometers from one year.
56:60
You don't think that you have to re-operate, because maybe you can reduce again the volume and to update the neuropathological examination, so it's not against the root classification. It's by
57:11
comparing long GTD nearly over years to decades, and suddenly you have the solution at the individual level based on updated, integrated information, and when they speak about integration, they
57:26
are speaking about molecular biology and metilome, and speaking about molecular biology and metilome, but long GTD nearly acquired, plus the real quality of life, including return to work
57:39
cognition and so on and so on, plus seizures, plus kinetics on regular MRI's, plus volumes and so on and so on, and when you explain that to the patient, they believe on that just because this is
57:56
full of logic and common science.
57:60
This is the solution. And this is the reason why so many of my patients were not irradiated, because I applied the concept of epochaties, not by attending. You have not to be irradiated. But by
58:11
giving the choice and by attending, be careful. You could have also adverse effect on radiotherapy, especially cognitively speaking. Within the next five to 10 years, you spoke about young
58:25
patients who would like to enjoy a normal life So if you're obese against this principle, you have to explain that. And by telling, be careful, if we use radiotherapy now, it will not be possible
58:36
in vast majority of cases to reuse in 15 years if you are still alive. And at that time, I'm not sure I will be able to reapply and so on and so on. And finally, even if you have medical legal
58:48
issues, the patient can decide for himself. So if you decided not to be regulated, it's okay. And strangely, if I can say they are living longer and better, and now I do not forget this decision
59:03
20 to 25 years later. So I will do exactly the same thing for the rosy, the need. And when I retire, they will do what they want.
59:21
I have a question. Sure, go ahead, Horisho
59:26
What is your policy with tumors that are only infiltrated?
59:35
If there is a two-diffuse infiltration, a glioma to this light
59:42
is strange to say that because according to the nucleosification, it does not exist anymore. Of course, it exists when you start to have a
59:52
bifurnto calleur, calleur, tumor, sometimes you cannot do, of course, even a subtle removal We proposed, 20 years ago, with our colleagues in the young country, to do biopsy first, and to
1:00:09
give adjuvant, narrow adjuvant, narrow adjuvant, chemotherapy, natural therapy, of course. Otherwise, we will radiate,
1:00:20
in this case, bifurnto calleur, calleur, tumor. The patient will have dementia within
1:00:23
the five years for knowing the right therapy So chemotherapy first, and even if in astrocytoma, because I remember the first
1:00:33
case report we published on together with Lucte-Ionzi, it was in 2006, so 20 years ago, it was
1:00:42
astrocytoma and there was a very impressive shrinkage giving me the opportunity to apply the patient because of course, it continued to enjoy our life by decreasing this infiltration you spoke about,
1:00:60
and finally, giving the opportunity, at least, to reach, not a super totalization, but a sub totalization, to reduce the volume and to prevent maximum transformation, why preserving the quality
1:01:12
of life.
1:01:17
Thank you. Okay. Said, do you have any questions? I have a doubt.
1:01:24
Okay. Let the gentleman ask, then I have a comment, okay. Oh, so thank you, professor, for a wonderful lecture. It is always a great opportunity, whether to hear in a Society of
1:01:38
Interoperative Neuro-Moltinger webinar So you mentioned that 86 cognitive preservation and 10 improvement in the patient across the 30 years of experience. Can you please elaborate on which specific
1:01:52
cognitive domains show the most improvement and also which are the most vulnerable during the awake surgeries?
1:02:02
When you are speaking about cognition, in the vast majority of cases, we have to think about not complex movement or language, we already spoke about that, but executive functions. Working memory,
1:02:16
the possibility to maintain, you know, and to manipulate many information
1:02:24
is possible simultaneously Another flexibility, I did something in the real life, suddenly the phone rings and you have a two minutes later to continue exactly where you were by doing a combination
1:02:39
of tasks. Attention. To continue to be focused on what happens, for instance, our description after one hour and sometimes prolonged attention but also divided attention to do two things
1:02:55
simultaneously for more than one hour and so on and so on.
1:03:01
And you see that the vast majority of our patients, I'm sure that it's true for you to whatever the continent, the culture and the quality of the team, they are tired.
1:03:14
They are telling me since 30 years I am tired. Why? Because they have to focus in order to continue to do what they did before and they succeed. But by spending more energy in order to continue to
1:03:33
have this higher success in higher cognitive functions. And this is the reason why we can modulate in the operating field the external presentation at least during a first recession. If the patient
1:03:49
would like for instance to finish studies. So to be able to continue to learn and not just to live on the automatism, you have acquired the best of 50 years, if you are 60, for instance. And then,
1:04:05
to be honest, as a surgeon, you can remove metastasis without thinking a lot at 60 because you have a high level of automatism. But when you are young resident, you have to focus a lot. So if you
1:04:20
would like to continue to learn, when you are into the important theater, you can also integrate, as I said, switched from a combination of tasks to other combination of tasks, but also with time
1:04:34
constraint. And so many visitors were surprised that these past 20 years, by telling me, you stopped the reservation just because the patient was not able to continue to perform own tasks just in
1:04:48
five seconds. One aisle, of course, they were not a physical epidemic. And I say, yes, because they asked me to enjoy a perfect normal life.
1:04:59
tumor, for instance, at the level of the SMA order for testosterone tract. I said, yes, we'll come back after compensating thanks to the control at the right side, because during this surgery,
1:05:10
when I stimulated, I induced a transitory, mutism, andor akinesia. And I know that if the tumor continues to grow in this location, then the control at the right SMA and system will compensate
1:05:24
within the next years. So I will come back, and at that time, I will remove completely without any SMA syndrome. So that means that patient will not be slow, so it will not be tired.
1:05:40
Along those lines here, in terms of how robust the
1:05:44
neuroplasticity is, do you have a sense of what proportion of patients in which you initially do a subtotal resection? On the second or third procedure, you're able to do a super total resection.
1:06:00
and yet preserve your function.
1:06:05
Very difficult to tell you exactly the proportion like this, but what I can tell you that approximately 50 of my patients benefited from reoperation. So that means that to be honest, 50 of my
1:06:20
patients had an invasion of the connectivity. And I was not able to redo a preventive surgery I'm not speaking about metlinon transformation and reoperate in order to remove enhancement, okay? But
1:06:35
preventively, 50 of patients, first, will have adjuvant treatment at some point of their evolution because invasion of the connectivity is a limitation of neoplasticity. And this is this
1:06:51
proportion I would like to change In the 50 of patients are reapprated and preventively,
1:06:60
I was able to do, at least, a self-totalization. Or a totalization, if
1:07:25
I did a totalization the first time, so to reproduce the same score than during the first surgery, in more than 90 of that. In other words, very, very rapidly, you will know if you will be able
1:07:26
to deal with the mechanisms of your plasticity by your own as a new surgeon, because you will see that if you have a rigorous, it will be much more bulky at the level of the
1:07:39
corticone, subcopterial junction, and not diffusion within a way much track. And second, because the patient will continue to have exactly the same quality of life validated by the similar
1:07:50
cognitive assessment over yours On the other hand, there is also a third group now.
1:08:00
I was not able to reapply it because diffusion in the depth. We had chemotherapy, yes. And now Neelajevon chemotherapy offered re-operation
1:08:12
because the shrinkage of the diffusion of reading the connectivity. And now I would like to push a little bit more in this subgroup by inducing
1:08:23
more efficient mechanisms from your plasticity
1:08:29
by using more rehabilitation and maybe stimulation, magnetic or transcranial stimulation. So the mechanisms of metaplasticity, changing the pattern of plasticity.
1:08:45
But it's much more to be harnessed clinical research today.
1:08:52
Dr. Azman. Okay. Dr. Azman. Dr. Azman. Sir, yes. Yes I think this is a new era. that we have to start to consider for training the neurosurgeon. I recommend if we can get few videos of
1:09:08
entire operation of Dr. Dufo, two hours, three hours, put it on the SNI, because we have to start to turn. It's very hard to change the mind of the old neurosurgeon, majority of them, that
1:09:23
they are fixed to do this and that. I'm sorry, this is the exact problem If the resident is trying to do this way to remove it, it's gonna be very hard to change their mind. But this is an error.
1:09:38
We have to start to educate the new generation. Hopefully, Dr. Dufour, I'm sure he has the video of all the surgeries that the entire surgery, maybe one hour, two hours, he can cut it out to
1:09:54
put it on SNI So all the new neurosurgeon to start to. change their mind of what they have been trained because this is a new fantastic area and we have to change it because no surgery is not very
1:10:09
advanced in certain aspects. I'm sorry to say but the mind of the no surgeon do this and that's it. That's why I think because it's a fantastic approach for the new era, for the treatment of the
1:10:22
low grade kineoma and he has a fantastic serious experience. So we have to use his experience for the next generation. That's my and thank you very much. Beautiful talk, Dr. Divour. Thank you.
1:10:37
Thank you in practice. You know, I published a lot of videos. I mean for surgeries, already available but we have to ask for the right or to put the link for instance in journal Youngcology for
1:10:53
insular tumor. In some books with surgeries for 30 to more on 60 minutes in your surgical focus movies with 30 minutes and looking at the patient and also the speech therapist and what happens during
1:11:16
stimulation at the level of the cortex and the way that it tracks. So more or less, I would say everything is already for label But of course I can discuss with Jamie if it's possible to put the
1:11:30
link and for younger people just to click on it and to have the access to these videos which were really performed in a didactic view and not just before he's doing something. We have understood
1:11:45
nothing. It was beautiful. No, no, we explained everything. Thank you very much, really. That's going to be in the next stage for the advancement on neurosurgery of the brain tumors. because
1:11:58
in the past, they did, as you know, Dr. Harvey Cushing started a neurosurgery, the field of neurosurgery in the US, and it is 100 years has passed, many of the things they have started. It
1:12:11
isn't, it's a new era for the treatment of the low-grade tumors and with your explanation, then we can advance the field of the neurosurgery, for brain tumor with all your expertise. Thank you
1:12:27
very much, Doc. Okay, thank you again, but I have just to conclude that to be honest with myself. Maybe it's a little bit new in the great lemma because it was not reported 100 years ago, but
1:12:41
regarding brain surgery and field spoke about that. It spoke about the instability of the motor point. If you read panfield directly his book in the text, you will see that it was not serregid.
1:12:57
Speaking about the Amunkaluz, is that everything is much more complex and no one except George Ojman was interested by that since 80 years. So for the younger people, think about that. Why?
1:13:14
Okay, let's say if there's any more questions, I have some questions I wanted to ask, but Christo, do you have any questions or Eva? Any questions
1:13:29
you'd like to ask? Are Laura Danna and Emmanuelle?
1:13:35
Okay, while they're thinking about it, I'm gonna ask you some things that you need police protection for, okay? The first thing you first allied you had is it was a simple problem, simple concept,
1:13:51
50 50
1:13:53
of patients who will come to a neurosurgeon and examine it are found to be normal. Actually have neurological deficits, is that correct?
1:14:04
Correct, they have in more than 50 of cases cognitive deficit and without an objective your psychological examination, you
1:14:31
will miss that. So it says that again, it breaks with a controversy and that is we can examine the patient that's not enough. You need neuropsychologic studies, the imaging may not show you about
1:14:31
function and so fundamentally the patient comes back to the clinic, how you're doing, okay, do a few tests, they won't tell you anything. You need more detailed examination of brain functions.
1:14:41
Correct. Second thing is a concept, second thing you raised. You raised the concept about radiation therapy and chemotherapy, radiation therapies has existed. since 1946, when they radiated the
1:14:56
whole brain to cure major low blastomas. And they found that it was so toxic they couldn't do that. Chemotherapy came later, it was in the '50s, late '60s with intra arterial methotrexate. I was
1:15:12
in on that. The constant problem is, and we published a Dr. Blalock published some articles and surgical neurologies, SI digital, the video version, which says that tumors are not a genetic
1:15:29
disease. They are a metabolic disease. It's the metabolism that's been destroyed. And it even goes further to indicate that there's virus disruption from all
1:15:42
the latent viruses in the cells. The reason I mention that is that there are many toxins, Radiation
1:15:52
therapies atoxin, chemotherapies atoxin. There are other kinds of toxins, but we're giving patients as treatment, toxins, radiation therapy kills cells, which is why you found if your patient
1:16:05
had radiation therapy, their quality of life was worse. Because it couldn't allow any plasticity or any change that the cells and the tracks were killed. They're dead. Is that correct?
1:16:22
Especially at the level of the axons. And this is the point. Because if you induce degeneration, the concept of a lupeti, they did not wait for me to see a typical imagine after a radiotherapy,
1:16:35
you know, if this flare eye proceeding on around the ventricle, it destroys the axon. But we didn't know at that time that the axon was the limitation of your plasticity So that means that once
1:16:50
again, if you destroy not just two centimeters at the level of the very plastic cortex, but two centimeters of why matter tracked in the perivontic ventricular area, you will use a disconnectionism
1:17:07
syndrome and definitely the quality of life of the patient will be so poor for a certain time for nothing. So there's another revolutionary concept besides the fact that the examination is inadequate.
1:17:21
Now we're recommending treatments that are toxic, that are supposed to be therapeutic, but they aren't. They actually kill the brain and the chemotherapy kills the brain. And it stops the
1:17:34
protective inflammatory response from the surrounding perincoma from occurring,
1:17:40
which again feeds into your idea that they have a shorter quality of life survival because you've stopped the immune suppression.
1:17:51
So anyway, those are some revolutionary ideas. Then you told us, another revolutionary concept, you had a grade two and a grade three glioma. And you went ahead and operated and looked at them
1:18:06
long term. If they did this the way you suggest and didn't
1:18:12
discontinue the therapy and go to radiation chemotherapy, they would have much longer survivals with a functional removal Isn't that correct?
1:18:23
Yes, because first of all, we have to, once again, make the difference between a real high-grade glioma with foci everywhere. And of course, what you will leave will continue to evolve very
1:18:37
quickly. While you have some tumors with just one focus in the middle, even grade four. And then if you did a super total recession, you can wait. So you can postpone chemo and all-ray therapy.
1:18:51
Second, because I cannot cure patients, except maybe some of them, as I have demonstrated in the first case illustration. So that means that one day, I knew 20 years ago that I will have to
1:19:06
propose to patients to be irrigated. Why? Because I did three surgeries. Now the tumor invaded the why matter track limitation of neuroplasticity We used chemosolomine and or PCV. We tried to use
1:19:22
rhizoidinib. And
1:19:24
finally, the patient is still well, but the tumor is still migrating. And at that time, what do you want to do? And I'm so happy to say. Of course, I know that probably in five years, you will
1:19:37
have a decline of cognitive functions. But your survival will have been 25 years So by postponing, write your therapy, not only you increase the quality of life for the first 10 to 15 years, but
1:19:53
also you increase the median survival because you keep a weapon in case of good growth. It's so logical.
1:20:03
Now, I'm gonna mention a couple of other things you said that are very controversial and go against everyone. But Said was saying everybody's learned for their entire neurosurgical life. Now you
1:20:15
tell us that you get people who come with an insular glioma, insular glioma. Nobody wants to operate on the insular, it's a terribly dangerous territory. 97 of your patients return to work.
1:20:33
I'm absolutely revolutionary. And then you'd beside that go and operate in a corpus callosum and most people give up on the imaging and say there's nothing I can do because it's already in the other
1:20:45
side of the brain.
1:20:50
I will explain a little bit more because, as you know, I will have two lectures specifically dedicated to insular logarithm or hybrid, if you want to, and the invasion of caucous calism. But to
1:21:03
make a long history short today, just a summary, why I have so good results in insular logarithm because I go through the upper column I am a brain surgeon, I am not afraid by the brain because the
1:21:18
metaplasticity will protect me. In other words, I am not a surgeon. I do not try to open the civilian official, especially posteriorly, because you know the numbers of vessels you have. You know
1:21:32
the veins, the traulars, the labes. You know the implication between the parietal and the temporal lobe If you have
1:21:43
a posterior insular tumor, while as you will see in my talk. I'm going through the brain by doing a survival decision and by avoiding the critical structures, network, and how I know it and don't
1:21:59
give your living trust by doing wedding and cognitive monitoring. And once you are at the level of the insular, try just to remove it. Sub-bialy, my secret is that never I have seen directly one
1:22:14
vessel not protected by the pyrometer since 20 years So no stroke. So if you are no stroke and if you preserve the connectivity, why do you want to have a problem? Thank you very much. Abba, did
1:22:28
you want to ask a question?
1:22:32
Abba from Syria, did you want to ask a question? Mr. Dafoe, that's a
1:22:36
great opportunity to listen to this lecture and new concepts about the
1:22:44
great glioma.
1:22:47
you change my mind and I'm trying to watch various concepts with my colleagues. Thank you very much.
1:22:59
Thank you.
1:23:05
Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. The best way to establish the results by telling that you increase and your
1:23:14
patience and your patience are living more than 90 of the return to work. We will try
1:23:24
to have you advice about books or
1:23:31
to beginning study these concepts
1:23:38
May paper and see if you
1:23:41
look at your reviews.
1:23:46
of the brain is totally wrong. If you cannot be that and if you cannot be that, you will go. When you build the location of the brain, whatever the location of the brain is everywhere, way
1:23:56
between us and the person on the wrist between us and everyone on that to see what the world
1:24:02
is. Nature of the vision. And we're getting some feedback here. After the meantime, I remember very well my first surgery. And finally, I went through broker's area, but because the patient was
1:24:16
well before and because the tumor, the level of the left inferior frontal gyrus, then opening me, the door, to the insular. And I said, Finally, it's so easy to remove the insular after
1:24:29
removing the operculum. So I said, Maybe it could be possible to remove the operculum, even if there is no invasion of the operculum by the tumor. And the answer was given in these cases by the
1:24:45
cognitive assessment, because if the cognition was perfect with no fragility in some domains, that means that the brain was able to compensate optimally. So of course, you can tell me, but the
1:25:01
brain is normal at the level of the upper column in order to have a surgical approach, but if the brain compensated so much, it was really exceptionally in my life, in fact, it never happened to
1:25:15
have, for instance, in the left inferior frontal geros, a positive side at the level of the partial peculiaris, it happened of course. Also at the level of the past triangularis, it happened of
1:25:28
course sometimes in isolation and at the level of the past obitaries So finally, I was in only no cases to identify a surgical approach.
1:25:43
And sometimes, of course, a little bit reduced. But without any risk, because I wish, typically, a case like this during the next talk, speaking about insular surgery. And you will see that
1:25:57
just in 10 minutes, you arrive at the living room of the insular surface, without any risk.
1:26:06
That's fascinating. Outstanding. Really? Anybody else have any questions here?
1:26:13
I have another question for you. I'm sorry I had some technical difficulty there. You've operated on, say,
1:26:23
1400 tumors. You've seen a lot of this over 25 years. You mentioned in one of the previous sessions that when you were taking out
1:26:34
a tumor that had mixed grade two and grade three, that you found at the grade 3 area. what was not diffused throughout the tour, but was localized.
1:26:48
So the question is, one is in the growth of the tumors, we can have foci of grade two, grade three, maybe grade four.
1:26:60
And what is your thinking that you learned biologically about the behavior of the tumor from what you've seen over 25 years? It doesn't grow as a ball, is that correct?
1:27:16
Typically, you're right, I think just my hypothesis, but as you know, also I have seen some incidentaluma. For loud and aware, it happened to me a recently very diffused left insular tumor. And
1:27:32
in fact, the patient told me at the end of the consultation. But you know, I had an imagine, an
1:27:39
MRI 10 years ago. because of my head injury and I said you have it yes and they told me that it was normal and in fact I saw the start of the tumor at the level of the left apex ensilon just to tell
1:27:57
you that my hypothesis is that you have a focus maybe several for size in some high in some gliomas, but one and from this focus you have a diffusion of the tumor and at the level of this focus you
1:28:17
have an increase of the tumor sense density and you have an increase of Magdalene transformation mainly in the middle of the tumor So that means that more you have a diffusion around where you can not
1:28:33
go in all cases Especially invading the connectivity more you have a chance to see a real look regular I am not either tomorrow. of course, look regularly and initially, so IDH, metadata, and so
1:28:44
on. So if you remove the middle of the tumor, I have the habit to do samples around at the level of the ages of the cavity. Even if I know that I did not perform super-authorization and I can refer
1:29:02
these samples in isolation to the lab by telling me, please can you tell me if at this level they wear fusseive magnetic transformation or not. Or if I can do super-authorization, I try to do a
1:29:16
look back to me and to refer on the block by telling me, please can you analyze the periphery. In fact, the center of the tumor, I do not share.
1:29:29
Right, I did. Total or revolutionary concept, another one. So tremendous. And then you had another slide where you buy up seed you had patients who had been referred because they were inoperable
1:29:41
from a biopsy, a biopsy. And of those using a functional resection, you had much, much longer survivals.
1:29:52
More than 20 years to. In fact, I started to have for our daily limitation that the level of between 20 and 25 years. But I need a few more years of follow-up to demonstrate that. But yes,
1:30:04
definitely because in this paper, now in preparation, I have some patients who had a biopsy in 2025. So not 20 years ago, with in the meantime the understanding of my lectures about, okay, I met
1:30:21
the brain plasticity since the beginning of my life. And I published more than 500 papers about that. No, they continue to think that because this is in broken area. While the patient is perfect
1:30:33
before surgery, they cannot remove broken area. Well, if the patient is perfect before surgery, according to an extensive cognitive assessment, in essence, that means that the brain compensated
1:30:44
thanks to mechanism from your plasticity, and you will do a priori, at least, a subtlet or report. That's crazy. They do not want to accept that, despite more than 1, 000 of
1:30:57
patients. That's right. Now, one other thing you mentioned, I'm sorry to ask all these questions, but you stimulated me to do this When you have these people who come back and get chemotherapy or
1:31:08
radiation therapy, they lose the ability from the surrounding environment to attack
1:31:17
the tumor. Now, we don't have the proof, but my suspicion is that's right. The inflammatory response is cut back. So the natural brain, the natural body reactions are stopped. That's probably
1:31:31
why they do worse. What do you think?
1:31:35
Not completely, because I think that there is a difference between radiotherapy and chemotherapy, because radiotherapy definitely will attack the periphery and the brain itself. With now more than
1:31:50
20 years of thymosolomide, I must acknowledge that when I showed patients living more than 20 years, half of them finally had, at some point of their history, at least one adjurant treatment. And
1:32:09
if I can really postpone radiotherapy, I will do it. But chemotherapy, when you have the diffusion within the white matter tract, I have to accept it. And finally, with this fallout, they
1:32:20
continue to leave. So that means I mean in good condition. I did not see a sudden drop of the cognition after 10, 15 years Come with us later, ride your trapeze. So this is the reason why we like
1:32:35
to make a difference based on fat and long term for life between chemotherapy, attacking more directly the tumor on science, rather than radiotherapy, irrigating also the connectivity and the brain
1:32:52
itself.
1:32:55
Okay, I'll just try to do that. Are there any more questions?
1:33:00
I don't think so It was very thorough, right? So compelling, you have to wonder, why would you treat brain tumors any other way? That's right, that's right. Well, we hope, I think, oh, I'm
1:33:14
sorry, they think some, Santa, Eva left, Eva, but these all videos are posted on SI Digital. We keep sending you the blast twice a week and in there you can always tell your friends and so forth.
1:33:33
These are available to you there.
1:33:36
Okay, thank you so much. Just very provocative, outstanding work. A real neuroscientist. Thank you so much. And once again, for giving me this opportunity to deliver message and to give the
1:33:52
choice to New York Sanjans and young colleges. And after that, everyone can do what he wants, like the patients But in evidence-based medicine, the goal is to avoid, to give the choice to
1:34:04
patients, and to impose indirectly the current protocol. I am there in order to inform my showing pros, cons of each strategies.
1:34:18
And now you're coming out against Evan and toothpaste medicine. So they're really gonna attack you. The next thing to attack is randomized control trials Thank you.
1:34:29
Okay, say.
1:34:32
Yeah, but I think you was here a minute ago ever this should be these are all on video You can tell all your colleagues and friends. They can watch it and it's on s and I digital will keep sending
1:34:44
you the I did you I will keep saying the
1:34:51
Okay Okay, thank you. He was thank you, sir. Thank you. Thank you, but man Oh, boy. Oh fun. Goodbye. Okay. Thank you. Bye bye.
1:35:06
Thank you, Mike
1:35:12
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