Giant Pediatric Supratentorial Tumor: Clinical Feature and Surgical Strategy

PURPOSE

To analyze the clinical character of giant pediatric supratentorial tumor (GPST) and explore prognostic factors.

MATERIALS AND METHODS

We analyzed the clinical data comprising of 35 cases of GPST from a single center between January 2015 and December 2020. The tumor volume was measured by 3D slicer software based on preoperative magnetic resonance imaging (MRI). Glasgow Outcome Scale (GOS) was used to evaluate the short-term prognosis.

RESULT

The tumor volume varied from 27.3 to 632.8 ml (mean volume 129.8 ml/ median volume 82.8 ml). Postoperative histopathological types include ependymoma, pilocytic astrocytoma, choroid plexus papilloma (CPP), craniopharyngioma, primitive neuroectoderm tumor (PNET), choroid plexus carcinoma (CPC), immature teratoma, atypical teratoid rhabdoid tumor (AT/RT), anaplastic astrocytoma, and gangliocytoma. Tumors in children younger than 3 years and tumors located at the hemispheres appeared to be larger than their respective counterparts, though no statistical significance was found. A patient with giant immature teratoma died during the operation because of excessive bleeding. Postoperative complications include cerebrospinal fluid subgaleal collection/effusion, infection, neurological deficits, and seizures. The mean GOS score of patients with GPST in 6 months is 3.43 ± 1.12, and 83% of patients (29/35) showed improvement. Favorable GPST characteristics to indicated better GOS included small tumor (≤100 ml) (p = 0.029), low-grade (WHO I-II) (p = 0.001), and gross total resection (GTR) (p = 0.015). WHO grade was highly correlated with GOS score (correlation coefficient = -0.625, p < 0.001). GTR and tumor volume were also correlated (correlation coefficient = -0.428, p = 0.010).

CONCLUSION

The prognosis of GPST is highly correlated with the histopathological type. Smaller tumors are more likely to achieve GTR and might lead to a higher GOS score. Early diagnosis and GTR of the tumor are important for GPST management.

Volumetric Resection and Complications in Nonfunctioning Pituitary Adenoma by Fully Endoscopic Transsphenoidal Approach along 15 Years of Single-Center Experience

Objective  The aim of this study was to evaluate the rate of complications and the extent of resection (EOR) of nonfunctioning pituitary adenomas by endoscopic endonasal approach (EEA) in a 15-year learning curve. Methods  A total of 100 patients operated by the same surgical team were divided chronologically into two, three, and four groups, comparing differences in EOR measured by a semiautomatic software (Smartbrush, Brainlab), rate of immediate postoperative complications, and the visual and hormonal status at 6 months. Results  There were no significant differences over the years in rates of postoperative complications and in visual status at 6 months. A significant linear correlation between the EOR and the number of surgeries (rho = 0.259, p  = 0.007) was found. The analysis was performed in three groups because of the remarkable differences among them; the EOR were: 87.2% (early group), 93.03% (intermediate group), and 95.1% (late group) ( p  = 0.019). Gross total resection was achieved in 30.3, 51.5, and 64%, respectively ( p  = 0.017); also, the rate of reoperation and the worsening of at least one new hormonal axis were worse in the early group. Consequently, the early group had a higher risk of incomplete resection compared with the late group (odds ratio: 4.2; 95% confidence interval: 1.5-11.7). The three groups were not different in demographic and volume tumor variables preoperatively. Conclusions  The first 33 interventions were associated with a lower EOR, a high volume of residual tumor, a high reoperation rate, and a higher rate of hormonal dysfunction. We did not find differences in terms of postoperative complications and the visual status at 6-month follow-up.

Postoperative Adjuvant Radiotherapy in Atypical Meningioma Patients: A Meta-Analysis Study

Background and Purpose

Consensus regarding the need for adjuvant radiotherapy (RT) in patients with atypical meningiomas (AMs) is lacking. We compared the effects of adjuvant RT after surgery, gross total resection (GTR), and subtotal resection (STR) on progression-free survival (PFS) and overall survival (OS) in patients with AMs, respectively.

Methods

We performed a systematic review and meta-analysis of the literature published in PubMed, Embase, and the Cochrane Library from inception to February 1, 2021, to identify articles comparing the PFS and OS of patients receiving postoperative RT after surgery, GTR and STR.

Results

We identified 2307 unique studies; 24 articles including 3078 patients met the inclusion criteria. The sensitivity analysis results showed that for patients undergoing undifferentiated surgical resection, adjuvant RT reduced tumor recurrence (HR=0.70, p<0.0001) with no significant effect on survival (HR=0.89, p=0.49). Postoperative RT significantly increased PFS (HR=0.69, p=0.01) and OS (HR=0.55, p=0.007) in patients undergoing GTR. The same improvement was observed in patients undergoing STR plus RT (PFS: HR=0.41, p<0.00001; OS: HR=0.47, p=0.01). A subgroup analysis of RT in patients undergoing GTR showed no change in PFS in patients undergoing Simpson grade I and II resection (HR=1.82, p=0.22) but significant improvement in patients undergoing Simpson grade III resection (HR=0.64, p=0.02).

Conclusion

Regardless of whether GTR or STR was performed, postoperative RT improved PFS and OS to varying degrees. Especially for patients undergoing Simpson grade III or IV resection, postoperative RT confers the benefits for recurrence and survival.

Rapid Interval Recurrence of Glioblastoma Following Gross Total Resection: A Possible Indication for GammaTileⓇ Brachytherapy

Glioblastoma recurrence between initial resection and standard-of-care adjuvant chemoradiotherapy (CRT) is a negative prognostic factor in an already highly aggressive disease. Re-resection with GammaTileⓇ(GT Medical Technologies Inc., Tempe, AZ) placement affords expedited adjuvant radiation to mitigate the likelihood of such growth. Here, we report a glioblastoma patient who underwent re-resection and GammaTileⓇ (GT) placement within two months of the initial gross total resection due to regrowth that reached the size of the original presenting tumor. The patient subsequently received concurrent temozolomide and 60 Gy external beam to regions outside of the brachytherapy range, fulfilling the generally accepted Stupp regimen. The patient tolerated the treatment without complication. The dosimetrics and implications of the case presentation are reviewed.

Multivariate Analysis and Validation of the Prognostic Factors for Skull Base Chordoma

Background: Skull base chordoma is a rare tumor with low-grade malignancy and a high recurrence rate, the factors affecting the prognosis of patients need to be further studied. For that, we investigated prognostic factors of skull base chordoma through the database of the Surveillance, Epidemiology, and End Results (SEER) program, and validated in an independent data set from the Xiangya Hospital.

Methods: Six hundred and forty-three patients diagnosed with skull base chordoma were obtained from the SEER database (606 patients) and the Xiangya Hospital (37 patients). Categorical variables were selected by Chi-square test with a statistical difference. Survival curves were constructed by Kaplan–Meier analysis and compared by log-rank test. Univariate and multivariate Cox regression analyses were used to explore the prognostic factors. Propensity score matching (PSM) analysis was undertaken to reduce the substantial bias between gross total resection (GTR) and subtotal resection (STR) groups. Furthermore, clinical data of 37 patients from the Xiangya Hospital were used as validation cohorts to check the survival impacts of the extent of resection and adjuvant radiotherapy on prognosis.

Results: We found that age at diagnosis, primary site, disease stage, surgical treatment, and tumor size was significantly associated with the prognosis of skull base chordoma. PSM analysis revealed that there was no significant difference in the OS between GTR and STR (p = 0.157). Independent data set from the Xiangya Hospital proved no statistical difference in OS between GTR and STR groups (p = 0.16), but the GTR group was superior to the STR group for progression-free survival (PFS) (p = 0.048). Postoperative radiotherapy does not improve OS (p = 0.28), but it can prolong PFS (p = 0.0037). Nomograms predicting 5- and 10-year OS and DSS were constructed based on statistically significant factors identified by multivariate Cox analysis. Age, primary site, tumor size, surgical treatment, and disease stage were included as prognostic predictors in the nomograms with good performance.

Conclusions: We identified age, tumor size, surgery, primary site, and tumor stage as main factors affecting the prognosis of the skull base chordoma. Resection of the tumor as much as possible while ensuring safety, combined with postoperative radiotherapy may be the optimum treatment for skull base chordoma.

Primary Squamous Cell Carcinomas Arising in Intracranial Epidermoid Cysts: A Series of Nine Cases and Systematic Review

Objective

Primary squamous cell carcinomas (PSCCs) arising in intracranial epidermoid cysts (IECs) are very rare, and their management and prognostic factors remain unclear. This study aimed to enunciate the clinical features and suggest a treatment protocol based on cases from the literature and the cases from our institution.

Methods

The clinicoradiological data were obtained from nine patients with PSCCs arising in IECs, who underwent surgical treatment at Beijing Tiantan Hospital between July 2012 and June 2018. We also searched the PubMed database using the keywords “epidermoid cyst(s)” or “epidermoid tumor(s)” combined with “malignant” or “malignancy” or “intracranial” or “brain” or “squamous cell carcinoma” between 1960 and 2020. Risk factors for overall survival (OS) were evaluated in the pooled cohort.

Results

The mean age of our cohort was 51.2 ± 8.3 years (range: 39–61 years), which included eight males and one female. Gross total resection (GTR) was achieved in three patients, while non-GTR was achieved in six patients. Radiotherapy was administered to five patients. After a median follow-up of 16.7 ± 21.6 months (range: 3–72 months), eight patients died with a mean OS time of 9.75 ± 6.6 months (range: 3–23 months). In the literature between 1965 and 2020, 45 cases of PSCCs arising in IECs were identified in 23 males and 22 females with a mean age of 55.2 ± 12.4 years. GTR, non-GTR, and biopsy were achieved in six (13.3%), 36 (80%), and three (6.7%) cases, respectively. After a mean follow-up of 12.7 ± 13.4 months (range: 0.33–60 months), 54.1% (20/37) patients died, and recurrence occurred in 53.6% (15/28) patients. A multivariate analysis demonstrated that postoperative radiotherapy (p = 0.002) was the only factor that favored OS. The Kaplan–Meier analysis showed that, compared with no radiotherapy (median survival time: 4 months), radiotherapy (median survival time: 24 months) had significantly prolonged OS (p = 0.0011), and GTR could not improve OS (p = 0.5826), compared with non-GTR. The 1-year OS of patients with or without radiotherapy was 72.5% or 18.2%, respectively.

Conclusion

Malignant transformation of IEC into PSCC was prevalent in elderly patients, with slight male predominance. GTR of previous benign IECs is recommended. For remnant benign IECs, close follow-up should be performed. Postoperative radiotherapy for PSCCs could bring survival benefit. GTR of these malignant intracranial tumors is difficult when they involve important brain structures. Future studies with larger cohorts are necessary to verify our findings.

Tanycytic ependymoma: highlighting challenges in radio-pathological diagnosis

Background

Tanycytic ependymoma (TE) (WHO grade II) is a rare and morphologically distinct variant of ependymoma with only 77 cases reported worldwide so far. Variable clinical and radio-pathological features lead to misdiagnosis as WHO grade 1 tumors. On imaging, differentials of either schwannoma, meningioma, low-grade glial (like angiocentric glioma), or myxopapillary ependymoma are considered. In this study, we aim to discuss clinical, radiological, and pathological features of TE from our archives.

Method

We report clinicopathological aspects of six cases of TE from archives of tertiary care center between 2016 and 2018. Detailed histological assessment in terms of adequate tissue sampling and immunohistochemistry was done for each case.

Result

The patient's age ranged between 10 and 53 years with a slight male predilection. Intraspinal location was seen in two cases (intramedullary and extramedullary), three cases were cervicomedullary (intramedullary), and one was intracranial. One case was associated with neurofibromatosis type 2. Four cases mimicked as either schwannoma or low-grade glial tumor on squash smears. On imaging, ependymoma as differential was kept in only two cases and misclassified remaining either as low-grade glial or schwannoma.

Discussion

In initial published reports, the spine is the most common site (50.4%) followed by intracranial (36.4%) and cervicomedullary (3.9%). They have also highlighted the challenges in diagnosing them intraoperatively and radiologically. Treatment is similar to conventional ependymoma if diagnosed accurately. A multidisciplinary approach with the integration of neurosurgeon, neuroradiologist, and neuropathologist is required for accurate diagnosis and better treatment of patients.

Intraoperative low-field magnetic resonance imaging-guided tumor resection in glioma surgery: Pros and cons

BACKGROUNDIntraoperative magnetic resonance imaging (MRI) is useful for identifying residual tumors during surgery. It can improve the resection rate; however, complications related to prolonged operating time may be increased. We assessed the advantages and disadvantages of using low-field intraoperative MRI and compared them with non-use of iMRI during glioma surgery.METHODSThe study included 22 consecutive patients who underwent total tumor resection at Shinshu University Hospital between September 2017 and October 2020. Patients were divided into two groups (before and after introducing 0.4-T low-field open intraoperative MRI at the hospital). Patient demographics, gross total resection (GTR) rate, postoperative neurological deficits, need for reoperation, and operating time were compared between the groups.RESULTSNo significant differences were observed in patient demographics. While GTR of the tumor was achieved in 8/11 cases (73%) with intraoperative MRI, 2/11 cases (18%) of the control group achieved GTR (p=0.033). Seven patients had transient neurological deficits: 3 in the intraoperative MRI group and 4 in the control group, without significant differences between groups. There was no unintended reoperation in the intraoperative MRI group, except for one case in the control group. Mean operating time (465.8 vs. 483.6 minutes for the intraoperative MRI and control groups, respectively) did not differ.CONCLUSIONSLow-field intraoperative MRI improves the GTR rate and reduces unintentional reoperation incidence compared to the conventional technique. Our findings showed no operating time prolongation in the MRI group despite intraoperative imaging, which considered that intraoperative MRI helped reduce decision-making time and procedural hesitation during surgery.

Microsurgical resection of giant T11/T12 conus cauda equina schwannoma

In this video, we highlight the anatomy involved with microsurgical resection of a giant T11/T12 conus cauda equina schwannoma. Spinal schwannoma remains the third most common intradural spinal tumor. Tumors undergoing gross total resection usually do not recur. To our knowledge, this is the first video case report of giant cauda equina schwannoma resection. A 55-year-old female presented with paraparesis and urinary retention. Lumbar spine MRI revealed a contrast-enhancing intradural extramedullary tumor at the T11/T12 level. Surgery was performed in the prone position with intraoperative neurophysiology monitoring (somatosensory and motor evoked potentials-SSEPs and MEPs). T11/T12 laminectomies were performed. After opening the dura and arachnoid, the tumor was found covered with cauda equina nerve roots. We delineated the inferior pole of the tumor, followed by opening of the capsule and debulking the tumor. Subsequently, the cranial pole was dissected from the corresponding cauda equina nerve roots. Finally, the tumor nerve origin was identified and divided after nerve stimulation confirmed the tumor arose from a sensory nerve root. The tumor was removed; histological analysis revealed a schwannoma (WHO Grade I). Postoperative MRI revealed complete resection. The patient fully recovered her neurological function. This case highlights the importance of careful microsurgical technique and gross total resection of the tumor in the view of favorable postoperative neurological recovery of the patient. Intraoperative use of ultrasound is helpful to delineate preoperatively tumor extension and confirm postoperative tumor resection.

The Role of Advanced Endoscopic Resection of Diverse Skull Base Malignancies: Technological Analysis during an 8-Year Single Institutional Experience

Background  Resection of skull base malignancies poses complex pathological and treatment-related morbidities. Recent technological advancements of endoscopic endonasal surgery (EES) offer the ability to reexamine traditional treatment paradigms with endoscopic procedures. The utility of EES was quantitatively examined in a longitudinal series with attention to morbidities and postoperative outcomes. Methods  A single-center retrospective review was performed of all malignant sinonasal tumors from 2010 to 2018. Patients with purely EES were selected for analysis. Disease features, resection extent, complications, adjuvant treatment, recurrence, and survivability were assessed. Despite the mixed pathological cohort, analysis was performed to identify technical aspects of resection. Results  A total of 68 patients (47.6% males and 52.4% females, average age: 60.3 years) were included. A diversity of histotypes included clival chordoma (22.1%), olfactory neuroblastoma (14.7%), squamous cell carcinoma (11.8%), and adenoid cystic carcinoma (11.8%). Gross total resection (GTR) was achieved in 83.8% of cases. Infection (4.4%) and cerebrospinal fluid leak (1.5%) were the most common postoperative complications. Total 46 patients (67.6%) underwent adjuvant treatment. The average time between surgery and initiation of adjunctive surgery was 55.7 days. Conclusion  In our 8-year experience, we found that entirely endoscopic resection of mixed pathology of malignant skull base tumors is oncologically feasible and can be accomplished with high GTR rates. There may be a role for EES to reduce operative morbidity and attenuate time in between surgery and adjuvant treatment, which can be augmented through recent mixed reality platforms. Future studies are required to systematically compare the outcomes with those of open surgical approaches.

Rare asymptomatic giant cerebral cavernous malformation in adults: two case reports and a literature review

Cavernous malformations are benign vascular malformations. Giant cavernous malformations are very rare. All reported cases have been symptomatic because of the large size and compression of the surrounding brain tissue. We report two asymptomatic cases of giant cavernous malformation that were both misdiagnosed as neoplasms because of their atypical presentations. The first case was a 54-year-old man whose computed tomography and magnetic resonance imaging scans revealed an inhomogeneous lesion of 6 cm diameter and mild enhancement in the left frontal lobe. A left lateral supraorbital and transcortical approach was applied and the lesion was completely removed. The second case was a 36-year-old man with an irregular large mass in the parasellar region. Craniopharyngioma was suspected and gross total resection was performed. Post-surgical pathological analyses confirmed the diagnoses as cavernous malformations. Both patients recovered uneventfully. The rare asymptomatic giant cavernous malformations reported here in adults had benign behavior for this specific disease entity. The different clinical characteristics of ordinary cavernous malformation and adult and pediatric giant cavernous malformation imply complex and distinct genetic backgrounds. Concerns should be raised when considering giant cavernous malformation as a differential diagnosis for atypical large lesions. Surgical resection is recommended as the primary treatment option.

Predictors of Survival in Atypical Meningiomas

Simple Summary

Meningiomas are the most common intracranial tumor [1] and are classified by the World Health Organization (WHO) as grade I (benign), grade II (atypical), or grade III (anaplastic) [2]. Regarding atypical meningiomas, predictors of overall survival (OS) and progression-free survival (PFS) are less well documented compared to their benign counterparts. Moreover, one of the most critical aspects of meningiomas is tumor relapse/progression that may also take place after the complete removal of the lesion. Recurrent lesions pose the question whether it is reasonable to perform second surgery. Alternative approaches include radiotherapy (RT) (stereotactic radiosurgery or conventional fractionated RT). We investigated 77 consecutive patients who underwent craniotomy for intracranial atypical meningiomas to evaluate predictors of OS and retreatment-free survival, and to assess the benefits of surgical retreatment for subsequent recurrences. We concluded that gross total resection (GTR) significantly prolonged retreatment-free survival but had no significant impact on OS. GTR was also associated with improved/stable neurological outcomes at 6–12 months. Age at surgery, preoperative Karnofsky performance scale (KPS), and retreatment were all strong prognostic factors of OS. Time-to-retreatment did not decrease significantly in patients requiring repeated surgical excision.

Abstract

Introduction: Predictors of survival and progression of disease in atypical meningiomas are less well documented in the literature compared to benign meningiomas. Higher grade meningiomas tend to recur often and one of the most critical aspects is how to best deal with relapses. Methods: A total of 77 consecutive patients who underwent craniotomy for atypical meningioma between 1990–2010 at Oslo University Hospital (OUH) were reviewed. Results: Median age at surgery was 62.21 [interquartile range (IQR): 22.87] years. Fifty-one patients (66.2%) had neurological deficits at presentation. Fifty-four patients (70.1%) underwent gross total resection (GTR). Thirty-nine patients (50.7%) had improved/stable neurological outcomes at 6–12 months. Twenty-two patients (28.6%) underwent retreatment, of whom 20 (26.0%) were subjected to resection followed by adjuvant radiotherapy. Overall survival (OS) was significantly longer in patients <65 years (p < 0.001), with preoperative Karnofsky performance scale (KPS) score of ≥ 70 (p = 0.006), and who required no retreatment (p = 0.033). GTR significantly prolonged the retreatment-free survival rate (p < 0.001). STR carried almost a six-fold greater risk of neurological outcome deterioration (p = 0.044). Conclusions: GTR significantly prolonged retreatment-free survival but had no significant impact on OS. STR was a significant risk factor for deteriorated neurological outcome. Age, preoperative KPS, and retreatment were all strong predictors of OS. Median time-to-retreatment (TTR) did not shorten significantly throughout repeated surgeries.

The Survival Benefits of Surgical Resection and Adjuvant Therapy for Patients With Brainstem Glioma

Purpose

The role of surgical resection in the treatment of brainstem glioma (BSG) is poorly understood. For pediatric low-grade (LGBSG) group, several monocentric small-scale retrospective studies reported contradictory conclusions. And there was no clinical study focused on surgical resection for adult or pediatric high-grade (HG) patient groups. This study aims to illustrate whether surgical resection and adjuvant therapy provide survival benefits for patients with histologically confirmed BSG.

Patients and Methods

This retrospective cohort study included 529 patients with histologically confirmed BSG in Surveillance Epidemiology and End Results (SEER) database from 2006-2015. Patients were divided into four groups by age and World Health Organization (WHO) grade. Kaplan-Meier curves of CSS were plotted by different treatment options to compare the survival probability. Univariate and multivariable analyses were then conducted to determine the prognosis effects of surgical resection and adjuvant therapy on cancer specific survival (CSS). All analyses were done in four different groups separately.

Results

The final sample included 529 patients. The entire study population was divided into groups of pediatric LG (n=236, 44.6%), pediatric HG (n=37, 7.0%), adult LG (n=204, 38.6%) and adult HG (n=52, 9.8%). 52.7% (n=144) of pediatric patients had pilocytic astrocytoma and 45.3% (n=116) of adult patients had ependymoma. Pediatric LGBSG group had the highest gross total resection (GTR) rate (61.4%) and 5-year CSS rate (88.6%). Kaplan-Meier curves of pediatric LGBSG group revealed that patients treated with GTR had significantly better survival probability (P=0.033). Multivariable analysis identified GTR as independently significant predictor for prolonged CSS in pediatric LGBSG group (HR0.29, 95%CI 0.11-0.78, P=0.015); Surgical resection showed no relation to CSS in other patient groups. Kaplan-Meier curves of adult HGBSG group showed that patients treated with both RT and CT in adult HGBSG group had the best survival probability (P=0.02). However, multivariable analysis showed the combination of radiotherapy (RT) and chemotherapy (CT) was not significantly related to better CSS in adult HGBSG group (HR0.35, 95%CI 0.11-1.09, P=0.070). Adjuvant therapy didn’t associate with better CSS in other patient groups.

Conclusion

Pediatric LGBSG group had the highest GTR rate and the most favorable clinical outcome. GTR can provide significant survival benefits for pediatric LGBSG group.

Surgery After Surgery for Vestibular Schwannoma: A Case Series

Objective

We retrospectively evaluated the oncological and functional effectiveness of revision surgery for recurrent or remnant vestibular schwannoma (rVS).

Methods

We included 29 consecutive patients with unilateral hearing loss (16 women; mean age: 42.2 years) that underwent surgery for rVS. Previous surgeries included gross total resections (GTRs, n=11) or subtotal resections (n=18); mean times to recurrence were 9.45 and 4.15 years, respectively. House–Brackmann (HB) grading of facial nerve (FN) weakness (grades II-IV) indicated that 22 (75.9%) patients had deep, long-lasting FN paresis (HB grades: IV-VI). The mean recurrent tumor size was 23.3 mm (range: 6 to 51). Seven patients had neurofibromatosis type 2.

Results

All patients received revision GTRs. Fourteen small- to medium-sized tumors located at the bottom of the internal acoustic canal required the translabyrinthine approach (TLA); 12 large and small tumors, predominantly in the cerebellopontine angle, required the retrosigmoid approach (RSA); and 2 required both TLA and RSA. One tumor that progressed to the petrous apex required the middle fossa approach. Fifteen patients underwent facial neurorrhaphy. Of these, 11 received hemihypoglossal–facial neurorrhaphies (HHFNs); nine with simultaneous revision surgery. In follow-up, 10 patients (34.48%) experienced persistent deep FN paresis (HB grades IV-VI). After HHFN, all patients improved from HB grade VI to III (n=10) or IV (n=1). No tumors recurred during follow-up (mean, 3.46 years).

Conclusions

Aggressive microsurgical rVS treatment combined with FN reconstruction provided durable oncological and neurological effects. Surgery was a reasonable alternative to radiosurgery, particularly in facial neurorrhaphy, where it provided a one-step treatment.

Surgical Strategies and Clinical Outcome of Large to Giant Sphenoid Wing Meningiomas: A Case Series Study

Large to giant sphenoid wing meningiomas (SWMs) remain surgically challenging due to frequent vascular encasement and a tendency for tumoral invasion of the cavernous sinus and optic canal. We aimed to study the quality of resection, postoperative clinical evolution, and recurrence rate of large SWMs. This retrospective study enrolled 21 patients who underwent surgery between January 2014 and December 2019 for SWMs > 5 cm in diameter (average 6.3 cm). Tumor association with cerebral edema, extension into the cavernous sinus or optic canal, degree of encasement of the major intracranial arteries, and tumor resection grade were recorded. Cognitive decline was the most common symptom (65% of patients), followed by visual decline (52%). Infiltration of the cavernous sinus and optical canal were identified in five and six patients, respectively. Varying degrees of arterial encasement were seen. Gross total resection was achieved in 67% of patients. Long-term follow-up revealed improvement in 17 patients (81%), deterioration in two patients (9.5%), and one death (4.7%) directly related to the surgical procedure. Seven patients displayed postoperative tumor progression and two required reintervention 3 years post initial surgery. Tumor size, vascular encasement, and skull base invasion mean that, despite technological advancements, surgical results are dependent on surgical strategy and skill. Appropriate microsurgical techniques can adequately solve arterial encasement but tumor progression remains an issue.

Gross Total Versus Subtotal Surgical Resection in the Management of Craniopharyngiomas

Craniopharyngiomas (CP) are suprasellar tumors that can grow into vital nearby structures and thus cause significant visual, endocrine, and hypothalamic dysfunction. Debate persists as to the optimal treatment strategy for these benign lesions, particularly with regards to the extent of surgical resection. The goals of tumor resection are to eliminate the compressive effect of the tumor on surrounding structures and minimize recurrence. It remains unclear whether a gross total resection (GTR) or subtotal resection (STR) with adjuvant therapy confers a better prognosis. Chemotherapy and radiation therapy (RT) have been explored as both neoadjuvant and adjuvant treatments to decrease tumor burden and prevent recurrence. The objective of this paper is to review the risks and benefits of GTR versus STR, specifically with regard to risk of recurrence and postoperative morbidity. Aggregated data suggest that STR monotherapy is associated with higher rates of recurrence relative to GTR (50.6% ± 22.1% vs 20.2% ± 13.5%), while STR combined with RT leads to recurrence rates similar to GTR. However, both GTR and RT are independently associated with higher rates of comorbidities including panhypopituitarism, diabetes insipidus, and visual deficits. The treatment strategy for CPs should ultimately be tailored to each patient's individual tumor characteristics, risk, symptoms, and therapeutic goals.

Surgical outcomes in patients with endoscopic versus transcranial approach for skull base malignancies: a 10-year institutional experience

Object: The authors performed an extensive comparison between patients treated with open versus an endoscopic approach for skull base malignancy with emphasis on surgical outcomes.Methods: A single-institution retrospective review of 60 patients who underwent surgery for skull base malignancy between 2009 and 2018 was performed. Disease features, surgical resection, post-operative morbidities, adjuvant treatment, recurrence, and survival rates were compared between 30 patients who received purely open surgery and 30 patients who underwent purely endoscopic resection for a skull base malignancy.Results: Of the 60 patients with skull base malignancy, 30 underwent open resection and 30 underwent endoscopic resection. The most common hisotype for endoscopic resection was squamous cell carcinoma (26.7%), olfactory neuroblastoma (16.7%), and sarcoma (10.0%), and 43.3%, 13.3%, and 10.0% for the open resection cohort, respectively. There were no statistical differences in gross total resection, surgical-associated cranial neuropathy, or ability to achieve negative margins between the groups (p > 0.1, all comparisons). Patients who underwent endoscopic resection had shorter surgeries (320.3 ± 158.5 minutes vs. 495.3 ± 187.6 minutes (p = 0.0003), less intraoperative blood loss (282.2 ± 333.6 ml vs. 696.7 ± 500.2 ml (p < 0.0001), and shorter length of stay (3.5 ± 3.7 days vs. 8.8 ± 6.0 days (p < 0.0001). Additionally, patients treated endoscopically initiated adjuvant radiation treatment more quickly (48.0 ± 20.3 days vs. 72.0 ± 20.5 days (p = 0.01).Conclusions: An endoscopic endonasal approach facilitates a clinically meaningful improvement in surgical outcomes for skull base malignancies.

Advantages of gross total resection in patients with astrocytoma: A population-based study

The present study aimed to investigate the association between surgical methods and survival outcomes in patients with astrocytoma. Patients diagnosed with astrocytoma between January 2004 and December 2015 were identified using the Surveillance, Epidemiology and End Results database. Kaplan-Meier curves and Cox regression were used to analyze the effects of surgical methods on overall survival (OS) and cancer-specific survival (CSS). Among 42,224 eligible patients with astrocytoma, 11,427 (27.1%) patients did not receive surgery, 7,661 (18.1%) received excisional biopsy (EB), 5,520 (13.1%) received a subtotal resection (STR), 6,037 (14.3%) received a gross resection (GR), 5,314 (12.6%) received a partial resection (PR) and 6,265 (14.8%) received a gross total resection (GTR). Patients who underwent GR had the longest survival time (17.00 months). However, over time, the proportion of patients who underwent STR or GR increased, whereas the proportion of patients who did not undergo surgery, PR or GTR decreased. Furthermore, surgical method was an independent prognostic factor for OS and CSS for the patients with astrocytoma. Multivariate Cox regression showed that GTR was associated with the more favorable OS [hazard ratio (HR), 0.80; 95% confidence interval (CI), 0.77-0.83; P<0.001] and CSS (HR, 0.80; 95% CI, 0.77-0.83; P<0.001) times compared with EB. Moreover, similar results were observed in subgroup analyses based on summary stage and grade. In the present study, it was demonstrated that GTR was one of the effective surgical methods for improved OS and CSS time in patients with astrocytoma. However, among the American astrocytoma population, the proportion of patients who underwent GTR decreased. It is necessary to further advocate for the efficacy of GTR.

Gross Total vs. Subtotal Resection on Survival Outcomes in Elderly Patients With High-Grade Glioma: A Systematic Review and Meta-Analysis

Background: The optimal strategy for the management of high-grade glioma in the elderly (≥60.0 years) remains controversial, especially regarding the effects of surgical extent on survival outcomes. The purpose of this study was to compare gross total resection (GTR) with subtotal resection (STR) for treatment effects in elderly patients with high-grade glioma.

Methods: Three electronic databases were systematically searched, including PubMed, EmBase, and the Cochrane library, from inception to August 2018. Hazard ratios (HRs) or odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were used to express summary effect estimates using the random-effects model. Nineteen retrospective observational studies involving a total of 10,815 elderly patients with high-grade glioma were included in this meta-analysis.

Results: The summary results indicated that GTR was associated with a significant improvement in overall survival (OS) compared with STR (HR = 0.70, 95% CI = 0.64–0.77). In addition, elderly patients administered GTR showed lower risk of 3-month mortality (OR = 0.47, 95% CI = 0.24–0.93), 6-month mortality (OR = 0.38, 95% CI = 0.26–0.56), 9-month mortality (OR = 0.35, 95% CI = 0.25–0.49), and 1-year mortality (OR = 0.40, 95% CI = 0.29–0.56). Pooled OS data differed when stratified by publication year, country, sample size, disease status, and study quality.

Conclusion: GTR seems to be more effective than STR in achieving longer survival in elderly patients with high-grade glioma.

Association between urbanicity and surgical treatment among patients with primary glioblastoma in the United States

Background

Glioblastoma (GB) is the most common and most lethal primary malignant brain tumor. Extent of surgical resection is one of the most important prognostic factors associated with improved survival. Historically, patients living in nonmetropolitan counties in the United States have limited access to optimal treatment and health care services. The aim of this study is to determine whether there is an association between urbanicity and surgical treatment patterns among US patients with primary GB.

Methods

Cases with histologically confirmed, primary GB diagnosed between 2005 and 2015 were obtained from the Central Brain Tumor Registry of the United States (CBTRUS) in collaboration with the Centers for Disease Control and Prevention, and the National Cancer Institute. Multivariable logistic regression models were constructed to assess the association between urbanicity and receipt of surgical treatment (gross total resection [GTR]/subtotal resection [STR] vs biopsy only/none) and extent of resection (GTR vs STR), adjusted for age at diagnosis, sex, race, US regional division, and primary tumor site.

Results

Patients residing in nonmetropolitan counties were 7% less likely to receive surgical treatment (odds ratio [OR] = 0.93, 95% CI: 0.89-0.96, P < .0001). Among those who received surgical treatment, metropolitan status was not significantly associated with receiving GTR vs STR (OR = 0.99, 95% CI: 0.94-1.04, P = .620).

Conclusions

Among US patients with GB, urbanicity is associated with receipt of surgical treatment, but among patients who receive surgery, urbanicity is not associated with extent of resection. These results point to potential differences in access to health care for those in nonmetropolitan areas that warrant further exploration.

Microsurgical Gross Total Resection of Foramen Magnum Meningioma via Far Lateral Approach

Foramen magnum meningiomas are one of the most challenging tumors for skull base neurosurgeons due to their proximity to critical neurovascular structures. The far-lateral approach demonstrated here facilitates access to lesions involving the anterior portion of the foramen magnum.

In this video, we present a 62-year-old woman with hand numbness and weakness. The patient had significant difficulty in fine motor movements of both hands. In the neurological examination, she had a significant right-hand intrinsic muscle weakness and mild quadriparesis.

Magnetic resonance imaging (MRI) showed a dural-based homogeneously enhancing extra-axial mass in the anterior foramen magnum with a significant mass effect on the brain stem and the upper cervical cord. The decision was made to proceed with a far lateral transcondylar skull base approach including partial C1 laminectomy.

The surgery and postoperative course were uneventful. The postoperative MRI showed gross total resection of the mass. The histopathology indicated a WHO (World health Organization) grade-I meningioma. The patient's postoperative course was uneventful. She improved to normal neurological function within several weeks and continues to do well without recurrence at 20 months' follow-up.

In this video, we demonstrated important steps for the microsurgical resection of these challenging lesions.

The link to the video can be found at: https://youtu.be/_nuX2Y7YU9w .

Extent of Resection, MGMT Promoter Methylation Status and Tumor Location Independently Predict Progression-Free Survival in Adult Sporadic Pilocytic Astrocytoma

In adults, pilocytic astrocytomas (PA) account for less than 2% of gliomas, resulting in uncertainty regarding the clinical course and optimal treatment, particularly in cases where gross total resection (GTR) could not be achieved. Moreover, information on molecular markers and their prognostic impact is sparse. In order to improve risk stratification, we analyzed our institutional series of 58 patients aged 17 years and older with histology-proven intracranial PA World Health Organization grade I for clinical and molecular prognosticators. Anaplastic and NF1-associated tumors were excluded. O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status was determined by pyrosequencing or 450k/850k DNA methylation array. A univariate log-rank test and multivariate StepAIC were applied to identify prognostic factors. The median age was 30 years (range 17–66). Tumors were located in the cerebral/cerebellar hemispheres, midline structures and cerebello-pontine angle in 53%, 38% and 9%. MGMT promoter methylation was present in eight patients (14%). GTR (39/58 patients) significantly reduced the likelihood of tumor recurrence (p = 0.0001). Tumor relapse occurred in 16 patients (28%) after a median progression-free survival (PFS) of 135 months (range 6–153 months); there was one tumor-related death. PFS at 5 and 10 years was 67% and 53%. In multivariate analysis, PFS was significantly prolonged in patients with GTR (HR 0.1; CI 0.03–0.37; p < 0.001), unmethylated MGMT promoter (HR 0.18; CI 0.05–0.64; p = 0.009) and midline tumors (HR 0.21; CI 0.06–0.78; p = 0.02). In conclusion, MGMT promoter methylation status and tumor location were identified as novel prognostic factors in adult PAs, pointing at distinct molecular subtypes and detecting patients in need of close observance and intensified treatment.

Survival Outcomes Among Patients With High-Grade Glioma Treated With 5-Aminolevulinic Acid-Guided Surgery: A Systematic Review and Meta-Analysis

Background: High-grade glioma (HGG) is associated with a dismal prognosis despite significant advances in adjuvant therapies, including chemotherapy, immunotherapy, and radiotherapy. Extent of resection continues to be the most important independent prognosticator of survival. This underlines the significance of increasing gross total resection (GTR) rates by using adjunctive intraoperative modalities to maximize resection with minimal neurological morbidity. 5-aminolevulinic acid (5-ALA) is the only US Food and Drug Administration–approved intraoperative optical agent used for fluorescence-guided surgical resection of gliomas. Despite several studies on the impact of intra-operative 5-ALA use on the extent of HGG resection, a clear picture of how such usage affects patient survival is still unavailable.

Methods: A systematic review was conducted of all relevant studies assessing the GTR rate and survival outcomes [overall survival (OS) and progression-free survival (PFS)] in HGG. A meta-analysis of eligible studies was performed to assess the influence of 5-ALA-guided resection on improving GTR, OS, and PFS. GTR was defined as >95% resection.

Results: Of 23 eligible studies, 19 reporting GTR rates were included in the meta-analysis. The pooled cohort had 998 patients with HGG, including 796 with newly diagnosed cases. The pooled GTR rate among patients with 5-ALA–guided resection was 76.8% (95% confidence interval, 69.1–82.9%). A comparative subgroup analysis of 5-ALA–guided vs. conventional surgery (controlling for within-study covariates) showed a 26% higher GTR rate in the 5-ALA subgroup (odds ratio, 3.8; P < 0.001). There were 11 studies eligible for survival outcome analysis, 4 of which reported PFS. The pooled mean difference in OS and PFS was 3 and 1 months, respectively, favoring 5-ALA vs. control (P < 0.001).

Conclusions: This meta-analysis shows a significant increase in GTR rate with 5-ALA–guided surgical resection, with a higher weighted GTR rate (~76%) than the pivotal phase III study (~65%). Pooled analysis showed a small yet significant increase in survival measures associated with the use of 5-ALA. Despite the statistically significant results, the low level of evidence and heterogeneity across these studies make it difficult to conclusively report an independent association between 5-ALA use and survival outcomes in HGG. Additional randomized control studies are required to delineate the role of 5-ALA in survival outcomes in HGG.

Management of Ependymoma in Children, Adolescents and Young Adults

Paediatric ependymomas are rare, malignant tumours arising throughout the central nervous system, but most frequently (in children) the posterior fossa. The standard of care for localised disease is gross total resection and focal radiotherapy, resulting in overall survival rates of up to 85%. Despite improvements in survival, treatment remains challenging, with persistently high rates of (rarely curable) relapse alongside risks of significant tumour and treatment-related toxicity. Systemic therapy is currently used to delay radiotherapy in very young children and in the management of metastatic or recurrent disease. Its use in the adjuvant setting is the subject of ongoing studies. Current research efforts are aimed at eliciting a better understanding of molecular biology, correlating this with tumour behaviour and defining targets for potential new agents. Prognosis seems to be related to the extent of surgical resection and the age at presentation. This article reviews clinical aspects of ependymoma management in children and young people.

Gross Total Resection of Large Cerebellopontine Angle Meningioma with a Supratentorial Extension via Retrosigmoid Approach with Suprameatal Drilling and Tentorial Sectioning

Meningiomas are the second most common neoplasm in the cerebellopontine angle (CPA), and are challenging lesions to treat surgically. With significant refinements in surgical techniques, operative morbidity, and mortality have been substantially reduced. Total or near-total surgical resection can be accomplished in the majority of cases via appropriately selected approaches, and with acceptable morbidity. In this video, we present a 51-year-old woman, who had a 2-year history of vertigo with symptoms that progressed over time. She presented with blurry vision, sensorineural hearing loss, tinnitus, left-sided facial numbness, and double vision. Magnetic resonance imaging (MRI) showed a left-sided homogeneously enhancing mass at CPA with a supratentorial extension. MRI appearance was consistent with a CPA meningioma with supratentorial extension. The patient underwent surgical resection via a retrosigmoid approach. Suprameatal drilling and tentorial sectioning were necessary to achieve gross total resection. The surgery and postoperative course were uneventful. The histopathology was a WHO (world health organization) grade I meningioma. MRI showed gross total resection of the tumor. After a 1.5-year follow-up, the patient is continuing to do well with no residual or recurrent disease. In this video, microsurgical techniques and important steps for the resection of this challenging meningioma of the cerebellopontine angle are demonstrated.

The link to the video can be found at: https://youtu.be/CDto52GxrG4 .