Category: Oncology

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Surgical results of an endoscopic endonasal approach for clival chordomas

Acta Neurochir (2012) 154:879–886. DOI 10.1007/s00701-012-1317-1

The surgical approaches for clival chordomas remain controversial, although the extent of resection is one of the most important factors for long survival rates. Recently an endoscopic endonasal approach in good collaboration with otolaryngologists has attracted major attention as a surgical approach for clival chordomas. We describe our experience with the endoscopic endonasal approach and provide a review of the literature.

Methods Between 2008 and 2011, six operations were performed via the endoscopic endonasal approach for clivus chordomas. The mean tumor size was 35 mm in diameter. The tumor location was mainly from the upper to middle clivus. The tumor extended into the cavernous sinus in five cases and intradurally in three cases. A binostril approach was performed in four cases, while a one nostril approach was performed in two cases.

Results Gross total removal was achieved in three cases. The analysis of cases with incomplete resection suggested that residual tumors were observed epidurally and subdurally. The residual on the epidura was observed from the posterior clinoid to the posterior compartment of the cavernous sinus. On the other hand, the residual on the subdural was observed behind the upper part of the pituitary gland. There was no postoperative cerebrospinal fluid (CSF) leakage using vascularized nasoseptal flaps in any of the cases.

Conclusions The endoscopic endonasal transclival approach allows an appropriate extent of resection with acceptable complication rates in comparison with other approaches. In our series, the accomplishment of gross total removal was associated with the relationship between the tumors and surrounding structures, such as the pituitary gland and the cavernous portion of the intracranial carotid artery (ICA).

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Predictive Value and Safety of Intraoperative Neurophysiological Monitoring With Motor Evoked Potentials in Glioma Surgery

Neurosurgery 70:1060–1071, 2012 DOI: 10.1227/NEU.0b013e31823f5ade

Resection of gliomas in or adjacent to the motor system is widely performed with intraoperative neuromonitoring (IOM). Despite the fact that data on the safety of IOM are available, the significance and predictive value of the procedure are still under discussion. Moreover, cases of false-negative monitoring affect the surgeon’s confidence in IOM.

OBJECTIVE: To examine cases of false-negative IOM to reveal structural explanations.

METHODS: Between 2007 and 2010, we resected 115 consecutive supratentorial gliomas in or close to eloquent motor areas using direct cortical stimulation for monitoring of motor evoked potentials (MEPs). The monitoring data were reviewed and related to new postoperative motor deficit and postoperative imaging. Clinical outcomes were assessed during follow-up.

RESULTS: Monitoring of MEPs was successful in 112 cases (97.4%). Postoperatively, 30.3% of patients had a new motor deficit, which remained permanent in 12.5%. Progression- free follow-up was 9.7 months (range, 2 weeks-40.6 months). In 65.2% of all cases, MEPs were stable throughout the operation, but 8.9% showed a new temporary motor deficit, whereas 4.5% (5 patients) presented with permanently deteriorated motor function representing false-negative monitoring at first glance. However, these cases were caused by secondary hemorrhage, ischemia, or resection of the supplementary motor area.

CONCLUSION: Continuous MEP monitoring provides reliable monitoring of the motor system, influences the course of operation in some cases, and has to be regarded as the standard for IOM of the motor system. In our series, we found no false-negative MEP results.

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Staged resection of large vestibular schwannomas

J Neurosurg 116:1126–1133, 2012.(http://thejns.org/doi/abs/10.3171/2012.1.JNS111402)

Staged resection of large vestibular schwannomas (VSs) has been proposed as a strategy to improve facial nerve outcomes and morbidity. The authors report their experience with 2-stage resections of large VSs and analyze the indications, facial nerve outcomes, surgical results, and complications. The authors compare these results with those of a similar cohort of patients who underwent a single-stage resection.

Methods. A retrospective review of all patients (age > 18 years) who underwent surgery from 2002 to 2010 for large (≥ 3 cm) VSs at the authors’ institution with a minimum of 6 months follow-up was undertaken. A first-stage retrosigmoid approach (without meatal drilling) was performed to remove the cerebellopontine angle portion of the tumor and to decompress the brainstem. A decision to stage the operation was made intraoperatively if there was cerebellar or brainstem edema, excessive tumor adherence to the facial nerve or brainstem, a poorly stimulating facial nerve, or a thinned or splayed facial nerve. A second-stage translabyrinthine approach was performed at a later date to remove the remaining tumor. The single-stage resection consisted of a retrosigmoid approach with meatal drilling. Patient charts were evaluated for tumor size, extent of resection, tumor recurrence, House-Brackmann facial nerve function grade, and complications.

Results. Twenty-eight and 19 patients underwent 2- or single-stage resection of a large VS, respectively. The average tumor size was 3.9 cm (range 3.2–7 cm) in the 2-stage group and 3.9 cm (range 3.1–5 cm) in the single-stage group. The mean follow-up was 36 ± 19 months in the 2-stage group versus 24 ± 14 months in the single-stage group. Gross-total or near-total resection was achieved in 27 (96.4%) of 28 patients in the 2-stage group and 15 (79%) of 19 patients in the single-stage group (p < 0.01). Anatomical facial nerve preservation was achieved in all but 1 patient (94.7%), and there were no recurrences on follow-up imaging in the 2-stage group. Good facial nerve functional outcome (House-Brackmann Grades I and II) at last follow-up was achieved in 23 (82%) of 28 patients in the 2-stage group and 10 (53%) of 19 patients in the single-stage group (p < 0.01). Cerebrospinal fluid leak–related complications (intracranial hypotension, blood patch, and lumboperitoneal shunt for pseudomeningocele) were more common in the 2-stage group. There were no postoperative strokes, hemorrhages, or deaths in either group.

Conclusions. The authors’ results suggest that staged resection of large VSs may potentially achieve better facial nerve outcomes. There does not appear to be added neurological morbidity with staged resections

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Influence of Navigated Transcranial Magnetic Stimulation on Surgical Planning for Tumors in or Near the Motor Cortex

Neurosurgery 70:1248–1257, 2012 DOI: 10.1227/NEU.0b013e318243881e 

Brain tumor surgery near the motor cortex requires careful planning to achieve the optimal balance between completeness of tumor resection and preservation of motor function. Navigated transcranial magnetic stimulation (nTMS) can be used to map functionally essential motor areas preoperatively.

OBJECTIVE: To evaluate how much influence, benefit, and impact nTMS has on the surgical planning for tumors near the motor cortex.

METHODS: This study reviewed the records of 73 patients with brain tumors in or near the motor cortex, mapped preoperatively with nTMS. The surgical team prospectively classified how much influence the nTMS results had on the surgical planning. Stepwise regression analysis was used to explore which factors predict the amount of influence, benefit, and impact nTMS has on the surgical planning.

RESULTS: The influence of nTMS on the surgical planning was as follows: it confirmed the expected anatomy in 22% of patients, added knowledge that was not used in 23%, added awareness of high-risk areas in 27%, modified the approach in 16%, changed the planned extent of resection in 8%, and changed the surgical indication in 3%.

CONCLUSION: nTMS had an objective benefit on the surgical planning in one fourth of the patients and a subjective benefit in an additional half of the patients. It had an impact on the surgery itself in just more than half of the patients. By mapping the spatial relationship between the tumor and functional motor cortex, nTMS improves surgical planning for tumors in or near the motor cortex.

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Surgery of Insular Nonenhancing Gliomas: Volumetric Analysis of Tumoral Resection, Clinical Outcome, and Survival in a Consecutive Series of 66 Cases

Neurosurgery 70:1081–1094, 2012.  DOI: 10.1227/NEU.0b013e31823f5be5

Despite intraoperative technical improvements, the insula remains a challenging area for surgery because of its critical relationships with vascular and neurophysiological functional structures.
OBJECTIVE: To retrospectively investigate the morbidity profile in insular nonenhancing gliomas, with special emphasis on volumetric analysis of tumoral resection.

METHODS: From 2000 to 2010, 66 patients underwent surgery. All surgical procedures were conducted under cortical-subcortical stimulation and neurophysiological monitor- ing. Volumetric scan analysis was applied on T2-weighted magnetic resonance images (MRIs) to establish preoperative and postoperative tumoral volume.

RESULTS: The median preoperative tumor volume was 108 cm3. The median extent of resection was 80%. The median follow-up was 4.3 years. An immediate postoperative worsening was detected in 33.4% of cases; a definitive worsening resulted in 6% of cases. Patients with extent of resection of . 90% had an estimated 5-year overall survival rate of 92%, whereas those with extent of resection between 70% and 90% had a 5-year overall survival rate of 82% (P , .001). The difference between preoperative tumoral volumes on T2-weighted MRI and on postcontrast T1-weighted MRI ([T2 2 T1] MRI volume) was computed to evaluate the role of the diffusive tumoral growing pattern on overall survival. Patients with preoperative volumetric difference , 30 cm3 demonstrated a 5-year overall survival rate of 92%, whereas those with a difference of . 30 cm3 had a 5-year overall survival rate of 57% (P = .02).

CONCLUSION: With intraoperative cortico-subcortical mapping and neurophysiologi- cal monitoring, a major resection is possible with an acceptable risk and a significant result in the follow-up.

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Intradural spinal metastases: a surgical series of 15 patients

Acta Neurochir (2012) 154:871–877. DOI 10.1007/s00701-012-1313-5

Intradural spinal metastases are rare, and little is known regarding surgical indications and outcomes.

Methods A retrospective search identified adults with intradural spinal metastases operated on at the Mayo Clinic from 1994-2011. Data were collected regarding demographics, tumor type and location, and outcomes.

Results Fifteen patients with intradural spinal metastases were investigated. The age range was 38-74 years (mean= 55 years; ±SD=11.1). Predominant tumor location and type were lumbosacral and adenocarcinoma, respectively: 3 intramedullary and 12 extramedullary. Patients were operated on to relieve or prevent progressive/intractable neurological sequelae and/or pain. Of 13 who underwent resection, gross total removal was reported in 10; simple biopsy was performed in 2. There was one surgical complication, no medical complications, and no surgical mortality. At median follow-up of 1 month postoperatively, 10 of 15 patients were stable or improved. Of 13 patients who underwent resection, 10 were stable or improved. Of two patients who underwent biopsy, neither was stable or improved at follow-up. Using the Modified McCormick Scale, 11 of 15 patients were “functional” preoperatively and 4 went from “functional” preoperatively to “non-functional” postoperatively. Three of those four died within 60 days of surgery from systemic disease progression. Median hospital stay was 8 days. Ten of 15 patients died by the end of the study period, and the median survival of 15 patients was 5 months.

Conclusions With improved outcomes in metastatic cancer, more patients are encountered in practice. An aggressive surgical approach is warranted for extramedullary lesions, whereas caution is advised for intramedullary lesions. Postoperative functional decline is more likely due to systemic disease progression rather than surgery.

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Jugular foramen paragangliomas: management, outcome and avoidance of complications in a series of 75 cases

Neurosurg Rev (2012) 35:185–194. DOI 10.1007/s10143-011-0346-1

Jugular foramen paragangliomas are rare skull base tumours posing multiple complex diagnostic and management problems. We did a study to evaluate surgical technique, outcome and complications in 75 cases of tumours treated by multidisciplinary approach (i.e. combined neurosurgery, neuroradiology, ear, nose and throat surgery and intensive care unit team).
Methods: Retrospective study on 75 consecutive patients with jugular foramen paragangliomas treated surgically from 1989 to 2005. Preoperative balloon occlusion test was performed in all patients as well as embolization (100%). A combined limited infratemporal and juxtacondylar approach was used in all patients.
Results: Gross total resection was achieved in 59 patients (78.7%). The most common complication was represented by lower cranial nerve deficits in five patients (6.6%), which was only temporary in three. Postoperative facial nerve weakness occurred in five cases (6.6%) and resolved in three of them. The remaining two patients underwent facial nerve reconstruction by hypoglossal/facial nerve anastomosis. Four patients (5.3%) had a postoperative cerebrospinal fluid leak, which was successfully treated by lumbar drainage. Two patients (2.7%) died because of complications related to surgical injury of lower cranial nerves: one patient developed aspiration pneumonia and septicemia and the second one developed a large cervicobulbar hematoma that led to severe respiratory distress and ultimately global cerebral hypoxia.
Conclusion: Paragangliomas are rare and complex skull base lesions that may be managed with low morbidity and mortality if a multidisciplinary approach is considered. Facial and lower cranial nerve postoperative deficits can be limited.

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Awake surgery for incidental WHO grade II gliomas involving eloquent areas

Acta Neurochir (2012) 154:575–584.DOI 10.1007/s00701-011-1216-x
WHO grade II glioma (G2G) is a premalignant tumor, usually revealed by seizures in young patients living normal lives. G2G grows constantly and will inevitably become anaplastic. Surgical resection significantly increases the overall survival by delaying malignant transformation. Recently, a similar natural history was demonstrated in a patient with incidental G2G, with continuous growth and risk of anaplasia. Here, the aim was to study for the first time the functional results and extent of resection in a prospective series of patients who underwent resection for incidental G2G within eloquent areas.
Method G2G involving functional regions in the left dominant hemisphere was incidentally diagnosed in 11 asymptomatic patients. Resection was achieved in all cases after demonstration of a volumetric increase on serial MRIs. Intraoperative awake mapping was performed in the 11 patients.
Findings There were no cases of mortality or permanent postoperative deficit. A subtotal, total or even “supratotal” resection was achieved in the 11 cases, with no partial resections. All patients resumed normal social and professional lives, with no seizures (KPS 100). Due to slow tumor re-growth in three patients with subtotal resection, adjuvant chemotherapy was administrated in two cases and radiotherapy in one. With a mean follow-up of 40 months since surgery, there was no anaplastic transformation.
Conclusion These results show that surgery can be considered in incidental G2G, even in critical areas, with a minimal risk and optimal resection, thanks to intraoperative mapping. Such findings raise the question of an early detection.

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Preoperative identification of the facial nerve in patients with large cerebellopontine angle tumors using high-density diffusion tensor imaging


 

J Neurosurg 116:697–702, 2012. http://thejns.org/doi/abs/10.3171/2011.12.JNS111404

Facial nerve paresis can be a devastating complication following resection of large (> 2.5 cm) cerebellopontine angle (CPA) tumors. The authors have developed and used a new high-density diffusion tensor imaging (HD-DT imaging) method, aimed at preoperatively identifying the location and course of the facial nerve in relation to large CPA tumors. Their study objective was to preoperatively identify the facial nerve in patients with large CPA tumors and compare their HD-DT imaging method with a traditional standard DT imaging method and correlate with intraoperative findings.

Methods. The authors prospectively studied 5 patients with large (> 2.5 cm) CPA tumors. All patients underwent preoperative traditional standard- and HD-DT imaging. Imaging results were correlated with intraoperative findings.

Results. Utilizing their HD-DT imaging method, the authors positively identified the location and course of the facial nerve in all patients. In contrast, using a standard DT imaging method, the authors were unable to identify the facial nerve in 4 of the 5 patients.

Conclusions. The HD-DT imaging method that the authors describe and use has proven to be a powerful, accurate, and rapid method for preoperatively identifying the facial nerve in relation to large CPA tumors. Routine integration of HD-DT imaging in preoperative planning for CPA tumor resection could lead to improved facial nerve preservation.

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5-Aminolevulinic acid-induced protoporphyrin IX fluorescence as immediate intraoperative indicator to improve the safety of malignant or high-grade brain tumor diagnosis in frameless stereotactic biopsies

Acta Neurochir (2012) 154:585–588. DOI 10.1007/s00701-012-1290-8

Frameless stereotactic biopsies are replacing frame-based stereotaxy as a diagnostic approach to brain lesions. In order to avoid a sampling bias or negative histology, multiple specimens are often taken. This in turn increases the risk of hemorrhagic complications.

Objective We present the use of 5-aminolevulinic acid (5- ALA)-induced protoporphyrin IX fluorescence in frameless stereotaxy to improve the procedure duration and yield, and thereby reduce the risk of complications.

Methods Patients with suspected high-grade brain tumors are given 5-ALA 4 h prior to stereotactic biopsy. The biopsy needle is guided to the target using frameless stereotaxy based either on preoperative images or combined with intraoperative MRI sequences. The specimen is illuminated with blue light to look for fluorescence. In case of a positive fluorescence within the tissue sample, no frozen sections are obtained, and no further specimens are taken.

Results The samples of 13 patients revealed a positive fluorescence and were histologically confirmed as malignant or high-grade brain neoplasms. four cases were fluorescence-negative, requiring frozen section confirmation and/or multiple samples. In theses cases histology was either nonspecific gliotic changes or low-grade tumors. There were no complications related to the additional use of 5-ALA.

Conclusion 5-ALA fluorescence in stereotactic biopsies can increase the safety and accuracy of these procedures by reducing sampling errors and eliminating the need for multiple samples and/or frozen section verification, creating a more accurate, faster and safer procedure for cases of suspected malignant or high-grade brain tumors situated in deep or eloquent areas.

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Restorative neurosurgery of the cortex: resections of pathologies of the central area can improve preexisting motor deficits

Neurosurg Rev (2012) 35:277–286. DOI 10.1007/s10143-011-0361-2

Different pathologies such as tumors or focal dysplasias can be removed from eloquent areas without subsequent functional deficits. What has not yet been established is the removal of structural abnormalities in sensorimotor area associated with substantial neurological deficits performed in order to accomplish functional improvement. Neurosurgical resections in highly eloquent areas thus hold promise to open a new field achievement of functional restitution even in cases with long-standing deficits.

We present four exemplary cases where the removal of different structural abnormalities led to an impressive improvement of motor deficits. One patient had bilateral ischemic lesion resulting from perinatal hypoxia, one cavernoma, and two focal cortical dysplasias. All presented with motor or sensorimotor deficits and three had long-standing therapy refractory focal seizures. The extent of safe lesionectomy was determined using fMRI, fiber tracking, and PET studies and performed with intraoperative functional neuronavigation guidance and cortical stimulation. The achievement of the planned amount of resection was verified with an intraoperative MR examination.

New persisting neurological deficits after surgery were not registered. One patient had temporary worsening of the right hand weakness that rapidly resolved. One patient was completely seizure free, and in two patients, the seizures’ frequency, duration, and severity were significantly reduced. The preoperatively disturbed motor function improved in all four cases in the course of days or weeks.

In summary, pathological processes affecting the sensorimotor area may cause focal seizures and/or compromise sensorimotor functions. Lesionectomy may accomplish not only the amelioration of focal seizures but also substantial functional improvement.

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En Bloc Resection of Sacral Chordomas Aided by Frameless Stereotactic Image Guidance

Neurosurgery 70[ONS Suppl 1]:ons82–ons88, 2012 DOI: 10.1227/NEU.0b013e31822dd958 

The most important predictor of survival for patients with sacral chordomas is an initial en bloc resection with negative margins. However, obtaining negative margins can be technically challenging. Intraoperative navigation may be helpful in attempting an excision with negative margins.

OBJECTIVE: This is the first report of partial sacrectomy guided by frameless stereotactic navigation.

METHODS: Three patients with a mean age of 58.7 years underwent en bloc resection of sacral chordomas aided by image guidance. Intraoperatively, the reference arc was clamped to the spinous process of L5 and the bony landmarks of S1 were used for registration. Subsequently, the drill was registered, allowing the osteotomy trajectory to be visualized in real time with reference to the patients’ anatomy and tumor location.

RESULTS: None of the patients had any intraoperative or postoperative complications. Two patients with smaller tumors (5 cm) had negative margins, whereas the third patient with an 11.5 cm tumor had marginal margins. With an average follow-up of 44 months, none of the patients have had a recurrence of the tumor.

CONCLUSION: The use of frameless stereotaxy during the en bloc resection of sacral tumors is safe and feasible. Frameless stereotactic navigation was a useful adjunct to preoperative imaging and to the surgeon’s anatomic knowledge. Image guidance was used during the osteotomies to decrease the likelihood of injury to vital adjacent structures or violation of the tumor capsule and to increase the likelihood that the appropriate surrounding tissue was resected to attempt a wide or marginal resection.


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Electromagnetic Image-Guided Biopsy of Cerebral Lesions

Neurosurgery 70[ONS Suppl 1]:ons29–ons33, 2012 DOI: 10.1227/NEU.0b013e31822d75af

In recent years, frameless navigation techniques have been reported to be safe and effective for biopsy of cerebral lesions.

OBJECTIVE: To evaluate the safety and efficacy of a technique of frameless, pinless electromagnetic-guided biopsy for brain lesions with the Medtronic Stealth AxiEM.

METHODS: Prospective data were collected on consecutive brain biopsies performed by a single surgeon (P.L.G.) with this technology between October 2007 and May 2010. One trajectory was made per lesion with multiple specimens taken for analysis. Outcome measures included measures of accuracy, histological yield, and complication rate.

RESULTS: A total of 150 biopsies were performed in 149 patients (84 male and 65 female patients; age range, 19.8-83.8 years). The consultant performed 49 procedures, supervising a trainee in the others. In only 1 case (0.7%) was there nondiagnosis consequent of a registration error and inaccurate trajectory. In 4 other cases (2.7%), no specific diagnosis was established, but abnormal tissue was identified histologically, and postoperative imaging confirmed accurate targeting of these lesions. There were no instances of intracranial hemorrhage or significant morbidity and no deaths directly attributable to the procedure. Four patients (2.7%) died within 30 days of the procedure but not of complications of surgery. One patient suffered a transitory neurological deficit.

CONCLUSION: Electromagnetic navigation is proven to be a simple, safe, and effective innovation for frameless and pinless biopsy of cerebral lesions. This technique is time efficient, and elimination of frame placement enhances patient comfort and facilitates the use of local anesthetic technique.

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Natural history and surgical management of incidentally discovered low-grade gliomas

J Neurosurg 116:365–372, 2012. DOI: 10.3171/2011.9.JNS111068

Low-grade gliomas (LGGs) are rarely diagnosed as an incidental, asymptomatic finding, and it is not known how the early surgical management of these tumors might affect outcome. The purpose of this study was to compare the outcomes of patients with incidental and symptomatic LGGs and determine any prognostic factors associated with those outcomes.

Methods. All patients treated by the lead author for an LGG incidentally discovered between 1999 and 2010 were retrospectively reviewed. “Incidental” was defined as a finding on imaging that was obtained for a reason not attributable to the glioma, such as trauma or headache. Primary outcomes included overall survival, progression-free survival (PFS), and malignant PFS. Patients with incidental LGGs were compared with a previously reported cohort of patients with symptomatic gliomas.

Results. Thirty-five patients with incidental LGGs were identified. The most common reasons for head imaging were headache not associated with mass effect (31.4%) and trauma (20%). Patients with incidental lesions had significantly lower preoperative tumor volumes than those with symptomatic lesions (20.2 vs 53.9 cm3, p < 0.001), were less likely to have tumors in eloquent locations (14.3% vs 61.9%, p < 0.001), and had a higher prevalence of females (57.1% vs 36%, p = 0.02). In addition, patients with incidental lesions were also more likely to undergo gross-total resection (60% vs 31.5%, p = 0.001) and had improved overall survival on Kaplan-Meier analysis (p = 0.039, Mantel-Cox test). Progression and malignant progression rates did not differ between the 2 groups. Univariate analysis identified pre- and postoperative volumes as well as the use of motor or language mapping as significant prognostic factors for PFS.

Conclusions. In this retrospective cohort of surgically managed LGGs, incidentally discovered lesions were associated with improved patient survival as compared with symptomatic LGGs, with acceptable surgical risks.

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Results after treatment of craniopharyngiomas: further experiences with 73 patients since 1997

J Neurosurg 116:373–384, 2012. DOI: 10.3171/2011.6.JNS081451

The authors report surgical and endocrinological results of a series of 73 cases of craniopharyngioma that they treated surgically since 1997 to demonstrate their change in treatment strategy and its effect on outcome compared with a previous series and results reported in the literature.

Methods. A total of 73 patients underwent surgery for craniopharyngiomas between May 1997 and January 2005. In patients with poor clinical or neuropsychological condition, even following pretreatment, only stereotactic cyst aspiration took place (8 cases). In the remaining patients, gross-total resection (GTR) was intended and appeared to be possible. The most frequent approaches were subfrontal (27 cases) and transsphenoidal (26 cases); in some cases, a multistep approach was used. The rate of GTR, complications, and functional outcome (comparing pre- and postoperative endocrine and neuropsychological testing) were evaluated. The mean duration of follow-up was 25.2 months.

Results. Gross-total resection was achieved in 88.5% of cases in which a transsphenoidal approach was used and 79.5% of those in which a transcranial approach was used (85.2% of those in which a subfrontal approach was used and 72.7% of those in which a frontolateral approach was used). In the total series, GTR was achieved in 83.1% of cases (vs 49.3% in the authors’ former series). The complication rate was 13.8% without any mortality. New endocrine deficits were observed more frequently in patients treated with transcranial approaches over the years (16.3%– 66.7% vs 2.6%–50.0%) but were less frequent after transsphenoidal approaches (5.2%–19.2% vs 2.9%–45.7%).

Conclusions. Open surgery with intended total resection remains the treatment of choice in most patients. Initial stereotactic cyst aspiration or medical pretreatment to improve the patients’ condition and adequate choice of surgical approach(es) are essential to achieve that goal. Nevertheless, a moderate increase in endocrinological deficits has to be accepted. The authors recommend using radiotherapy only in cases in which there are tumor remnants or disease progression after surgery.

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Image-Guided Thoracoscopic Resection of Thoracic Dumbbell Nerve Sheath Tumors

Neurosurgery 70:461–468, 2012 DOI: 10.1227/NEU.0b013e318235ba96

Surgical removal of dumbbell nerve sheath tumors (NSTs) remains challenging because these neoplasms occupy ≥ 2 spinal and extraspinal spaces. The presence of intraspinal extension, tumor dimension, and/or its location within the thoracic cavity have previously made the resection of these types of neoplasms difficult.

OBJECTIVE: To describe the feasibility of performing minimally invasive thoracoscopic surgery, as facilitated by an image guidance system (IGS), to achieve gross total resection of select dumbbell NSTs located in the thoracic spine.

METHODS: The 3 cases presented here contained small intraspinal or foraminal components. Preoperative symptoms included Horner syndrome and back and chest wall pain. We used IGS to help guide the complete thoracoscopic resection of select dumbbell NSTs, consisting of extradural, intraforaminal, and paravertebral tumor components, which previously would have been challenging with only a thoracoscopic approach.

RESULTS: IGS provided continuous intraoperative anatomic orientation to achieve gross total resection in all 3 cases. All surgical and postsurgical outcomes were satisfactory; preoperative symptoms improved or resolved; and no adverse events were observed.

CONCLUSION: Thoracic dumbbell NSTs that have small intraspinal or foraminal components could be resected thoracoscopically when facilitated by IGS. Image-guided thoracoscopic resection of such dumbbell tumors may not only improve the precision of resection, reduce recurrence, and avoid the need for spinal reconstruction but also obviate the need for more invasive or simultaneous posterior procedures. The IGS enhances the accuracy and safety of 2-dimensional thoracoscopic surgery and may reduce its learning curve.

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Prognostic factors and survival in a prospective cohort of patients with high-grade glioma treated with carmustine wafers or temozolomide on an intention-to-treat basis

Acta Neurochir (2012) 154:211–222.DOI 10.1007/s00701-011-1199-7

Patients with high-grade glioma can be treated with carmustine wafers or following the Stupp protocol. As far as we are aware, no scientific evidence has been published comparing the two treatments. The primary objective of this study was to analyse the survival of groups of patients with each of these treatment modalities. The secondary objective was to assess the influence of the usual prognostic factors on the patients in our hospital.

Methods A prospective cohort of 110 patients with single, supratentorial high-grade glioma treated by craniotomy and tumour resection was retrospectively studied. Half of the patients had carmustine wafers placed during this operation while the others (55) did not, the latter group receiving firstline systemic chemotherapy on an intention-to-treat basis.

Findings Patients treated with carmustine wafers had a median survival of 13.414 months compared with 11.047 in the group without implants (p=0.856). For the overall cohort of patients, the following factors were found to influence survival: age (p<0.0001), postoperative KPS score (p=0.001), histological grade (p=0.004), RPA class (p=0.001), extent of resection (p=0.002) and salvage surgery (p=0.028).

Conclusions In this prospective cohort of patients, analysed on the basis of intention-to-treat at the time of the first surgery, no statistically significant differences in survival were found between the two treatment modalities (carmustine wafers vs. first-line systemic chemotherapy). On the other hand, age, preoperative KPS, histological grade, and RPA class were confirmed to be prognostic factors in this cohort. Finally, the extent of resection was also found to influence survival.

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Glioblastoma therapy in the elderly and the importance of the extent of resection regardless of age

J Neurosurg 116:357–364, 2012. DOI: 10.3171/2011.8.JNS102114

The objective of this study was to analyze whether age influences the outcome of patients with glioblastoma and whether elderly patients with glioblastoma can tolerate the same aggressive treatment as younger patients.

Methods. Data from 361 consecutive patients with newly diagnosed cerebral glioblastoma (2000–2006) who underwent regular follow-up evaluation from initial diagnosis until death were prospectively entered into a database. Patients underwent resection (complete, subtotal, or partial) or biopsy, depending on tumor size, location, and Karnofsky Performance Scale score. Following surgery, all patients underwent adjuvant treatment consisting of radiotherapy, chemotherapy, or combined treatment. Patients older than 65 years of age were defined as elderly (146 total).

Results. Two hundred thirty-four patients underwent tumor resection (complete 26%, subtotal 29%, and partial 45%). One hundred twenty-seven underwent biopsy. Mean patient age was 61 years, and overall survival was 11.6 ± 12.1 months. The overall survival of elderly patients (9.1 ± 11.6 months) was significantly lower than that of younger patients (14.9 ± 16.7 months; p = 0.0001). Stratifying between resection or biopsy, age was a negative prognostic factor in patients undergoing biopsy (4.0 ± 7.1 vs 7.9 ± 8.7 months; p = 0.007), but not in patients undergoing tumor resection (13.0 ± 8.5 vs 13.3 ± 14.5 months; p = 0.86). Survival of elderly patients undergoing complete tumor resection was 17.7 ± 8.1 months.

Conclusions. In this series of patients with glioblastoma, age was a prognostic factor in patients undergoing biopsy, but not in patients undergoing resection. Tumor location and patient clinical status may prohibit extensive resection, but resection should not be withheld from patients only on the basis of age. In elderly patients with glioblastoma, undergoing resection to the extent feasible, followed by adjuvant therapies, is warranted.

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Percutaneous biopsy of lesions in the cavernous sinus region through the foramen ovale: diagnostic accuracy and limits in 50 patients

J Neurosurg 116:390–398, 2012.DOI: 10.3171/2011.10.JNS11783

The cavernous sinus and surrounding regions—specifically the Meckel cave, posterior sector of the cavernous sinus itself, and the upper part of the petroclival region—are the location of a large variety of lesions that require individual consideration regarding treatment strategy. These regions may be reached for biopsy by a percutaneous needle inserted through the foramen ovale. The aim of this retrospective study was to evaluate the diagnostic accuracy of percutaneous biopsy in a consecutive series of 50 patients referred for surgery between 1991 and 2010.

Methods. Seven biopsies (14%) were unproductive and 43 (86%) were productive, among which 28 lesions subsequently underwent histopathological examination during a second (open) surgery. To evaluate the diagnostic accuracy of the procedure, results from surgery were compared with those from the biopsy.

Results. Sensitivity of the percutaneous biopsy was 0.83 (95% CI 0.52–0.98), specificity was 1 (95% CI 0.79–1), and k coefficient was 0.81.

Conclusions. Because of its valuable diagnostic accuracy, percutaneous biopsy of the cavernous sinus and surrounding regions should be performed in patients with parasellar masses when neuroimaging does not provide sufficient information of a histopathological nature. This procedure would enable patients to obtain the most appropriate therapy, such as resective surgery, corticosteroids, chemotherapy, radiotherapy, or radiosurgery.

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A clinical trial of bevacizumab, temozolomide, and radiation for newly diagnosed glioblastoma

J Neurosurg 116:341–345, 2012.DOI: 10.3171/2011.9.JNS11656

The presence of angiogenesis is a hallmark of glioblastoma (GBM). Vascular endothelial growth factor (VEGF), which drives angiogenesis, provides an additional target for conventional therapy. The authors conducted a prospective clinical trial to test the effectiveness of bevacizumab, an inhibitor of VEGF, in newly diagnosed GBM.

Methods. From 2006 through 2010, 51 eligible patients with newly diagnosed GBM were treated with involvedfield radiation therapy and concomitant temozolomide (75 mg/m2 daily for 42 days) along with bevacizumab (10 mg/ kg every 2 weeks), starting 29 days after surgery. This was followed by 6 cycles of adjuvant temozolomide therapy (150 mg/m2 on Days 1–7 of a 28-day cycle) with bevacizumab administered at 10 mg/kg on Days 8 and 22 of each 28-day cycle.

Results. The 6- and 12-month progression-free survival (PFS) rates were 85.1% and 51%, respectively. The 12- and 24-month overall survival (OS) rates were 85.1% and 42.5%, respectively. Grade III/IV toxicities were noted in 10 patients (19.6%). No treatment-related deaths were observed. Asymptomatic intracranial bleeding was noted in 5 patients.

Conclusions. The addition of bevacizumab to conventional therapy in newly diagnosed GBM appears to improve both PFS and OS in patients with newly diagnosed GBM, with acceptable morbidity. A shift toward diffuse relapse was noted in a significant number of patients. Ongoing Phase III clinical trials will show the true benefit of this antiangiogenic approach.

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