{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T05:04:06Z","timestamp":1784696646786,"version":"3.55.0"},"reference-count":36,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,7,18]],"date-time":"2026-07-18T00:00:00Z","timestamp":1784332800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medical Sciences"],"abstract":"<jats:p>Postoperative radiotherapy (RT) improves survival in glioblastoma, and its role in standard management is not disputed. The randomized trials establishing this benefit, however, were conducted before computed tomography, magnetic resonance imaging (MRI), molecular classification, and temozolomide (TMZ), in heterogeneous populations of \u201coperated malignant glioma\u201d treated with whole-brain or large-field RT versus best supportive care. Their pooled survival benefit (risk ratio 0.81; 95% CI 0.74\u20130.88) robustly answers the historical question they were designed to address. Since then, advances in surgery, imaging, molecular diagnostics, and systemic therapy have created a modern best-prognosis subgroup\u2014young patients with excellent performance status, MRI-confirmed complete or supramaximal resection of an IDH-wildtype glioblastoma, and median survival approaching or exceeding three years\u2014for whom no clearly defined historical counterpart exists. This perspective provides a structured appraisal of the directness of the landmark randomized evidence using GRADE concepts and translates that appraisal into a graded roadmap for future de-escalation trial designs. Across population, intervention, comparator, and outcomes, the historical trials exhibit substantial indirectness, while the only randomized RT-versus-no-RT evidence from the modern era derives from elderly patients representing the opposite prognostic extreme. This is not an argument against RT. The infiltrative biology of glioblastoma, predominantly in-field recurrence, and radioresistant stem-cell populations strongly support continued benefit. Rather, the unresolved question concerns the magnitude of benefit after maximal contemporary therapy and whether selected de-escalation strategies merit prospective evaluation. Our thesis is one of collective scientific equipoise regarding an unresolved evidence question rather than individual clinician equipoise or refutation of current standard care.<\/jats:p>","DOI":"10.3390\/medsci14030404","type":"journal-article","created":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T06:09:09Z","timestamp":1784527749000},"page":"404","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["When Surgical Innovation Outpaces Evidence: Does Modern Maximal Resection Require Re-Evaluation of Postoperative Radiotherapy in Glioblastoma?"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6349-5301","authenticated-orcid":false,"given":"Tomasz","family":"Tykocki","sequence":"first","affiliation":[{"name":"Department of Paediatric Neurosurgery, Children\u2019s Hospital Named After Prof. Dr Med. Jan Bogdanowicz in Warsaw, 03-924 Warsaw, Poland"},{"name":"Faculty of Medicine, Lazarski Medical University of Warsaw, 02-662 Warsaw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1016\/S1470-2045(09)70025-7","article-title":"Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial","volume":"10","author":"Stupp","year":"2009","journal-title":"Lancet Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"987","DOI":"10.1056\/NEJMoa043330","article-title":"Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma","volume":"352","author":"Stupp","year":"2005","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1231","DOI":"10.1093\/neuonc\/noab106","article-title":"The 2021 WHO Classification of Tumors of the Central Nervous System: A summary","volume":"23","author":"Louis","year":"2021","journal-title":"Neuro-Oncology"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1016\/S0167-8140(02)00078-6","article-title":"Cancer Care Ontario Practice Guidelines Initiative Neuro-Oncology Disease Site Group. Radiotherapy for newly diagnosed malignant glioma in adults: A systematic review","volume":"64","author":"Laperriere","year":"2002","journal-title":"Radiother. Oncol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1007\/s10143-025-04081-0","article-title":"Connectome-guided glioma resection: A systematic review of white matter tract preservation and postoperative neurocognition","volume":"49","author":"Tykocki","year":"2026","journal-title":"Neurosurg. Rev."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"392","DOI":"10.1016\/S1470-2045(06)70665-9","article-title":"ALA-Glioma Study Group. Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: A randomised controlled multicentre phase III trial","volume":"7","author":"Stummer","year":"2006","journal-title":"Lancet Oncol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1016\/S0140-6736(04)17670-8","article-title":"External validity of randomised controlled trials: \u201cTo whom do the results of this trial apply?\u201d","volume":"365","author":"Rothwell","year":"2005","journal-title":"Lancet"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1303","DOI":"10.1016\/j.jclinepi.2011.04.014","article-title":"GRADE guidelines: 8. Rating the quality of evidence\u2014Indirectness","volume":"64","author":"Guyatt","year":"2011","journal-title":"J. Clin. Epidemiol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"333","DOI":"10.3171\/jns.1978.49.3.0333","article-title":"Evaluation of BCNU and\/or radiotherapy in the treatment of anaplastic gliomas: A cooperative clinical trial","volume":"49","author":"Walker","year":"1978","journal-title":"J. Neurosurg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1323","DOI":"10.1056\/NEJM198012043032303","article-title":"Randomized comparisons of radiotherapy and nitrosoureas for the treatment of malignant glioma after surgery","volume":"303","author":"Walker","year":"1980","journal-title":"N. Engl. J. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"475","DOI":"10.3109\/02841867809128178","article-title":"Postoperative irradiation of glioblastomas: Results in a randomized series","volume":"17","author":"Andersen","year":"1978","journal-title":"Acta Radiol. Oncol. Radiat. Phys. Biol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1002\/1097-0142(19810215)47:4<649::AID-CNCR2820470405>3.0.CO;2-W","article-title":"Combined modality therapy of operated astrocytomas grade III and IV. A prospective multicenter trial of the Scandinavian Glioblastoma Study Group","volume":"47","author":"Kristiansen","year":"1981","journal-title":"Cancer"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1002\/1097-0142(19910701)68:1<22::AID-CNCR2820680105>3.0.CO;2-2","article-title":"A randomized study of chemotherapy with procarbazine, vincristine, and lomustine with and without radiation therapy for astrocytoma grades 3 and\/or 4","volume":"68","year":"1991","journal-title":"Cancer"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1527","DOI":"10.1056\/NEJMoa065901","article-title":"Radiotherapy for glioblastoma in the elderly","volume":"356","author":"Chinot","year":"2007","journal-title":"N. Engl. J. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"719","DOI":"10.1007\/s10654-019-00533-2","article-title":"Extending inferences from a randomized trial to a target population","volume":"34","author":"Dahabreh","year":"2019","journal-title":"Eur. J. Epidemiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1097\/EDE.0b013e3181ba333c","article-title":"On the distinction between interaction and effect modification","volume":"20","author":"VanderWeele","year":"2009","journal-title":"Epidemiology"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1186\/1745-6215-11-85","article-title":"Assessing and reporting heterogeneity in treatment effects in clinical trials: A proposal","volume":"11","author":"Kent","year":"2010","journal-title":"Trials"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1001\/jama.2013.285063","article-title":"How to use a subgroup analysis: Users\u2019 guide to the medical literature","volume":"311","author":"Sun","year":"2014","journal-title":"JAMA"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1019","DOI":"10.1200\/JCO.19.02767","article-title":"Hippocampal avoidance during whole-brain radiotherapy plus memantine for patients with brain metastases: Phase III trial NRG Oncology CC001","volume":"38","author":"Brown","year":"2020","journal-title":"J. Clin. Oncol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1027","DOI":"10.1056\/NEJMoa1611977","article-title":"Short-course radiation plus temozolomide in elderly patients with glioblastoma","volume":"376","author":"Perry","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1106","DOI":"10.1136\/bmj.39500.677199.AE","article-title":"Grading quality of evidence and strength of recommendations for diagnostic tests and strategies","volume":"336","author":"Oxman","year":"2008","journal-title":"BMJ"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"190","DOI":"10.3171\/jns.2001.95.2.0190","article-title":"A multivariate analysis of 416 patients with glioblastoma multiforme: Prognosis, extent of resection, and survival","volume":"95","author":"Lacroix","year":"2001","journal-title":"J. Neurosurg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"940","DOI":"10.1093\/neuonc\/noac193","article-title":"Prognostic validation of a new classification system for extent of resection in glioblastoma: A report of the RANO resect group","volume":"25","author":"Karschnia","year":"2023","journal-title":"Neuro-Oncology"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1007\/s11060-025-04950-0","article-title":"Prognostic revalidation of RANO categories for extent of resection in glioblastoma: A reconstruction of individual patient data","volume":"172","author":"Wach","year":"2025","journal-title":"J. Neurooncol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"997","DOI":"10.1056\/NEJMoa043331","article-title":"MGMT gene silencing and benefit from temozolomide in glioblastoma","volume":"352","author":"Hegi","year":"2005","journal-title":"N. Engl. J. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e315","DOI":"10.1016\/S1470-2045(17)30194-8","article-title":"European Association for Neuro-Oncology (EANO) guideline on the diagnosis and treatment of adult astrocytic and oligodendroglial gliomas","volume":"18","author":"Weller","year":"2017","journal-title":"Lancet Oncol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"916","DOI":"10.1016\/S1470-2045(12)70265-6","article-title":"Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: The Nordic randomised, phase 3 trial","volume":"13","author":"Marosi","year":"2012","journal-title":"Lancet Oncol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e770","DOI":"10.1259\/bjr\/83827377","article-title":"Hypofractionated radiotherapy for glioblastoma: Strategy for poor-risk patients or hope for the future? Br","volume":"85","author":"Hingorani","year":"2012","journal-title":"J. Radiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"109663","DOI":"10.1016\/j.radonc.2023.109663","article-title":"ESTRO-EANO guideline on target delineation and radiotherapy details for glioblastoma","volume":"184","author":"Niyazi","year":"2023","journal-title":"Radiother. Oncol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"758","DOI":"10.1093\/aje\/kwv254","article-title":"Using Big Data to Emulate a Target Trial When a Randomized Trial Is Not Available","volume":"183","author":"Robins","year":"2016","journal-title":"Am. J. Epidemiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"865","DOI":"10.3171\/jns.1987.66.6.0865","article-title":"Imaging-based stereotaxic serial biopsies in untreated intracranial glial neoplasms","volume":"66","author":"Kelly","year":"1987","journal-title":"J. Neurosurg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1275","DOI":"10.1200\/JCO.2008.19.4969","article-title":"Recurrence pattern after temozolomide concomitant with and adjuvant to radiotherapy in newly diagnosed patients with glioblastoma: Correlation with MGMT promoter methylation status","volume":"27","author":"Brandes","year":"2009","journal-title":"J. Clin. Oncol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"756","DOI":"10.1038\/nature05236","article-title":"Glioma stem cells promote radioresistance by preferential activation of the DNA damage response","volume":"444","author":"Bao","year":"2006","journal-title":"Nature"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1016\/j.prro.2016.03.007","article-title":"Radiation therapy for glioblastoma: Executive summary of an American Society for Radiation Oncology Evidence-Based Clinical Practice Guideline","volume":"6","author":"Cabrera","year":"2016","journal-title":"Pract. Radiat. Oncol."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Watanabe, S., Nonaka, T., Yamada, M., Maeda, M., Sugii, N., Arakawa, Y., Hashimoto, K., and Ishikawa, E. (2026). Efficacy Endpoint Standardization in Adult Primary CNS Tumor Trials: Integrating Regulatory Science and Clinical Perspectives in the RANO 2.0 Era. Cancers, 18.","DOI":"10.3390\/cancers18121872"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1016\/j.semradonc.2014.02.004","article-title":"Clinical applications for diffusion magnetic resonance imaging in radiotherapy","volume":"24","author":"Tsien","year":"2014","journal-title":"Semin. Radiat. Oncol."}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/3\/404\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T04:24:00Z","timestamp":1784694240000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/3\/404"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,18]]},"references-count":36,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["medsci14030404"],"URL":"https:\/\/doi.org\/10.3390\/medsci14030404","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,18]]}}}