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Voglis S, Padevit L, van Niftrik CHB, Kälin V, Beyersdorf B, Da Mutten R, Stumpo V, Bellomo J, Sarnthein J, Staartjes VE, Carretta A, Krayenbühl N, Regli L, Serra C. Safety of microneurosurgical interventions for superficial and deep-seated brain metastases: single-center cohort study of 637 consecutive cases. J Neurooncol 2023; 165:271-278. [PMID: 37945819 PMCID: PMC10689541 DOI: 10.1007/s11060-023-04478-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/10/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE Microneurosurgical techniques have greatly improved over the past years due to the introduction of new technology and surgical concepts. To reevaluate the role of micro-neurosurgery in brain metastases (BM) resection in the era of new systemic and local treatment options, its safety profile needs to be reassessed. The aim of this study was to analyze the rate of adverse events (AEs) according to a systematic, comprehensive and reliably reproducible grading system after microneurosurgical BM resection in a large and modern microneurosurgical series with special emphasis on anatomical location. METHODS Prospectively collected cases of BM resection between 2013 and 2022 were retrospectively analyzed. Number of AEs, defined as any deviations from the expected postoperative course according to Clavien-Dindo-Grade (CDG) were evaluated. Patient, surgical, and lesion characteristics, including exact anatomic tumor locations, were analyzed using uni- and multivariate logistic regression and survival analysis to identify predictive factors for AEs. RESULTS We identified 664 eligible patients with lung cancer being the most common primary tumor (44%), followed by melanoma (25%) and breast cancer (11%). 29 patients (4%) underwent biopsy only whereas BM were resected in 637 (96%) of cases. The overall rate of AEs was 8% at discharge. However, severe AEs (≥ CDG 3a; requiring surgical intervention under local/general anesthesia or ICU treatment) occurred in only 1.9% (n = 12) of cases with a perioperative mortality of 0.6% (n = 4). Infratentorial tumor location (OR 5.46, 95% 2.31-13.8, p = .001), reoperation (OR 2.31, 95% 1.07-4.81, p = .033) and central region tumor location (OR 3.03, 95% 1.03-8.60) showed to be significant predictors in a multivariate analysis for major AEs (CDG ≥ 2 or new neurological deficits). Neither deep supratentorial nor central region tumors were associated with more major AEs compared to convexity lesions. CONCLUSIONS Modern microneurosurgical resection can be considered an excellent option in the management of BM in terms of safety, as the overall rate of major AEs are very rare even in eloquent and deep-seated lesions.
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Affiliation(s)
- Stefanos Voglis
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Luis Padevit
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Christiaan Hendrik Bas van Niftrik
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Vincens Kälin
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Benjamin Beyersdorf
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Raffaele Da Mutten
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Vittorio Stumpo
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Jacopo Bellomo
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Johannes Sarnthein
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Victor Egon Staartjes
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Alessandro Carretta
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Müller SJ, Khadhraoui E, Voit D, Riedel CH, Frahm J, Romero JM, Ernst M. Comparison of EPI DWI and STEAM DWI in Early Postoperative MRI Controls After Resection of Tumors of the Central Nervous System. Clin Neuroradiol 2023; 33:677-685. [PMID: 36732415 PMCID: PMC10449950 DOI: 10.1007/s00062-023-01261-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/03/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Diffusion-weighted imaging (DWI) is important for differentiating residual tumor and subacute infarctions in early postoperative magnetic resonance imaging (MRI) of central nervous system (CNS) tumors. In cases of pneumocephalus and especially in the presence of intraventricular trapped air, conventional echo-planar imaging (EPI) DWI is distorted by susceptibility artifacts. The performance and robustness of a newly developed DWI sequence using the stimulated echo acquisition mode (STEAM) was evaluated in patients after neurosurgical operations with early postoperative MRI. METHODS We compared EPI and STEAM DWI of 43 patients who received 3‑Tesla MRI within 72 h after a neurosurgical operation between 1 October 2019 and 30 September 2021. We analyzed susceptibility artifacts originating from air and blood and whether these artifacts compromised the detection of ischemic changes after surgery. The DWI sequences were (i) visually rated and (ii) volumetrically analyzed. RESULTS In 28 of 43 patients, we found severe and diagnostically relevant artifacts in EPI DWI, but none in STEAM DWI. In these cases, in which artifacts were caused by intracranial air, they led to a worse detection of ischemic lesions and thus to a possible failed diagnosis or lack of judgment using EPI DWI. Additionally, volumetric analysis demonstrated a 14% smaller infarct volume detected with EPI DWI. No significant differences in visual rating and volumetric analysis were detected among the patients without severe artifacts. CONCLUSION The newly developed version of STEAM DWI with highly undersampled radial encodings is superior to EPI DWI in patients with postoperative pneumocephalus.
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Affiliation(s)
- Sebastian Johannes Müller
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany.
- Department of Neuroradiology, University Medicine Göttingen, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
| | - Eya Khadhraoui
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Dirk Voit
- Max-Planck-Institute for Multidisciplinary Sciences, Göttingen, Germany
| | | | - Jens Frahm
- Max-Planck-Institute for Multidisciplinary Sciences, Göttingen, Germany
| | - Javier M Romero
- Department of Radiology Division of Neuroradiology, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Marielle Ernst
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
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Voglis S, Schaller V, Müller T, Gönel M, Winklhofer S, Mangana J, Dummer R, Serra C, Weller M, Regli L, Le Rhun E, Neidert MC. Maximal surgical tumour load reduction in immune-checkpoint inhibitor naïve patients with melanoma brain metastases correlates with prolonged survival. Eur J Cancer 2022; 175:158-168. [PMID: 36126476 DOI: 10.1016/j.ejca.2022.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/04/2022] [Accepted: 08/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent therapeutic advances in metastatic melanoma have led to improved overall survival (OS) rates, with consequently an increased incidence of brain metastases (BM). The role of BM resection in the era of targeted and immunotherapy should be reassessed. In the current study we analysed the role of residual intracranial tumour load in a cohort of melanoma BM patients. METHODS Retrospective single-centre analysis of a prospective registry of resected melanoma BM from 2013 to 2021. Correlations of residual tumour volume and outcome were determined with respect to patient, tumour and treatment regimens characteristics. RESULTS 121 individual patients (66% male, mean age 59.9 years) were identified and included in the study. Pre- and postoperative systemic treatments included BRAF/MEK inhibitors, as well as combination or monotherapy of immune-checkpoint inhibitors (ICIs). Median OS of the entire cohort was 20 months. Cox proportional-hazard analysis revealed postoperative anti-CTLA4+anti-PD-1 therapy (HR 0.07, p = .01) and postoperative residual intracranial tumour burden (HR 1.4, p = .027) as significant predictors for OS. Further analysis revealed that ICI-naïve patients with residual tumour volume ≤3.5 cm3 and postoperative ICI showed significantly prolonged OS compared to patients with residual volume >3.5 cm3 (p < .0001). Subgroup analysis of ICI-naïve patients showed steroid intake postoperatively to be negatively associated with OS, however residual tumour volume ≤3.5 cm3 remained independently correlated with superior OS (HR 0.14, p < .001). CONCLUSION Besides known predictive factors like postoperative ICI, a maximal intracranial tumour burden reduction seems to be beneficial, especially in ICI-naïve patients. This highlights the importance of local CNS control and the need to further investigating the role of initial surgical tumour load reduction in randomised clinical trials.
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Affiliation(s)
- Stefanos Voglis
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland.
| | - Valentina Schaller
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Timothy Müller
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Meltem Gönel
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Sebastian Winklhofer
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Joana Mangana
- Department of Dermatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Reinhard Dummer
- Department of Dermatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Emilie Le Rhun
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland; Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Marian C Neidert
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland; Department of Neurosurgery, Cantonal Hospital St.Gallen, University of St.Gallen Medical School, St.Gallen, Switzerland
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Matsumae M, Nishiyama J, Kuroda K. Intraoperative MR Imaging during Glioma Resection. Magn Reson Med Sci 2022; 21:148-167. [PMID: 34880193 PMCID: PMC9199972 DOI: 10.2463/mrms.rev.2021-0116] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/11/2021] [Indexed: 11/09/2022] Open
Abstract
One of the major issues in the surgical treatment of gliomas is the concern about maximizing the extent of resection while minimizing neurological impairment. Thus, surgical planning by carefully observing the relationship between the glioma infiltration area and eloquent area of the connecting fibers is crucial. Neurosurgeons usually detect an eloquent area by functional MRI and identify a connecting fiber by diffusion tensor imaging. However, during surgery, the accuracy of neuronavigation can be decreased due to brain shift, but the positional information may be updated by intraoperative MRI and the next steps can be planned accordingly. In addition, various intraoperative modalities may be used to guide surgery, including neurophysiological monitoring that provides real-time information (e.g., awake surgery, motor-evoked potentials, and sensory evoked potential); photodynamic diagnosis, which can identify high-grade glioma cells; and other imaging techniques that provide anatomical information during the surgery. In this review, we present the historical and current context of the intraoperative MRI and some related approaches for an audience active in the technical, clinical, and research areas of radiology, as well as mention important aspects regarding safety and types of devices.
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Affiliation(s)
- Mitsunori Matsumae
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Jun Nishiyama
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kagayaki Kuroda
- Department of Human and Information Sciences, School of Information Science and Technology, Tokai University, Hiratsuka, Kanagawa, Japan
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