After Glioma Surgery: Decision Making and the Tumor Board

SurvivorNet discussed the importance of a multidisciplinary approach with Dr Jacob Young, a Neurosurgeon focused on glioma surgery at the University of California San Francisco.

First 48 Hours: The Scan That Sets The Stage

“We always get an MRI scan within two days of surgery so we can evaluate what’s been removed, what’s remaining, if there’s anything that we need to keep an eye on moving forward,” Dr. Young says.

This early MRI becomes your new baseline. It shows:

• Extent of resection: how much visible tumor was removed.
• Residual changes: expected postoperative swelling or small areas to watch.
• Targets for next steps: if anything looks worrisome or needs closer follow-up.

This post-operative MRI provides clarity and a new baseline brain image.  You and your team need a clean, post-op starting point to measure future scans against and to choose the safest plan.

What exactly is a tumor board?

Think of the tumor board as a round-table for your case. It’s a protected time when specialists look at your scans, your surgery, your pathology slides, and your day-to-day function and decide together what’s best.

“Patients get discussed at a multidisciplinary tumor board where it’s more than just neurosurgery. It’s neuro-oncology, radiation oncology, neuroradiology, pathology, neurosurgery… That’s where a comprehensive assessment of how the patient is doing. Their neurological exam, performance status, support team, where they live, and how feasible it is to come for certain treatments. And that’s where a treatment plan is designed,” Dr. Young explains.

Key points about tumor boards:

• Multidisciplinary means your plan isn’t built by one person’s opinion.
• Consensus-driven means disagreements are hashed out by evidence and safety.
• Patient-centered means your goals and realities (work, family, travel, support) are factored in — not just the biology.

Plain-language definition:

Tumor board: it’s a formal meeting of your brain tumor specialists (surgeons, neuro-oncologists, radiation oncologists, radiologists, pathologists, and others). They review your case together and agree on next steps. It adds a layer of safety and quality control to your care.

Pathology and genetics: why your final diagnosis takes time

You may hear about a “frozen section” during surgery: a quick, on-the-spot look at tissue to make sure surgeons are on the right track. But the definitive diagnosis requires more work.

“We get a snapshot… It’s called a frozen diagnosis. [During surgery] we send a sample, the pathologist look at it under the microscope and they give us their initial impression.”  – says Dr Young.

“We then get a series of stains and more comprehensive assessments from the neuropathologist, which takes anywhere from one to two weeks to come back. [And we also need] the genetics, which every institution does slightly differently. But it’s often a next generation sequencing panel of the most common mutations that are seen in cancers. That can take two to three weeks to come back, at least at our institution. So we’re getting more and more information as time goes on and we update their diagnosis and the treatment plan as that information is coming in.”

Understanding IDH: The Game-Changing Mutation

One of the most critical pieces of the molecular puzzle is the IDH (isocitrate dehydrogenase) gene. Gliomas are generally split into two main groups based on IDH status:

IDH-Mutant Gliomas

• Tend to occur in younger patients
• Often have a better prognosis and respond well to treatment
• Classified as WHO grade 2, 3, or 4 – yet even within the higher grades, the mutant status often signals a more controlled course

IDH-Wild Type Gliomas

• Often more aggressive, with a higher tendency to behave like glioblastomas (WHO grade 4)
• Usually found in older patients
• Require intensive and multi-modal treatment strategies such as surgery, radiation, and chemotherapy

Identifying your tumor’s IDH status is a crucial first step in deciding what comes next for your care.

This classification is a must when evaluating newly diagnosed patients with glioma because it supports and guides the tumor’s grading, which is closely related to the aggressiveness of the cancer.

“The goal is to try to get a consensus, because these are very complicated treatments that often involve multiple types of providers. Whether it’s surgeons plus radiation, oncologists plus neuro oncologists. Even imaging interpretation gets somewhat tricky, particularly as patients go through more and more lines of therapy” – adds Dr Young.

Vorasidenib: an option for IDH1 or IDH2 mutation

“We have this really exciting new agent, an IDH inhibitor that’s been FDA approved for the IDH mutant tumors, which is incredible.” – sayr Dr Young. “It gives us a new tool in our arsenal against these tumors”.

Vorasidenib is a targeted approach, and may help patients avoid the harsh side effects associated with chemotherapy and radiation. However, there are limitations.

Vorasidenib (brand name Voranigo) is a medication specifically designed for patients whose gliomas have mutations in the IDH1 or IDH2 genes. Instead of using broad methods to kill cancer cells (as chemotherapy or radiation might), Vorasidenib zeroes in on the mutated enzymes driving the tumor’s growth.

A major study called the INDIGO trial looked at Vorasidenib’s effectiveness in patients with IDH-mutant low grade gliomas and found:

• Patients taking Vorasidenib had a 61% reduced risk of disease progression or death compared to those on a placebo.
• They also had a 74% reduced risk of needing a “next intervention” (like radiation or chemotherapy).

In plain-language, this targeted approach can potentially:

• Slow tumor progression
• Delay the need for more invasive treatments such as radiation or chemotherapy

Because it’s an oral medication, Vorasidenib also offers a more convenient form of therapy compared to intravenous infusions.

However, there are issues with it. Experts told SurvivorNet that this medication might not be an option for patients who have already had some other treatment like radiation or chemotherapy.

“Now we have a more nuanced understanding of the genetics of these tumors and we have the IDH inhibitors. It’s become a bit more nuanced. Which treatment makes the most sense? Should you go with surveillance imaging to see if [there] are anything changes? Should you consider starting the IDH inhibitor in the postoperative setting? Or should you still consider radiation in chemotherapy? That’s a conversation that happens between the neurooncologist and the patient and they come to a decision sort of on an individual basis.” –  explains Dr Young.

“[Vorasidenib] Most commonly it’s used at the time of progression from a low grade tumor that had surgery and then starts to change or evolve. But there’s also the opportunity to use it right away after surgery, particularly for the astrocytomas, which we think of as being slightly more aggressive than the oligodendroglioma variety.”

“But all these questions remain. How long should the patient stay on it? How can we tell how quickly they’re going to respond or not respond? Are there resistance mechanisms that emerge if you’re on it for long periods of time? These are all questions we’re excited to answer and currently looking into.”

You are not alone

Post-surgery, it’s normal to feel impatient for answers. It’s also normal to be hopeful. Both are appropriate. The system is designed to protect you: a fresh MRI, meticulous pathology, careful genetic testing, and a tumor board whose only job is to get your plan right.

As Dr. Young puts it, the aim is not only to treat the tumor — it’s to protect you: “We want people to be able to return to work… have the same personality and memory and executive functioning… and that’s our goal.”

At SurvivorNet, we’re here to walk this with you: to translate the medical language, highlight the decisions that matter, and remind you that your voice belongs in every meeting about your care.

Ask questions. Bring your priorities. Lean on your team.

There is a path forward, and you do not have to travel it alone.

Learn more about SurvivorNet's rigorous medical review process.

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