OBJECTIVE Laser interstitial thermal therapy (LITT), sometimes referred to as 
"stereotactic laser ablation," has demonstrated utility in a subset of high-risk 
surgical patients with difficult to access (DTA) intracranial neoplasms. 
However, the treatment of tumors larger than 10 cm3 is associated with 
suboptimal outcomes and morbidity. This may limit the utility of LITT in dealing 
with precisely those large or deep tumors that are most difficult to treat with 
conventional approaches. Recently, several groups have reported on minimally 
invasive transsulcal approaches utilizing tubular retracting systems. However, 
these approaches have been primarily used for intraventricular or 
paraventricular lesions, and subtotal resections have been reported for 
intraparenchymal lesions. Here, the authors describe a combined approach of LITT 
followed by minimally invasive transsulcal resection for large and DTA tumors. 
METHODS The authors retrospectively reviewed the results of LITT immediately 
followed by minimally invasive, transsulcal, transportal resection in 10 
consecutive patients with unilateral, DTA malignant tumors > 10 cm3. The 
patients, 5 males and 5 females, had a median age of 65 years. Eight patients 
had glioblastoma multiforme (GBM), 1 had a previously treated GBM with radiation 
necrosis, and 1 had a melanoma brain metastasis. The median tumor volume treated 
was 38.0 cm3. RESULTS The median tumor volume treated to the yellow thermal dose 
threshold (TDT) line was 83% (range 76%-92%), the median tumor volume treated to 
the blue TDT line was 73% (range 60%-87%), and the median extent of resection 
was 93% (range 84%-100%). Two patients suffered mild postoperative neurological 
deficits, one transiently. Four patients have died since this analysis and 6 
remain alive. Median progression-free survival was 280 days, and median overall 
survival was 482 days. CONCLUSIONS Laser interstitial thermal therapy followed 
by minimally invasive transsulcal resection, reported here for the first time, 
is a novel option for patients with large, DTA, malignant brain neoplasms. There 
were no unexpected neurological complications in this series, and operative 
characteristics improved as surgeon experience increased. Further studies are 
needed to elucidate any differences in survival or quality of life metrics.