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Koay JM, Michaelides L, Moniz-Garcia DP, Quinones-Hinojosa A, Chaichana K, Almeida JP, Gruenbaum BF, Sherman WJ, Sabsevitz DS. Repeated surgical resections for management of high-grade glioma and its impact on quality of life. J Neurooncol 2024; 167:267-273. [PMID: 38349476 DOI: 10.1007/s11060-024-04600-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/06/2024] [Indexed: 04/18/2024]
Abstract
PURPOSE High-grade gliomas (HGG) are aggressive cancers, and their recurrence is inevitable, despite advances in treatment options. While repeated tumor resection has been shown to increase survival rate, its impact on quality of life is not clearly defined. To address this gap, we compared quality of life (QoL) changes in HGG patients who underwent first-time (FTR) versus repeat surgical resections (RSR) for management of recurrence. METHODS Forty-four adults with HGG who underwent tumor resection were included in this study and classified into either the FTR group (n = 23) or the RSR group (n = 21). All patients completed comprehensive neuropsychological evaluations that included the Functional Assessment of Cancer Therapy-General (FACT-G) and Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) scales, pre-operatively and at two weeks post-operatively. RESULTS There was no difference between the FTR and RSR groups in any of the QoL indices (all p > .05), except for improved emotional well-being and worsened social well-being, suggesting minimal detrimental effects of repeat surgeries on QoL in comparison to first time surgery. CONCLUSIONS These results suggest that repeated resection is a viable strategy in certain cases for management of HGG recurrence, with similar impact on QoL as observed in patients undergoing first time surgery. These encouraging outcomes provide useful insight to guide treatment strategies and patient and clinician decision making to optimize surgical and functional outcomes.
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Affiliation(s)
- Jun Min Koay
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, USA.
| | | | | | | | - Kaisorn Chaichana
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Benjamin F Gruenbaum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Wendy J Sherman
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - David S Sabsevitz
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, USA
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
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de Macedo Filho L, Machado CCP, Mendes GBB, Santana LMF, Ruella ME, Grewal S, Chaichana KL, Quinones Hinojosa A, Fermo O, Almeida JP. Spontaneous rhinorrhea and idiopathic intracranial hypertension: a complex and challenging association. Neurol Neurochir Pol 2024; 58:31-37. [PMID: 38393958 DOI: 10.5603/pjnns.98054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/24/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Spontaneous CSF leak is a known complication of idiopathic intracranial hypertension (IIH). Patients with CSF rhinorrhea present a unique challenge within the IIH population, as the occurrence of a leak can mask the typical IIH symptoms and signs, complicating the diagnosis. Treatment of leaks in this population can also be challenging, with the risk of rhinorrhea recurrence if intracranial hypertension is not adequately treated. OBJECTIVE The aim of this narrative review was to examine current literature on the association between spontaneous CSF rhinorrhea leaks and IIH, focusing on key clinical features, diagnostic approaches, management strategies, and outcomes. MATERIAL AND METHODS A literature search was executed using the PubMed and Scopus databases. The search was confined to articles published between January 1985 and August 2023; extracted data was then analysed to form the foundation of the narrative review. RESULTS This search yielded 26 articles, comprising 943 patients. Average age was 46.8 ± 6.5 years, and average body mass index was 35.8 ± 4.8. Most of the patients were female (74.33%). Presenting symptoms were rhinorrhea, headaches and meningitis. The most common imaging findings were empty sella and encephalocele. The standard treatment approach was endoscopic endonasal approach for correction of CSF rhinorrhea leak, and shunt placement was also performed in 128 (13%) patients. Recurrences were observed in 10% of cases. CONCLUSIONS The complex relationship between spontaneous CSF leaks and IIH is a challenge that benefits from multidisciplinary evaluation and management for successful treatment. Treatments such as endoscopic repair, acetazolamide, and VP/ /LP shunts reduce complications and recurrence. Personalised plans addressing elevated intracranial pressure are crucial for successful outcomes.
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Affiliation(s)
- Leonardo de Macedo Filho
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States.
| | | | | | | | | | - Sanjeet Grewal
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, United States
| | - Kaisorn L Chaichana
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, United States
| | | | - Olga Fermo
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States
| | - Joao Paulo Almeida
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, United States
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3
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Alvarez Caicedo DC, Donaldson AM, Samson SL, Chaichana KL, Almeida JP. Endoscopic Endonasal Transcavernous Hemipituitary Transposition for Resection of Invasive Prolactinoma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01038. [PMID: 38299803 DOI: 10.1227/ons.0000000000001075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/13/2023] [Indexed: 02/02/2024] Open
Abstract
Invasive prolactinomas often require multimodal management including medical and surgical interventions. Here, we present the case of a 34-year-old man with a history of progressive visual disturbances. MRI unveiled a sella lesion with suprasellar and retrosellar extensions. Elevated prolactin levels (6125 ng/mL) confirmed the diagnosis of prolactinoma, leading to initiation of medical treatment, with gradual escalation to maximum dosing. The patient achieved only partial hormonal response and incomplete improvement of symptoms, and therefore, surgical intervention was pursued with objective of maximum safe resection. The patient consented to the procedure. An endonasal endoscopic approach was selected. Surgical procedures encompassed transsellar, transtuberculum, and transplanum approaches, extended laterally to expose the right parasellar carotid and the anterior wall of the cavernous sinus. Subsequent steps involved opening the sellar and suprasellar dura mater, anterior wall of the cavernous sinus, and transcavernous hemipituitary transposition for access to the retrosellar region.1-5 Debulking of the lesion was performed, followed by dissection of the retrosellar space and resection of tumor component within the interpeduncular cistern. Reconstruction employed dura substitute and vascularized nasoseptal flap. Histopathology confirmed diagnosis of prolactinoma. Postoperative MRI findings and significantly improved prolactin levels (50 ng/mL) were compatible with near total resection. The patient's postoperative course was uneventful, resulting in discharge on the second postoperative day. The patient was additionally started on cabergoline 0.5 mg 2x/week to achieve hormonal control. This case demonstrates the application of surgical anatomy and its translation in modern surgical techniques that allow improved resection of such complex tumors while ensuring optimal clinical outcomes.
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Affiliation(s)
- Diana C Alvarez Caicedo
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
- Department of Neurosurgery, Hospital El Cruce, Buenos Aires, Argentina
| | - Angela M Donaldson
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Susan L Samson
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Ghaith AK, El-Hajj VG, Sanchez-Garavito JE, Zamanian C, Ghanem M, Bon-Nieves A, Chen B, Drees CN, Miller D, Parker JJ, Almeida JP, Elmi-Terander A, Tatum W, Middlebrooks EH, Bydon M, Van-Gompel JJ, Lundstrom BN, Grewal SS. Trends in the Utilization of Surgical Modalities for the Treatment of Drug-Resistant Epilepsy: A Comprehensive 10-Year Analysis Using the National Inpatient Sample. Neurosurgery 2024:00006123-990000000-01011. [PMID: 38189460 DOI: 10.1227/neu.0000000000002811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/10/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Epilepsy is considered one of the most prevalent and severe chronic neurological disorders worldwide. Our study aims to analyze the national trends in different treatment modalities for individuals with drug-resistant epilepsy and investigate the outcomes associated with these procedural trends in the United States. METHODS Using the National Inpatient Sample database from 2010 to 2020, patients with drug-resistant focal epilepsy who underwent laser interstitial thermal therapy (LITT), open surgical resection, vagus nerve stimulation (VNS), or responsive neurostimulation (RNS) were identified. Trend analysis was performed using piecewise joinpoint regression. Propensity score matching was used to compare outcomes between 10 years prepandemic before 2020 and the first peak of the COVID-19 pandemic. RESULTS This study analyzed a total of 33 969 patients with a diagnosis of drug-resistant epilepsy, with 3343 patients receiving surgical resection (78%), VNS (8.21%), RNS (8%), and LITT (6%). Between 2010 and 2020, there was an increase in the use of invasive electroencephalography monitoring for seizure zone localization (P = .003). There was an increase in the use of LITT and RNS (P < .001), while the use of surgical resection and VNS decreased over time (P < .001). Most of these patients (89%) were treated during the pre-COVID pandemic era (2010-2019), while a minority (11%) underwent treatment during the COVID pandemic (2020). After propensity score matching, the rate of pulmonary complications, postprocedural hematoma formation, and mortality were slightly higher during the pandemic compared with the prepandemic period (P = .045, P = .033, and P = .026, respectively). CONCLUSION This study indicates a relative decrease in the use of surgical resections, as a treatment for drug-resistant focal epilepsy. By contrast, newer, minimally invasive surgical approaches including LITT and RNS showed gradual increases in usage.
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Affiliation(s)
- Abdul Karim Ghaith
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Victor Gabriel El-Hajj
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Cameron Zamanian
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Marc Ghanem
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Antonio Bon-Nieves
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Baibing Chen
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - David Miller
- Department of Diagnostic Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jonathon J Parker
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Joao Paulo Almeida
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - William Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie J Van-Gompel
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Sanjeet S Grewal
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Moniz-Garcia D, Bojaxhi E, Borah BJ, Dholakia R, Kim H, Sousa-Pinto B, Almeida JP, Mendhi M, Freeman WD, Sherman W, Christel L, Rosenfeld S, Grewal SS, Middlebrooks EH, Sabsevitz D, Gruenbaum BF, Chaichana KL, Quiñones-Hinojosa A. Awake Craniotomy Program Implementation. JAMA Netw Open 2024; 7:e2352917. [PMID: 38265799 PMCID: PMC10809012 DOI: 10.1001/jamanetworkopen.2023.52917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/30/2023] [Indexed: 01/25/2024] Open
Abstract
Importance Implementing multidisciplinary teams for treatment of complex brain tumors needing awake craniotomies is associated with significant costs. To date, there is a paucity of analysis on the cost utility of introducing advanced multidisciplinary standardized teams to enable awake craniotomies. Objective To assess the cost utility of introducing a standardized program of awake craniotomies. Design, Setting, and Participants A retrospective economic evaluation was conducted at Mayo Clinic Florida. All patients with single, unilateral lesions who underwent elective awake craniotomies between January 2016 and December 2021 were considered eligible for inclusion. The economic perspective of the health care institution and a time horizon of 1 year were considered. Data were analyzed from October 2022 to May 2023. Exposure Treatment with an awake craniotomy before standardization (2016-2018) compared with treatment with awake craniotomy after standardization (2018-2021). Main Outcomes and Measures Patient demographics, perioperative, and postoperative outcomes, including length of stay, intensive care (ICU) admission, extent of resection, readmission rates, and 1-year mortality were compared between patients undergoing surgery before and after standardization. Direct medical costs were estimated from Medicare reimbursement rates for all billed procedures. A cost-utility analysis was performed considering differences in direct medical costs and in 1-year mortality within the periods before and after standardization of procedures. Uncertainty was explored in probability sensitivity analysis. Results A total of 164 patients (mean [SD] age, 49.9 [15.7] years; 98 [60%] male patients) were included in the study. Of those, 56 underwent surgery before and 108 after implementation of procedure standardization. Procedure standardization was associated with reductions in length of stay from a mean (SD) of 3.34 (1.79) to 2.46 (1.61) days (difference, 0.88 days; 95% CI, 0.33-1.42 days; P = .002), length of stay in ICU from a mean (SD) of 1.32 (0.69) to 0.99 (0.90) nights (difference, 0.33 nights; 95% CI, 0.06-0.60 nights; P = .02), 30-day readmission rate from 14% (8 patients) in the prestandardization cohort to 5% (5 patients) (difference, 9%; 95% CI, 19.6%-0.3%; P = .03), while extent of resection and intraoperative complication rates were similar between both cohorts. The standardized protocol was associated with mean (SD) savings of $7088.80 ($12 389.50) and decreases in 1-year mortality (dominant intervention). This protocol was found to be cost saving in 75.5% of all simulations in probability sensitivity analysis. Conclusions and Relevance In this economic evaluation of standardization of awake craniotomy, there was a generalized reduction in length of stay, ICU admission time, and direct medical costs with implementation of an optimized protocol. This was achieved without compromising patient outcomes and with similar extent of resection, complication rates, and reduced readmission rates.
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Affiliation(s)
| | - Elird Bojaxhi
- Department of Anesthesiology, Mayo Clinic Florida, Jacksonville
| | - Bijan J Borah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Ruchita Dholakia
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Han Kim
- Department of Anesthesiology, Mayo Clinic Florida, Jacksonville
| | - Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | | | - Marvesh Mendhi
- Department of Anesthesiology, Mayo Clinic Florida, Jacksonville
| | | | - Wendy Sherman
- Department of Neurology, Mayo Clinic Florida, Jacksonville
| | - Lynda Christel
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville
| | | | | | | | - David Sabsevitz
- Department of Neuropsychology, Mayo Clinic Florida, Jacksonville
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Almeida JP, Finger G, Weber MD, Damante MA, Wu KC, Walz P, Leonard JR, Carrau RL, Prevedello DM. Intradural Pituitary Hemitransposition: Technical Note and Case Series Illustration. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-01003. [PMID: 38132563 DOI: 10.1227/ons.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Lesions located in the retrosellar region, interpeduncular cistern, and petroclival region are among the most difficult to access in neurosurgery. Transcranial approaches are useful; however, the large distance between the surgeon and the lesion as well as the presence of major neurovascular structures surrounding the lesion may limit surgical exposure. A midline transsphenoidal route avoids transgression of the neurovascular plane and provides direct access to the interpeduncular cistern. To safely access the interpeduncular fossa, it requires mobilization of the pituitary gland. The pituitary hemitransposition technique permits mobilization of the gland, while preserving its venous drainage and arterial supply to the gland on one of its sides, preserving gland function. The authors aim to describe the intradural pituitary hemitransposition technique and to demonstrate its safe application for resection of skull base tumors in the retrosellar space. METHODS The authors describe the surgical technique and illustrate its application in 5 cases of different types of skull base tumors, including a video demonstrating all the steps to perform this approach. In addition, the authors discuss the advantages and limitations of this technique compared with other approaches to the retrosellar space. RESULTS The intradural pituitary hemitransposition technique was used to safely resect a chondrosarcoma, chordoma, craniopharyngioma, teratoma, and meningioma involving the parasellar and retrosellar spaces, while minimizing endocrine morbidity. We had one patient with mild, albeit permanent hyperprolactinemia and hypothyroidism after surgery. No other patients had permanent dysfunction related to surgery. CONCLUSION The endonasal endoscopic intradural pituitary hemitransposition approach is an effective technique for resection of lesions located within the retrosellar and petroclival regions, allowing adequate exposure while potentially optimizing the preservation of the pituitary function.
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Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Guilherme Finger
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthieu D Weber
- The Ohio State University College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Mark A Damante
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kyle C Wu
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Patrick Walz
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jeffrey R Leonard
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Ramos-Fresnedo A, Al-Kharboosh R, Twohy EL, Basil AN, Szymkiewicz EC, Zubair AC, Trifiletti DM, Durand N, Dickson DW, Middlebrooks EH, Abarbanel DN, Tzeng SY, Almeida JP, Chaichana KL, Green JJ, Sherman WJ, Quiñones-Hinojosa A. Phase 1, Dose Escalation, Nonrandomized, Open-Label, Clinical Trial Evaluating the Safety and Preliminary Efficacy of Allogenic Adipose-Derived Mesenchymal Stem Cells for Recurrent Glioblastoma: A Clinical Trial Protocol. Neurosurg Pract 2023; 4:e00062. [PMID: 38464470 PMCID: PMC10923529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background and Objectives Despite standard of care with maximal safe resection and chemoradiation, glioblastoma is the most common and aggressive type of primary brain cancer. Surgical resection provides a window of opportunity to locally treat gliomas while the patient is recovering, and before initiating concomitant chemoradiation. To assess the safety and establish the maximum tolerated dose of adipose-derived mesenchymal stem cells (AMSCs) for the treatment of recurrent glioblastoma (GBM). Secondary objectives are to assess the toxicity profile and long-term survival outcomes of patients enrolled in the trial. Additionally, biospecimens will be collected to explore the local and systemic responses to this therapy. Methods We will conduct a phase 1, dose escalated, non-randomized, open label, clinical trial of GBM patients who are undergoing surgical resection for recurrence. Up to 18 patients will receive intra-cavitary application of AMSCs encapsulated in fibrin glue during surgical resection. All patients will be followed for up to 5 years for safety and survival data. Adverse events will be recorded using the CTCAE V5.0. Expected Outcomes This study will explore the maximum tolerated dose (MTD) of AMSCs along with the toxicity profile of this therapy in patients with recurrent GBM. Additionally, preliminary long-term survival and progression-free survival outcome analysis will be used to power further randomized studies. Lastly, CSF and blood will be obtained throughout the treatment period to investigate circulating molecular and inflammatory tumoral/stem cell markers and explore the mechanism of action of the therapeutic intervention. Discussion This prospective translational study will determine the initial safety and toxicity profile of local delivery of AMSCs for recurrent GBM. It will also provide additional survival metrics for future randomized trials.
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Affiliation(s)
| | | | - Erin L. Twohy
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Abba C. Zubair
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
- Center for Regenerative Biotherapeutics, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Nisha Durand
- Center for Regenerative Biotherapeutics, Mayo Clinic, Jacksonville, Florida, USA
| | - Dennis W. Dickson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - Erik H. Middlebrooks
- Department of Radiology, Neuroradiology Division, Mayo Clinic, Jacksonville, Florida, USA
| | - David N. Abarbanel
- Department of Neurology, Neuro-Oncology Division, Mayo Clinic, Jacksonville, Florida, USA
| | - Stephany Y. Tzeng
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Jordan J. Green
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Wendy J. Sherman
- Department of Neurology, Neuro-Oncology Division, Mayo Clinic, Jacksonville, Florida, USA
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8
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Almeida JP, Marenco-Hillembrand L, Moniz-Garcia D, Goyal A, Olomu OU, Quinones-Hinojosa A. Endoscopic Endonasal Approach for Resection of a Recurrent Craniopharyngioma: Techniques to Maximize Surgical Exposure and Extent of Resection. World Neurosurg 2023; 180:66. [PMID: 37454903 DOI: 10.1016/j.wneu.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
Craniopharyngiomas are challenging tumors of the central nervous system that originate from epithelial remnants of the Rathke pouch.1-3 Despite maximum safe resection, these tumors present a high tendency to recur (∼20%-40%), even after apparent gross total resection.1,2 The management of recurrent craniopharyngiomas is more challenging, associated with a higher risk of permanent morbidity and complications.1,3 The endoscopic endonasal approach is an option for recurrent tumors, especially in the presence of a previous transcranial approach.1,3-7 In Video 1, we present a case of a 63-year-old man with a recurrent craniopharyngioma with a 2-month history of visual decline, confusion, impaired memory, and episodes of urinary incontinence. On physical examination, he presented slow speech, word-finding difficulties, and left homonymous hemianopsia. Magnetic resonance imaging evidenced a large suprasellar, retrochiasmatic mass with solid (calcified) and cystic components with interval progression compared with previous scans. Treatment options were discussed, and the patient consented to undergo maximum safe resection through an extended endoscopic endonasal approach. Surgical techniques are presented side by side with anatomic dissections to illustrate key steps of the procedure. The patient tolerated the procedure well, with gross total resection of the tumor and without complications or postoperative cerebrospinal fluid leaks. He was subsequently discharged home on postoperative day 5 with continued hormonal replacement therapy. On follow-up, the patient presented marked improvement in his cognitive function. The patient gave informed consent for the use of their images.
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Affiliation(s)
- Joao Paulo Almeida
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA.
| | | | - Diogo Moniz-Garcia
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Anshit Goyal
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Osarenoma U Olomu
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
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9
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Kalyvas A, Almeida JP, Nassiri F, Lau R, O'Halloran PJ, Mohan N, Wälchli T, Ye VC, Tang DM, Soni P, Potter T, Ezzat S, Kshettry VR, Zadeh G, Recinos PF, Gentili F. Endoscopic endonasal surgery for prolactinomas: prognostic factors for disease control and management of persistent disease. Neurosurg Rev 2023; 46:295. [PMID: 37940745 DOI: 10.1007/s10143-023-02199-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/19/2023] [Accepted: 10/22/2023] [Indexed: 11/10/2023]
Abstract
Only a limited number of studies have focused on the results of the Endoscopic Endonasal Approach (EEA) for treatment of prolactinomas. We sought to assess the effectiveness of EEA for prolactinoma surgery, identify factors for disease remission, and present our approach for the management of persistent disease. Forty-seven prolactinomas operated over 10 years, with a mean follow-up of 59.9 months, were included. The primary endpoints were early disease remission and remission at last follow-up. Resistance/intolerance to DA were surgical indications in 76.7%. Disease remission was achieved in 80% of microprolactinomas and 100% of microprolactinomas enclosed by the pituitary. Early disease remission was correlated with female gender (p=0.03), lower preoperative PRL levels (p=0.014), microadenoma (p=0.001), lack of radiological hemorrhage (p=0.001), absence of cavernous sinus (CS) invasion (p<0.001), and extent of resection (EOR) (p<0.001). Persistent disease was reported in 48.9% of patients, with 47% of them achieving remission at last follow-up with DA therapy alone. Repeat EEA and/or radiotherapy were utilized in 6 patients, with 66.7% achieving remission. Last follow-up remission was achieved in 76.6%, with symptomatic improvement in 95.8%. Factors predicting last follow-up remission were no previous operation (p=0.001), absence of CS invasion (p=0.01), and EOR (p<0.001). Surgery is effective for disease control in microprolactinomas. In giant and invasive tumors, it may significantly reduce the tumor volume. A multidisciplinary approach may lead to long-term disease control in three-quarters of patients, with symptomatic improvement in an even greater proportion.
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Affiliation(s)
- Aristotelis Kalyvas
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
| | | | - Farshad Nassiri
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ruth Lau
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Philip J O'Halloran
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nilesh Mohan
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Thomas Wälchli
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vincent C Ye
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Dennis M Tang
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Pranay Soni
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tamia Potter
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Shereen Ezzat
- Endocrine Oncology Site, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Varun R Kshettry
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Pablo F Recinos
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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10
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Geltzeiler M, Choby GW, Ji KSY, JessMace C, Almeida JP, de Almeida J, Champagne PO, Chan E, Ciporen JN, Chaskes MB, Cornell S, Drozdowski V, Fernandez-Miranda J, Gardner PA, Hwang PH, Kalyvas A, Kong KA, McMillan RA, Nayak JV, Patel C, Patel ZM, Celda MP, Pinheiro-Neto C, Sanusi OR, Snyderman CH, Thorp BD, Van Gompel JJ, Zadeh G, Zenonos G, Zwagerman NT, Wang EW. Radiographic predictors of occult intracranial involvement in olfactory neuroblastoma patients. Int Forum Allergy Rhinol 2023; 13:1876-1888. [PMID: 36841933 DOI: 10.1002/alr.23145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/30/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND Traditional management of olfactory neuroblastoma (ONB) includes margin-negative resection with removal of cribriform plate, dura, and olfactory bulb, regardless of intracranial disease. This approach may be overtreating certain patients. Our investigation examines risk factors associated with occult intracranial disease to optimize therapeutic outcomes. METHODS This retrospective, multi-institutional cohort study examined clinical covariates associated with occult intracranial involvement. Patient demographics, staging, Hyam's grade, and pathologic involvement of dura, olfactory bulb/tract, and brain were collected. Diagnostic imaging was reviewed. Positive and negative predictive value (NPV) were estimated along with effect size estimates. Cox hazard regression examined associations with overall survival (OS) and disease-free survival (DFS). RESULTS A total of 224 subjects with new diagnoses of ONB (2005-2021) were identified. Skull base bone involvement on computed tomography (CT) had the highest NPV for pathologic dura (88.0%), olfactory bulb (88%), and brain involvement (97.3%). Hyam's grade category was significantly associated with dural involvement (φC = 0.26; 95% confidence interval [CI]: 0.16, 0.42). Subjects without radiologic skull base involvement (n = 66) had pathologic positivity of 12.1%. Within this subgroup, Hyam's grade was clinically significant for dural positivity (φ = 0.34; 95% CI: -0.12, 0.71) with 28.6% involvement in high grade tumors. Neither clinical nor pathologic positivity of intracranial structures were associated with significantly different OS or DFS. CONCLUSIONS Both CT and magnetic resonance imaging (MRI) had reasonably good NPV for involvement of dura and olfactory bulb. Higher Hyam's grade was associated with dural involvement. Patients with low-grade tumors not involving the skull base may be suitable for avoiding skull base resection; however, further investigation is warranted.
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Affiliation(s)
- Mathew Geltzeiler
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Garret W Choby
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Keven Seung Yong Ji
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - C JessMace
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Joao Paulo Almeida
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - John de Almeida
- Department of Surgery, University of Toronto, Ontario, Canada
| | | | - Erik Chan
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Jeremy N Ciporen
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark B Chaskes
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sarah Cornell
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Veronica Drozdowski
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | | | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | | | - Keonho A Kong
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ryan A McMillan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jayakar V Nayak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Chirag Patel
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Zara M Patel
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Maria Peris Celda
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Carlos Pinheiro-Neto
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Olabisi R Sanusi
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Carl H Snyderman
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian D Thorp
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jamie J Van Gompel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gelareh Zadeh
- Department of Surgery, University of Toronto, Ontario, Canada
| | - Georgios Zenonos
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nathan T Zwagerman
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Eric W Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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11
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McKevitt C, Gabriel E, Marenco-Hillembrand L, Otamendi-Lopez A, Jeevaratnam S, Almeida JP, Samson S, Chaichana KL. Supervised machine learning to validate a novel scoring system for the prediction of disease remission of functional pituitary adenomas following transsphenoidal surgery. Sci Rep 2023; 13:15409. [PMID: 37717023 PMCID: PMC10505180 DOI: 10.1038/s41598-023-42157-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/06/2023] [Indexed: 09/18/2023] Open
Abstract
Functional pituitary adenomas (FPAs) are associated with hormonal hypersecretion resulting in systemic endocrinopathies and increased mortality. The heterogenous composition of the FPA population has made modeling predictive factors of postoperative disease remission a challenge. Here, we aim to define a novel scoring system predictive of disease remission following transsphenoidal surgery (TSS) for FPAs and validate our process using supervised machine learning (SML). 392 patients with FPAs treated at one of the three Mayo Clinic campuses were retrospectively reviewed. Variables found significant on multivariate analysis were incorporated into our novel Pit-SCHEME score. The Pit-SCHEME score with a cut-off value ≥ 6 achieved a sensitivity of 86% and positive likelihood ratio of 2.88. In SML models, without the Pit-SCHEME score, the k-nearest neighbor (KNN) model achieved the highest accuracy at 75.6%. An increase in model sensitivity was achieved with inclusion of the Pit-SCHEME score with the linear discriminant analysis (LDA) model achieving an accuracy of 86.9%, which suggests the Pit-SCHEME score is the variable of most importance for prediction of postoperative disease remission. Ultimately, these results support the potential clinical utility of the Pit-SCHEME score and its prospective future for aiding in the perioperative decision making in patients with FPAs.
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Affiliation(s)
- Chase McKevitt
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| | - Ellie Gabriel
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Lina Marenco-Hillembrand
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Andrea Otamendi-Lopez
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Suren Jeevaratnam
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Joao Paulo Almeida
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Susan Samson
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
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12
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Choby G, Geltzeiler M, Almeida JP, Champagne PO, Chan E, Ciporen J, Chaskes MB, Fernandez-Miranda J, Gardner P, Hwang P, Ji KSY, Kalyvas A, Kong KA, McMillan R, Nayak J, O’Byrne J, Patel C, Patel Z, Peris Celda M, Pinheiro-Neto C, Sanusi O, Snyderman C, Thorp BD, Van Gompel JJ, Young SC, Zenonos G, Zwagerman NT, Wang EW. Multicenter Survival Analysis and Application of an Olfactory Neuroblastoma Staging Modification Incorporating Hyams Grade. JAMA Otolaryngol Head Neck Surg 2023; 149:837-844. [PMID: 37535372 PMCID: PMC10401389 DOI: 10.1001/jamaoto.2023.1939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Abstract
Importance Current olfactory neuroblastoma (ONB) staging systems inadequately delineate locally advanced tumors, do not incorporate tumor grade, and poorly estimate survival and recurrence. Objective The primary aims of this study were to (1) examine the clinical covariates associated with survival and recurrence of ONB in a modern-era multicenter cohort and (2) incorporate Hyams tumor grade into existing staging systems to assess its ability to estimate survival and recurrence. Design, Setting, and Participants This retrospective, multicenter, case-control study included patients with ONB who underwent treatment between January 1, 2005, and December 31, 2021, at 9 North American academic medical centers. Intervention Standard-of-care ONB treatment. Main Outcome and Measures The main outcomes were overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) as C statistics for model prediction. Results A total of 256 patients with ONB (mean [SD] age, 52.0 [15.6] years; 115 female [44.9%]; 141 male [55.1%]) were included. The 5-year rate for OS was 83.5% (95% CI, 78.3%-89.1%); for DFS, 70.8% (95% CI, 64.3%-78.0%); and for DSS, 94.1% (95% CI, 90.5%-97.8%). On multivariable analysis, age, American Joint Committee on Cancer (AJCC) stage, involvement of bilateral maxillary sinuses, and positive margins were associated with OS. Only AJCC stage was associated with DFS. Only N stage was associated with DSS. When assessing the ability of staging systems to estimate OS, the best-performing model was the novel modification of the Dulguerov system (C statistic, 0.66; 95% CI, 0.59-0.76), and the Kadish system performed most poorly (C statistic, 0.57; 95% CI, 0.50-0.63). Regarding estimation of DFS, the modified Kadish system performed most poorly (C statistic, 0.55; 95% CI, 0.51-0.66), while the novel modification of the AJCC system performed the best (C statistic, 0.70; 95% CI, 0.66-0.80). Regarding estimation of DSS, the modified Kadish system was the best-performing model (C statistic, 0.79; 95% CI, 0.70-0.94), and the unmodified Kadish performed the worst (C statistic, 0.56; 95% CI, 0.51-0.68). The ability for novel ONB staging systems to estimate disease progression across stages was also assessed. In the novel Kadish staging system, patients with stage VI disease were approximately 7 times as likely to experience disease progression as patients with stage I disease (hazard ratio [HR], 6.84; 95% CI, 1.60-29.20). Results were similar for the novel modified Kadish system (HR, 8.99; 95% CI, 1.62-49.85) and the novel Dulguerov system (HR, 6.86; 95% CI, 2.74-17.18). Conclusions and Relevance The study findings indicate that 5-year OS for ONB is favorable and that incorporation of Hyams grade into traditional ONB staging systems is associated with improved estimation of disease progression.
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Affiliation(s)
- Garret Choby
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mathew Geltzeiler
- Department of Otolaryngology–Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon
| | | | | | - Erik Chan
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Jeremy Ciporen
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Mark B. Chaskes
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill
| | | | - Paul Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Peter Hwang
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Keven Seung Yong Ji
- Department of Otolaryngology–Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon
| | | | - Keonho A. Kong
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill
| | - Ryan McMillan
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jayakar Nayak
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Jamie O’Byrne
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Chirag Patel
- Department of Otolaryngology–Head and Neck Surgery, Loyola University, Maywood, Illinois
| | - Zara Patel
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Maria Peris Celda
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Carlos Pinheiro-Neto
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Olabisi Sanusi
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill
| | - Carl Snyderman
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian D. Thorp
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill
| | | | - Sarah C. Young
- Department of Neurological Surgery, University of Wisconsin, Milwaukee, Wisconsin
| | - Georgios Zenonos
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nathan T. Zwagerman
- Department of Neurological Surgery, University of Wisconsin, Milwaukee, Wisconsin
| | - Eric W. Wang
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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13
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Figueredo LF, Shelton WJ, Tagle-Vega U, Sanchez E, de Macedo Filho L, Salazar AF, Murguiondo-Pérez R, Fuentes S, Marenco-Hillembrand L, Suarez-Meade P, Ordoñez-Rubiano E, Gomez Amarillo D, Albuquerque LAF, de Amorim RLO, Vasquez CM, Baldoncini M, Mejia JA, Niño C, Ramon JF, Hakim F, Mendez-Rosito D, Navarro-Bonnet J, Quiñones-Hinojosa A, Almeida JP. The state of art of awake craniotomy in Latin American countries: a scoping review. J Neurooncol 2023; 164:287-298. [PMID: 37698707 DOI: 10.1007/s11060-023-04433-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/22/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Awake craniotomy (AC) is a valuable technique for surgical interventions in eloquent areas, but its adoption in low- and middle-income countries faces challenges like limited infrastructure, trained personnel shortage, and inadequate funding. This scoping review explores AC techniques in Latin American countries, focusing on patient characteristics, tumor location, symptomatology, and outcomes. METHODS A scoping review followed PRISMA guidelines, searching five databases in English, Spanish, and Portuguese. We included 28 studies with 258 patients (mean age: 43, range: 11-92). Patterns in AC use in Latin America were analyzed. RESULTS Most studies were from Brazil and Mexico (53.6%) and public institutions (70%). Low-grade gliomas were the most common lesions (55%), most of them located in the left hemisphere (52.3%) and frontal lobe (52.3%). Gross-total resection was achieved in 34.3% of cases. 62.9% used an Asleep-Awake-Asleep protocol, and 14.8% used Awake-Awake-Awake. The main complication was seizures (14.6%). Mean post-surgery discharge time was 68 h. Challenges included limited training, infrastructure, and instrumentation availability. Strategies discussed involve training in specialized centers, seeking sponsorships, applying for awards, and multidisciplinary collaborations with neuropsychology. CONCLUSION Improved accessibility to resources, infrastructure, and adequate instrumentation is crucial for wider AC availability in Latin America. Despite disparities, AC implementation with proper training and teamwork yields favorable outcomes in resource-limited centers. Efforts should focus on addressing challenges and promoting equitable access to this valuable surgical technique in the region.
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Affiliation(s)
- Luisa F Figueredo
- Department of Psychiatry, NYU Langone Health, New York City, New York, USA.
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA.
- Faculty of Medicine, Universidad de Los Andes, Bogota, Colombia.
| | - William J Shelton
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
- Faculty of Medicine, Universidad de Los Andes, Bogota, Colombia
| | - Uriel Tagle-Vega
- Facultad de Ciencias de La Salud, Escuela Profesional de Medicina Humana, Universidad Andina del Cusco, Cusco, Perú
| | - Emiliano Sanchez
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Leonardo de Macedo Filho
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Andres F Salazar
- Department of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
- Faculty of Medicine, Universidad de Los Andes, Bogota, Colombia
| | - Renata Murguiondo-Pérez
- Faculty of Health Sciences, Universidad Anáhuac México Norte, Huixquilucan, Edo. Mex, México
| | - Santiago Fuentes
- Department of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | | | - Paola Suarez-Meade
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | | | | | | | - Robson Luis Oliveira de Amorim
- Getúlio Vargas Universitary Hospital, Manaus, Amazonas, Brazil
- Department of Neurosurgery, Hospital Adventista de Manaus, Amazonas, Brazil
| | - Carlos M Vasquez
- Unidad de Neurocirugía Funcional Y Oncológica, Instituto Nacional de Ciencias Neurológicas, Lima, Perú
| | - Matias Baldoncini
- Department of Neurosurgery, Hospital de San Fernando, Buenos Aires, Argentina
| | - Juan Armando Mejia
- Department of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Claudia Niño
- Department of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | | | - Fernando Hakim
- Department of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Diego Mendez-Rosito
- Centro Médico Nacional 20 de Noviembre, Skull Base Program Director, Mexico D. F, Mexico
| | - Jorge Navarro-Bonnet
- Department of Neurosurgery, Angeles Health System/Medica Sur Clinical Foundation, Mexico City, Mexico
| | | | - Joao Paulo Almeida
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
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14
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Murayi R, Trivedi MM, Almeida JP, Yeaney G, Isada C, Kshettry VR. Rathke's cleft cyst presenting with recurrent aseptic meningitis and inflammatory apoplexy: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE2383. [PMID: 37399168 PMCID: PMC10550551 DOI: 10.3171/case2383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/17/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Rathke's cleft cyst (RCC) is a benign sellar/suprasellar lesion often discovered incidentally. Rarely, symptomatic cases can present with headache and may exhibit concomitant aseptic meningitis or apoplexy. The authors describe a patient with an RCC presenting with recurring episodes of aseptic meningitis and ultimately inflammatory-type apoplexy. OBSERVATIONS A 30-year-old female presented with three episodes of intractable headaches over 2 months. Each episode's clinical picture was consistent with meningitis though cerebrospinal fluid cultures, and viral tests remained negative. Imaging demonstrated a sellar lesion, initially thought to be coincidental. On the third presentation, there was rapid interval growth of the lesion, adjacent cerebritis, and new endocrinopathy. Resection was then performed via an endoscopic endonasal approach. Pathology showed an RCC with acute and chronic inflammation and no evidence of hemorrhage. Cultures were negative for organisms. The patient received several weeks of antibiotic treatment with the resolution of all symptoms and no recurrence. LESSONS Recurrent aseptic meningitis with apoplexy-like symptoms is a rare presentation of RCC. The authors propose the term inflammatory apoplexy to describe such a presentation without evidence of abscess, necrosis, or hemorrhage. The mechanism is unclear although may be due to intermittent microleakage of cyst contents into the subarachnoid space.
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Affiliation(s)
- Roger Murayi
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Megh M. Trivedi
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Joao Paulo Almeida
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
- Department of Neurosurgery, Mayo Jacksonville, Jacksonville, Florida; and
| | | | - Carlos Isada
- Infectious Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Varun R. Kshettry
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
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15
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Figueredo LF, Martínez AL, Suarez-Meade P, Marenco-Hillembrand L, Salazar AF, Pabon D, Guzmán J, Murguiondo-Perez R, Hallak H, Godo A, Sandoval-Garcia C, Ordoñez-Rubiano EG, Donaldson A, Chaichana KL, Peris-Celda M, Bendok BR, Samson SL, Quinones-Hinojosa A, Almeida JP. Current Role of Endoscopic Endonasal Approach for Craniopharyngiomas: A 10-Year Systematic Review and Meta-Analysis Comparison with the Open Transcranial Approach. Brain Sci 2023; 13:842. [PMID: 37371322 DOI: 10.3390/brainsci13060842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/29/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023] Open
Abstract
In recent years, the endoscopic endonasal approach (EEA) for craniopharyngiomas has proven to be a safe option for extensive tumor resection, with minimal or no manipulation of the optic nerves and excellent visualization of the superior hypophyseal branches when compared to the Transcranial Approach (TCA). However, there is an ongoing debate regarding the criteria for selecting different approaches. To explore the current results of EEA and discuss its role in the management of craniopharyngiomas, we performed MEDLINE, Embase, and LILACS searches from 2012 to 2022. Baseline characteristics, the extent of resection, and clinical outcomes were evaluated. Statistical analysis was performed through an X2 and Fisher exact test, and a comparison between quantitative variables through a Kruskal-Wallis and verified with post hoc Bonferroni. The tumor volume was similar in both groups (EEA 11.92 cm3, -TCA 13.23 cm3). The mean follow-up in months was 39.9 for EEA and 43.94 for TCA, p = 0.76). The EEA group presented a higher visual improvement rate (41.96% vs. 25% for TCA, p < 0.0001, OR 7.7). Permanent DI was less frequent with EEA (29.20% vs. 67.40% for TCA, p < 0.0001, OR 0.2). CSF Leaks occurred more frequently with EEA (9.94% vs. 0.70% for TCA, p < 0.0001, OR 15.8). Recurrence rates were lower in the EEA group (EEA 15.50% vs. for TCA 21.20%, p = 0.04, OR 0.7). Our results demonstrate that, in selected cases, EEA for resection of craniopharyngiomas is associated with better results regarding visual preservation and extent of tumor resection. Postoperative CSF leak rates associated with EEA have improved compared to the historical series. The decision-making process should consider each person's characteristics; however, it is noticeable that recent data regarding EEA justify its widespread application as a first-line approach in centers of excellence for skull base surgery.
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Affiliation(s)
- Luisa F Figueredo
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Andrea L Martínez
- Faculty of Medicine, Universidad de Los Andes, Bogotá 111711, Colombia
| | - Paola Suarez-Meade
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | | | | | - Daniela Pabon
- Faculty of Medicine, Universidad de Los Andes, Bogotá 111711, Colombia
| | - Juan Guzmán
- Faculty of Medicine, Universidad de Los Andes, Bogotá 111711, Colombia
| | | | - Hana Hallak
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN 55901, USA
| | - Alex Godo
- Faculty of Medicine, Universitat Pompeu Fabra & Universitat Autònoma de Barcelona, 08002 Barcelona, Spain
| | | | - Edgar G Ordoñez-Rubiano
- Department of Neurological Surgery, Fundación Universitaria de las Ciencias de la Salud, Hospital de San José-Sociedad de Cirugía de Bogotá, Bogotá 111711, Colombia
| | - Angela Donaldson
- Department of Otolaryngology (ENT), Head and Neck Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - María Peris-Celda
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN 55901, USA
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Susan L Samson
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
- Department of Internal Medicine, Division of Endocrinology, Mayo Clinic, Jacksonville, FL 32224, USA
| | | | - Joao Paulo Almeida
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
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McKevitt C, Marenco-Hillembrand L, Bamimore M, Chandler R, Otamendi-Lopez A, Almeida JP, Quiñones-Hinojosa A, Chaichana KL. Predictive factors for post operative seizures following meningioma resection in patients without preoperative seizures: a multicenter retrospective analysis. Acta Neurochir (Wien) 2023; 165:1333-1343. [PMID: 36977866 DOI: 10.1007/s00701-023-05571-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/15/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE Meningiomas are the most common primary brain tumor and represent 35% of all intracranial neoplasms. However, in the early post-operative period approximate 3-5% of patients experience an acute symptomatic seizure. Establishing risk factors for postoperative seizures will identify those patients without preoperative seizures at greatest risk of postoperative seizures and may guide antiseizure medications (ASMs) management. METHODS Adult seizure naïve patients who underwent primary resection of a World Health Organization (WHO) Grade 1-3 meningioma at the three Mayo Clinic Campuses between 2012-2022 were retrospectively reviewed. Multivariate regression analyses were used to identify radiological, surgical, and management features with the development of new-onset seizures in patients undergoing meningioma resection. RESULTS Of 113 seizure naïve patients undergoing meningioma resection 11 (9.7%) experienced a new-onset post-operative seizure. Tumor volume ≥ 25 cm3 (Odds Ratio (OR) 5.223, 95% Confidence Interval (CI) 1.546 - 17.650, p = 0.008) and cerebral convexity meningiomas (OR 4.742, 95% CI 1.255 - 14.336, p = 0.016) were most associated with new onset postoperative seizures in multivariate analysis. ASMs and corticosteroid therapies did not display a significant difference among those with and without a new onset postoperative seizure. CONCLUSION In the current study, a larger tumor volume (≥ 25 cm3) and/or convexity meningiomas predicted the development of new onset post-operative seizures. Those who present with these factors should be counseled for their increased risk of new onset post-operative seizures and may benefit from prophylactic ASMs therapy.
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Affiliation(s)
- Chase McKevitt
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Lina Marenco-Hillembrand
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Michael Bamimore
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
- Department of Neurological Surgery, Cooper University Health Care, 1 Cooper Plz, Camden, NJ, 08103, USA
| | - Rosemary Chandler
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Andrea Otamendi-Lopez
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Joao Paulo Almeida
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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17
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Almeida JP, Marigil-Sanchez M, Karekezi C, Witterick I, Gentili F. Different Approaches in Skull Base Surgery Carry Risks for Different Types of Complications. Acta Neurochir Suppl 2023; 130:13-18. [PMID: 37548718 DOI: 10.1007/978-3-030-12887-6_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Complications are not uncommon in the complex field of skull base surgery. The intrinsic relationship of lesions in this region to important neurovascular structures, dura mater, and bone may lead to significant morbidity and mortality. The evolution of endoscopic endonasal surgery has had a significant impact on this field as a less invasive option for treatment of selected lesions, but major morbidity may still occur; moreover, endoscopic approaches have been associated with higher rates of some specific complications, such as cerebrospinal fluid leaks. Based on a presented case report, the authors discuss the management of various complications associated with different approaches for resection of skull base malignancies, including epidural and intradural pneumocephalus, subdural hematoma, and subdural empyema. Important lessons learned by the senior author throughout more than 30 years of his skull base surgery practice are highlighted. The inherent risk of complications in skull base surgery emphasizes the importance of their avoidance, prevention, and learning from one's unfavorable experience so as not to repeat them.
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Affiliation(s)
- Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Miguel Marigil-Sanchez
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Claire Karekezi
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Ian Witterick
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada.
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18
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de Macêdo Filho LJM, Diógenes AVG, Barreto EG, Pahwa B, Samson SL, Chaichana K, Quinones-Hinojosa A, Almeida JP. Endoscopic Endonasal Resection of the Medial Wall of the Cavernous Sinus and Its Impact on Outcomes of Pituitary Surgery: A Systematic Review and Meta-Analysis. Brain Sci 2022; 12:brainsci12101354. [PMID: 36291288 PMCID: PMC9599381 DOI: 10.3390/brainsci12101354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/21/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction. Pituitary adenomas have the potential to infiltrate the dura mater, skull, and the venous sinuses. Tumor extension into the cavernous sinus is often observed in pituitary adenomas and techniques and results of surgery in this region are vastly discussed in the literature. Infiltration of parasellar dura and its impact for pituitary surgery outcomes is significantly less studied but recent studies have suggested a role of endoscopic resection of the medial wall of the cavernous sinus, in selected cases. In this study, we discuss the techniques and outcomes of recently proposed techniques for selective resection of the medial wall of the cavernous sinus in endoscopic pituitary surgery. Methods. We performed a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and protocol and a total of 4 studies with 106 patients that underwent an endoscopic approach for resection of pituitary tumors with resection of medial wall from cavernous sinus were included. Clinical and radiological data were extracted (sex, mean age, Knosp, prior surgery, tumor size and type, complication rate, and remission) and a meta-analysis using the RevMan 5.4 software was performed. Results. A total of 5 studies with 208 patients were included in this analysis. The mean age of the study population was 48.87 years (range 25−82) with a female/male ratio of 1:1.36. Majority of the patients had Knosp Grade 1 (n = 77, 37.02%) and Grade 2 (n = 53, 25.48%). The complication rate was 4.81% (n = 33/106) and the most common complication observed was a new transient CN dysfunction and diplopia. Early disease remission was observed in 94.69% of the patients (n = 196/207). The prevalence rate of CS medial wall invasion varied from 10.4 % up to 36.7%. This invasion rate increased in frequency with higher Knosp Grade. The forest plot of persistent disease vs. remission in this surgery approach showed a p < 0.00001 and heterogeneity (I^2 = 0%). Discussion. Techniques to achieve resection of the medial wall of the cavernous sinus via the endoscopic endonasal approach include the “anterior to posterior” technique (opening of the anterior wall of the cavernous sinus) and the “medial to lateral” technique (opening of the inferior intercavernous sinus and). Although potentially related with improved endocrinological outcomes, these are advanced surgical techniques and require extensive anatomical knowledge and extensive surgical experience. Furthermore, to avoid procedure complications, extensive study of the patient’s configuration of cavernous ICA, Doppler-guided intraoperative imaging, surgical navigation system, and blunt tip knives to dissect the ICA’s plane are recommended. Conclusion. Endoscopic resection of the medial wall of the cavernous sinus has been associated with reports of high rates of postoperative hormonal control in functioning pituitary adenomas. However, it represents a more complex approach and requires advanced experience in endoscopic skull base surgery. Additional studies addressing case selection and studies evaluating long term results of this technique are still necessary.
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Affiliation(s)
- Leonardo J. M. de Macêdo Filho
- Health Science Center, University of Fortaleza, Av. Washington Soares 1321, Fortaleza 60811-905, Ceará, Brazil
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Ana Vitória G. Diógenes
- Health Science Center, University of Fortaleza, Av. Washington Soares 1321, Fortaleza 60811-905, Ceará, Brazil
| | - Esther G. Barreto
- Health Science Center, University of Fortaleza, Av. Washington Soares 1321, Fortaleza 60811-905, Ceará, Brazil
| | - Bhavya Pahwa
- Department of Medicine, University College of Medical Sciences, 2, Tahirpur Rd, GTB Enclave, Dilshad Garden, New Delhi, Delhi 110095, India
| | - Susan L. Samson
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
- Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Kaisorn Chaichana
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | | | - Joao Paulo Almeida
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
- Correspondence:
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19
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Trivedi MM, Momin AA, Shao J, Soni P, Almeida JP, Lee J, Recinos PF, Kshettry VR. Radiographic Differentiation of Secretory Meningiomas and WHO Grade 2 Meningiomas: When Atypical Features Are Not Always Predictive of Atypical Tumors. World Neurosurg 2022; 165:e386-e392. [PMID: 35724883 DOI: 10.1016/j.wneu.2022.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/12/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Secretory meningioma (SM) is a rare subtype of World Health Organization (WHO) grade 1 meningioma, associated with significant peritumoral brain edema (PTBE). Because of this, SM may be mistaken preoperatively to be a WHO grade 2 meningioma (G2M). In this study, we identified radiographic features to differentiate these 2 tumor types preoperatively to help inform surgical decision-making. METHODS We performed a retrospective review of all patients with histologically confirmed intracranial SM and G2M at a single institution from 2000 to 2019. Relevant clinic, demographic and radiographic data were collected. We performed a stepwise multivariable logistic regression to identify independent predictors of SM. RESULTS A total of 43 SM and 140 G2M patients were included in this study. In multivariable analysis, severe PTBE, meaning edema size greater than tumor size (odds ratio [OR] 4.44, P = 0.01), tumor hyperintensity on fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging sequences (OR 7.80, P = 0.002), and higher normalized apparent diffusion coefficient (nADC) values (OR 1.54, P < 0.001) were strong predictors of SM. Conversely, larger tumor volume (OR 1.79 per 10 mL volume increase, P < 0.001) and cystic component (OR 12.50, P = 0.007) correlated with G2M. CONCLUSIONS In this study, we found that preoperative FLAIR hyperintensity, severe PTBE, and higher nADC values correlated with SM pathology, and larger size and cystic component were associated with G2M. Accurate identification of SM on preoperative imaging may provide surgeons useful information in decision-making.
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Affiliation(s)
- Megh M Trivedi
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arbaz A Momin
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jianning Shao
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pranay Soni
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joao Paulo Almeida
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA; Department of Neurosurgery, Mayo Jacksonville, Jacksonville, Florida, USA
| | - Jonathan Lee
- Division of Neuroradiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA.
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20
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Almeida JP, Sreenath SB, de Andrade EJ, Recinos PF, Woodard TD, Kshettry VR. Endoscopic Transpterygoid Transcavernous Approach for Resection of a Petroclival Chondrosarcoma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e60-e61. [PMID: 35726942 DOI: 10.1227/ons.0000000000000222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 01/26/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida (Current Affiliation), USA
| | - Satyan B Sreenath
- Department of Otolaryngology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erion J de Andrade
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Troy D Woodard
- Department of Otolaryngology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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21
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Almeida JP, de Andrade E, Reghin-Neto M, Radovanovic I, Recinos PF, Kshettry VR. From Above and Below: The Microsurgical Anatomy of Endoscopic Endonasal and Transcranial Microsurgical Approaches to the Parasellar Region. World Neurosurg 2021; 159:e139-e160. [PMID: 34906753 DOI: 10.1016/j.wneu.2021.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The parasellar region is one of the most complex of the skull base. In this study, we review the anatomy and approaches to this region through a 360° perspective, correlating microsurgical and endoscopic anatomic nuances of this area. METHODS An endoscopic endonasal approach (EEA) and microsurgical dissections were performed. The parasellar anatomy is reviewed and common areas of tumor extensions are assessed. Surgical approaches are discussed based on the anatomic nuances of those regions. RESULTS The cavernous sinus (CS) can be divided into 2 spaces: posterosuperior, above and behind the internal carotid artery (ICA); and anterior, in front of the cavernous ICA. Those spaces can be approached through the CS walls: anterior and/or medial wall via EEA; or superior and/or lateral wall via transcranial approaches. The relationship of the Meckel cave, adjacent to the lateral and posterior wall of the CS, is relevant for surgical planning. Areas often affected by tumor extension can be divided into 6 regions: superior (cisternal), superolateral (parapeduncular), posterolateral (Meckel cave and petrous bone), medial (sella), anterior (superior orbital fissure), and anterior inferior (pterygopalatine fossa). Anatomic and technical nuances of each of those regions should be taken into consideration when dealing with tumors in the parasellar space. CONCLUSIONS A transcranial approach and EEA provide effective access to the parasellar region. Management of cavernous sinus and Meckel cave tumors requires familiarity with those approaches. Understanding of the surgical anatomy of the parasellar region, from above and below, is therefore necessary for adequate surgical planning and execution.
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Affiliation(s)
| | - Erion de Andrade
- Rosa Ella Burkhardt Brain Tumor Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mateus Reghin-Neto
- Institute of Neurological Sciences, Hospital BP Sao Paulo, Sao Paulo, Brazil
| | - Ivan Radovanovic
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pablo F Recinos
- Rosa Ella Burkhardt Brain Tumor Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Rosa Ella Burkhardt Brain Tumor Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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22
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Zuccato J, Patil V, Mansouri S, Liu J, Nassiri F, Mamatjan Y, Chakravarthy A, Karimi S, Almeida JP, Bernat AL, Hasen M, Khan S, Kislinger T, Sinha N, Froelich S, Adle-Biassette H, Aldape K, De Carvalho D, Zadeh G. EPCO-32. IDENTIFICATION OF PROGNOSTIC CHORDOMA SUBGROUPS USING DNA METHYLATION SIGNATURES IN TISSUE AND PLASMA. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab196.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Chordomas are malignant bone cancers arising from the skull-base and spine that are rare but cause devastating central nervous system morbidities. Survival is highly variable despite surgery and radiotherapy as 10% live under 1 year and 30-35% survive over 20 years. There are currently no reliable prognostic factors and this limits our ability to tailor patient treatment to their risk. Accordingly, this work identifies epigenetic prognostic chordoma subgroups that are detectable non-invasively through plasma methylomes to guide treatment.
METHODS
A total of 68 chordoma surgical specimens resected between 1996-2018 across three international centres underwent DNA methylation profiling. Cell-free methylated tumor DNA immunoprecipitation and high-throughput sequencing was performed on available matched plasma samples.
RESULTS
Two stable tumor clusters were identified through consensus clustering of tissue methylation data. Clusters had statistically significantly different disease-specific survivals (log-rank p=0.0062) independent of clinical factors in a multivariable Cox analysis (HR=16.5, 95%CI: 2.8-96, p=0.0018). The poorer-performing “Immune-infiltrated” cluster had genes hypomethylated at promoters, typically resulting in transcription, within immune-related pathways and higher immune cell abundance within tumors. The better-performing “Cellular” cluster showed higher tumor cellularity plus cell-to-cell interaction and extracellular matrix pathway hypomethylation. Fifty chordoma-versus-other binomial generalized linear models built using plasma methylome data distinguished chordomas from meningiomas and spinal metastases, as representative clinical differential diagnoses, in random left-out 20% testing sets (mean AUROC=0.84, 95%CI: 0.52-1.00). Plasma-based methylation signatures were highly correlated with tissue-based signals within both poor-performing (median r=0.69, 95%CI: 0.66-0.72) and better-performing cluster tumors (median r=0.67, 95%CI: 0.62-0.72).
CONCLUSIONS
The first identification of two distinct prognostic epigenetic chordoma subgroups is shown here with “Immune-infiltrated” tumors having a poorer prognosis than “Cellular” tumors. Plasma methylomes can be utilized for non-invasive chordoma diagnosis and subtyping. This work may transform chordoma treatment decision-making by guiding surgical planning in advance to match resection aggressiveness with patient prognosis.
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Affiliation(s)
| | - Vikas Patil
- Princess Margaret Cancer Centre, Toronto, Canada
| | | | - Jeffrey Liu
- Princess Margaret Cancer Centre, Toronto, Canada
| | - Farshad Nassiri
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | - Shahbaz Khan
- Princess Margaret Cancer Centre, Toronto, Canada
| | | | | | | | | | - Kenneth Aldape
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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23
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Ferreira C, Festas T, Alves P, Freitas A, Almeida JP, Martinho S, Goncalves V, Castro G, Baptista R, Goncalves L. Real-world, very long-term follow up survival of incident patients with pulmonary hypertension. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Pulmonary hypertension (PH) is a clinical syndrome characterized by an increase in pulmonary artery pressure. Among the five groups of PH, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) stand out due to their ominous prognosis without specific treatment. However, very long-term outcomes data are scarce.
Purpose
We aimed to assess the very long-term survival of PAH and CTEPH patients followed in a Portuguese PH referral center.
Methods
Between January 2009 and January of 2020, all incident PH cases were consecutively enrolled in a prospective cohort study. A total of 177 patients were followed up for a median of 5.0 [interquartile range 2.3–8.7] years. Kaplan-Meier survival analysis was used to estimate 1-, 5- and 9-year survival and multivariate regression was used to predict independent prognostic factors.
Results
Mean age was 49±20 years with a clear female preponderance (67%). The most common PH subgroups were congenital heart disease (PAH-CHD) (n=62; 35%), followed by CTEPH (n=52; 29,4%), connective tissue disease (PAH-CTD) (n=31; 17.5%), idiopathic/hereditary PAH (I/HPAH (n=22; 12.4%) and portopulmonary hypertension (PoPH) (n=8; 4.5%) (Table 1). PAH-specific drugs were used in 91% of the patients, dual combination therapy in 47.5%, and triple combination in 12.4%. The remaining 9% successfully received non-pharmacological treatment, namely cardiac surgery in PAH-CHD (n=7) and endarterectomy or angioplasty in CTEPH (n=9). Survival rates at 1-, 5- and 9-years were 97%, 80% and 66%, respectively. Age (hazard ratio [HR] 1.02; 95% CI 1.01–1.04; P=0.049), BNP [HR 2.04 (1.16–3.60); P=0.01], admission for decompensation of heart failure (HF) [HR 3.15 (1.71–5.83); P<0.001] and PH type [P=0.01] were predictors of all-cause mortality. PAH-CHD had the better long-term survival (9-year survival of 83%), whereas PAH-CTD and PoPH were associated with a worse prognosis (9-year survival of 24% and 28%, respectively) (Figure 1). Regarding admissions for decompensated right HF, BNP was an independent predictor [HR 3.39 (2.12– 5.43); P<0.001] and no difference was found between PH etiologies.
Conclusions
In this cohort of incident PH patients, the overall 9-year survival rate was 66%. PAH-CHD patients had better overall prognosis, while patients with PAH-CTD and PoPH had the worst prognosis. Additionally, older age, higher BNP and admission for HF were associated with higher mortality.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- C Ferreira
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - T Festas
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - P Alves
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - A Freitas
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - J P Almeida
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - S Martinho
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - V Goncalves
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - G Castro
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - R Baptista
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - L Goncalves
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
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24
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Zuccato JA, Patil V, Mansouri S, Liu JC, Nassiri F, Mamatjan Y, Chakravarthy A, Karimi S, Almeida JP, Bernat AL, Hasen M, Singh O, Khan S, Kislinger T, Sinha N, Froelich S, Adle-Biassette H, Aldape KD, De Carvalho DD, Zadeh G. DNA Methylation based prognostic subtypes of chordoma tumors in tissue and plasma. Neuro Oncol 2021; 24:442-454. [PMID: 34614192 DOI: 10.1093/neuonc/noab235] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Chordomas are rare malignant bone cancers of the skull-base and spine. Patient survival is variable and not reliably predicted using clinical factors or molecular features. This study identifies prognostic epigenetic chordoma subtypes that are detected non-invasively using plasma methylomes. METHODS Methylation profiles of 68 chordoma surgical samples were obtained between 1996-2018 across three international centres along with matched plasma methylomes where available. RESULTS Consensus clustering identified two stable tissue clusters with a disease-specific survival difference that was independent of clinical factors in a multivariate Cox analysis (HR=14.2, 95%CI: 2.1-94.8, p=0.0063). Immune-related pathways with genes hypomethylated at promoters and increased immune cell abundance were observed in the poor-performing "Immune-infiltrated" subtype. Cell-to-cell interaction plus extracellular matrix pathway hypomethylation and higher tumor purity was observed in the better-performing "Cellular" subtype. The findings were validated in additional DNA methylation and RNA sequencing datasets as well as with immunohistochemical staining. Plasma methylomes distinguished chordomas from other clinical differential diagnoses by applying fifty chordoma-versus-other binomial generalized linear models in random 20% testing sets (mean AUROC=0.84, 95%CI: 0.52-1.00). Tissue-based and plasma-based methylation signals were highly correlated in both prognostic clusters. Additionally, leave-one-out models accurately classified all tumors into their correct cluster based on plasma methylation data. CONCLUSIONS Here, we show the first identification of prognostic epigenetic chordoma subtypes and first use of plasma methylome-based biomarkers to non-invasively diagnose and subtype chordomas. These results may transform patient management by allowing treatment aggressiveness to be balanced with patient risk according to prognosis.
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Affiliation(s)
- Jeffrey A Zuccato
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Vikas Patil
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Sheila Mansouri
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey C Liu
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Farshad Nassiri
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yasin Mamatjan
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Ankur Chakravarthy
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Shirin Karimi
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Joao Paulo Almeida
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anne-Laure Bernat
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
| | - Mohammed Hasen
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada.,Department of Neurosurgery, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Olivia Singh
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Shahbaz Khan
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Thomas Kislinger
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Namita Sinha
- Department of Pathology, Shared Health, HSC, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sébastien Froelich
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
| | - Homa Adle-Biassette
- Department of Pathology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France
| | - Kenneth D Aldape
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Daniel D De Carvalho
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Almeida JP, Quinones-Hinojosa A, Dagi TF. Commentary: Evandro de Oliveira in the Historical Context of Brazilian Neurosurgery. Neurosurgery 2021; 89:E264-E265. [PMID: 34392361 DOI: 10.1093/neuros/nyab313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/28/2021] [Indexed: 11/13/2022] Open
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Almeida JP, Vescan A, Gentili F. Surgical Nuances of Endoscopic Endonasal Resection of Craniopharyngiomas: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 19:E70. [PMID: 31828350 DOI: 10.1093/ons/opz389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 10/13/2019] [Indexed: 11/14/2022] Open
Abstract
Understanding of the microsurgical anatomy of the sella and suprasellar space is necessary for successful selection of surgical approaches and resection of craniopharyngiomas. Endoscopic endonasal surgery provides excellent exposure of the suprasellar space and has become the approach of choice for most of those tumors. In this video, we discuss the anatomical and surgical nuances for resection of craniopharyngiomas via an endoscopic transtuberculum transplanum approach. Anatomical dissections and a clinical case are used to illustrate the technique. This is the case of a 52-yr-old woman who presented to our clinic with a history of progressive visual decline and headaches, but no hormonal deficiencies. Magnetic resonance imaging demonstrated the presence of a sella suprasellar solid cystic lesion suggestive of a craniopharyngioma. The lesion was mainly located anterior to the chiasm, preinfundibular and medial to the posterior-communicating artery. Considering the patient presented with no hormonal deficits, it was decided to proceed with an endoscopic extended approach for maximum tumor resection while attempting to preserve the pituitary stalk and gland and its function. The patient provided consent to undergo the procedure and for the surgical video. After a binostril approach and harvesting of vascularized flap, a large sphenoidotomy was performed, followed by a transtuberculum transplanum approach. The tumor was resected with blunt and sharp dissection with careful preservation of the branches of the superior hypophyseal and posterior-communicating arteries. Closure was performed in a multilayer fashion, with dura substitute, fascia lata, and vascularized flap. The patient had visual improvement after surgery and was discharged at postoperative day 5 with no complications. Anatomical dissection pictures © 2019 Joao Paulo Almeida, MD. Used with permission.
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Affiliation(s)
- Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Allan Vescan
- Department of Otolaryngology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
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Almeida JP, Tabasinejad R, Kalyvas A, Takami H, Mohan N, O'Halloran PJ, Sanchez MM, Velasquez C, Zadeh G, Gentili F. The Importance of Long Term Follow Up After Endoscopic Pituitary Surgery: Durability of Results and Tumor Recurrence. Neurol India 2021; 68:S92-S100. [PMID: 32611898 DOI: 10.4103/0028-3886.287675] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Endoscopic endonasal approach (EEA) has become the preferred surgical approach for resection of pituitary adenomas in most centers. This technique has a number of advantages such as improved visualization and maneuverability, when compared to microscopic transsphenoidal approach. However, the long-term results of this approach are still scarce. Ten years ago, we published our initial series of patients having undergone an endoscopic removal of their pituitary adenomas reporting favorable short-term results. This project aims to revisit the results of that series, addressing the long-term results regarding recurrence of pituitary adenomas. Methods A retrospective analysis of consecutive, endoscopically managed pituitary adenomas in a single center from 2004-2007. Only patients with >5 years of follow up (FU) and complete follow up data were included in this study. Recurrences were defined as evidence of any new tumor growth or enlargement of previously noted residual adenoma and/or biochemical recurrence of disease activity, in cases of functioning adenomas. Results A total of 98 patients matched the inclusion criteria for this study. The median follow-up period was 144 months. Nonfunctioning adenoma was the most common subtype (n = 66, 67.3%), followed by GH-secreting tumors (n = 19, 19.4%), ACTH-secreting tumors (n = 7, 7.1%), prolactinomas (n = 4, 4.1%) and TSH-secreting adenomas (n = 2, 2%). Age ranges from 23 to 82 years, with median age of 53 years. Preoperative visual deficits were observed in 46 patients (46.9%) and hormonal deficits were identified in 31% of cases. 22.4% of patients had undergone a previous pituitary adenomas resection prior to treatment in our center. Surgery achieved gross total resection (GTR) and near total resection (NTR) in 89 cases (90.8%) (56.1% and 34.7%, respectively). A total of 37 cases had recurrences during FU (mean recurrence free survival: 80 months). Recurrences were observed in 34% of patients who had had GTR while recurrences were observed in 39.5% of cases that underwent subtotal resection. Most recurrences occurred after 5 years of FU and univariate analysis demonstrated previous surgery (P = 0.005), cavernous sinus invasion (P = 0.05) and Ki-67 >5% (P = 0.01) to be factors associated with higher chance of recurrence. Multivariate Cox-regression analysis demonstrate that previous surgery and Ki-67 >5% are factors associated with recurrences. Surgery and/or radiation were utilized for management of recurrences in 29/37 cases. Conclusion Long-term FU analysis demonstrates that progression/recurrence of previously resected adenomas is observed in a significant number of patients, especially in those with previous/multiple surgical resections, elevated ki-67 and cavernous sinus invasion. Short-term FU may shadow real tumor control rates achieved after EEA and underscores the importance of long-term FU in these patients. Therefore, long-term FU should be pursued in all cases.
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Affiliation(s)
- Joao Paulo Almeida
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada; Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Raha Tabasinejad
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Aristotelis Kalyvas
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Hirokazu Takami
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Nilesh Mohan
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Philip J O'Halloran
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada; Clinical Neurological Sciences, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Miguel Marigil Sanchez
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Carlos Velasquez
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Fred Gentili
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
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Almeida JP, Kalyvas A, Mohan N, Oswari S, Takami H, Velasquez C, Asha M, Zadeh G, Gentili F. Current Results of Surgical Treatment of Craniopharyngiomas: The Impact of Endoscopic Endonasal Approaches. World Neurosurg 2021; 142:582-592. [PMID: 32987614 DOI: 10.1016/j.wneu.2020.05.174] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/05/2020] [Indexed: 10/23/2022]
Abstract
Surgery is the main treatment option for the management of craniopharyngiomas. Transcranial microsurgical approaches, such as pterional and subfrontal approaches, have constituted the classic operative strategy for resection of these tumors. However, the development of endoscopic endonasal approaches has revolutionized the treatment of craniopharyngiomas in the last 15 years, and endoscopic resection is favored for most craniopharyngiomas. In this article, we discuss our experience with the management of craniopharyngiomas and review the current results of the surgical treatment of those tumors, including discussion of goals of surgery, complications, recurrences, and the role of adjuvant treatment.
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Affiliation(s)
- Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Aristotelis Kalyvas
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nilesh Mohan
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Selfy Oswari
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hirokazu Takami
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Carlos Velasquez
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Asha
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Asha MJ, Oswari S, Takami H, Velasquez C, Almeida JP, Gentili F. Craniopharyngiomas: Challenges and Controversies. World Neurosurg 2021; 142:593-600. [PMID: 32987615 DOI: 10.1016/j.wneu.2020.05.172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/05/2020] [Indexed: 12/24/2022]
Abstract
Despite its benign histopathology, the treatment of craniopharyngioma remains one of the most formidable challenges faced by skull base surgeons. The technical challenges of tackling these complex central skull base lesions are paralleled by clinical challenges related to their unique tumor biology and the often-complex decision making required. In this article, we critically appraise the most recent literature to explore the challenges and controversies surrounding the management of these lesions. The role of curative resections and the shift in the surgical paradigm toward the multidisciplinary goal-directed management approach are discussed.
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Affiliation(s)
- Mohammed J Asha
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
| | - Selfy Oswari
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hirokazu Takami
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Carlos Velasquez
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Joao Paulo Almeida
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Fred Gentili
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Almeida JP, Workewych A, Takami H, Velasquez C, Oswari S, Asha M, Bernardo A, Gentili F. Surgical Anatomy Applied to the Resection of Craniopharyngiomas: Anatomic Compartments and Surgical Classifications. World Neurosurg 2021; 142:611-625. [PMID: 32987617 DOI: 10.1016/j.wneu.2020.05.171] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Resective surgery remains the main treatment option for most patients with craniopharyngiomas. Understanding of the microsurgical anatomy of the sella and suprasellar region and its relationship with these tumors is necessary to achieve effective surgical treatment and minimize complications. In this article, we review the surgical anatomy related to craniopharyngiomas and divide it in 5 compartments according to tumor extension. METHODS Endoscopic and microsurgical dissection were performed in 3 freshly injected cadaver heads at the Weill Cornell Surgical Innovations Laboratory (New York, New York, USA) and at the Surgical Skills Center at Mount Sinai Hospital (Toronto, Ontario, Canada). Tumor extension was classified as 1) inferomedial or sellar, 2) superomedial or suprasellar, 3) lateral or sylvian, 4) posterior or interpeduncular/prepontine, and 5) intraventricular. The selection of surgical approaches is discussed based on the anatomic nuances of each these regions. In addition, we reviewed the literature regarding previous anatomic classifications for resection of craniopharyngiomas. RESULTS Different approaches should be considered according to tumor extension into different compartments. Purely sellar tumors are amenable to endoscopic transsellar approaches, whereas those with a suprasellar extension require an extended transtuberculum approach. In some of those patients, a narrow chiasm-pituitary window may block access to the tumor and a transcranial translamina terminalis approach may be favored. Tumors occupying the interpeduncular fossa may pose a significant challenge for an endoscopic endonasal approach and transcranial approaches. Transcavernous approaches and anterior and posterior clinoidectomies may be required for adequate exposure in such patients. Translamina terminalis and/or transcallosal approaches are recommended for resection of purely intraventricular tumors. Tumors extending into the lateral compartment should be considered for transcranial frontotemporal approaches. CONCLUSIONS The understanding of such anatomic nuances aids in the selection of the most appropriate surgical approach and in the prevention of potential complications. Because most craniopharyngiomas are midline lesions, the endoscopic endonasal approach represents an excellent approach for most of those tumors. However, transcranial approaches should be considered for tumors with extension into the lateral compartment and for selected tumors involving the ventricular compartment (purely intraventricular tumors and those with extension to the foramen of Monro and/or lateral ventricles).
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Affiliation(s)
- Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adriana Workewych
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hirokazu Takami
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Carlos Velasquez
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Selfy Oswari
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Asha
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Antonio Bernardo
- Surgical Innovations Laboratory, Department of Neurological Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Takami H, Velásquez C, Asha MJ, Oswari S, Almeida JP, Gentili F. Creative and Innovative Methods and Techniques for the Challenges in the Management of Adult Craniopharyngioma. World Neurosurg 2021; 142:601-610. [PMID: 32987616 DOI: 10.1016/j.wneu.2020.05.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/05/2020] [Indexed: 10/23/2022]
Abstract
Craniopharyngioma remains a major challenge in daily clinical practice. The pathobiology of the tumor is still elusive, and there are no consensus or treatment guidelines on the optimal management strategy for this relatively rare tumor. However, recent technical and scientific advances, including genomic and radiomic profiling, innovation in surgical approaches, more precise radiotherapy protocols, targeted therapy, and restoration of lost functions all have the potential to significantly improve the outcome of patients with craniopharyngioma in the near future. Although many of these innovative tools in the new armamentarium of the clinician are still in their infancy, they could reduce craniopharyngioma-related morbidity and mortality and improve the patients' quality of life. In this article, we discuss these creative and innovative approaches that may offer solutions to the obstacles faced in treating craniopharyngioma and future possibilities in improving the care of these patients.
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Affiliation(s)
- Hirokazu Takami
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Carlos Velásquez
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Mohammed J Asha
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Selfy Oswari
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Joao Paulo Almeida
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Fred Gentili
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada.
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Bernat AL, Troude P, Priola SM, Elsawy A, Farrash F, Mete O, Ezzat S, Asa SL, De Almeida J, Vescan A, Monteiro E, Almeida JP, Zadeh GM, Gentili F. Endoscopic Endonasal Pituitary Surgery For Nonfunctioning Pituitary Adenomas: Long-Term Outcomes and Management of Recurrent Tumors. World Neurosurg 2020; 146:e341-e350. [PMID: 33203535 DOI: 10.1016/j.wneu.2020.10.083] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Endoscopic endonasal approaches (EEAs) provide improved access and operative visualization for resection of pituitary adenomas. Although the technique has gained wide acceptance, there is a paucity of data regarding late recurrence. OBJECTIVE We aim to assess long-term outcomes of patients with nonfunctioning pituitary adenomas (NFPAs) who underwent EEA. METHODS We reviewed 269 patients operated on for an NFPA between 2005 and 2015. Clinical and radiologic factors including those potentially related to higher chances of recurrence were analyzed. Progression-free survival was analyzed using the Kaplan-Meier method, and univariate and multivariate survival were analyzed using a Cox regression model. RESULTS The study included 269 patients. The gross total resection rate was 46.0% (n = 124) but cavernous sinus involvement was present in almost half the patients (n = 115). The probability of recurrence at 5 years and 10 years was 22.0% and 47.2%, respectively. The median time to recurrence was 10 years for patients without cavernous sinus involvement and 6 years for those with cavernous sinus involvement. Univariate and multivariate analysis showed that tumor size, cavernous sinus invasion, anterior skull base extensions, and residual tumor were significantly associated with recurrence. CONCLUSIONS Recurrence rate of NFPA remains high despite the better visualization offered by EEA, especially in those tumors involving the cavernous sinus and/or previously operated on. Repeat surgery is adequate for tumor debulking and decompression of the optic apparatus but is unlikely to achieve gross total resection if a successful previous EEA has been performed. Radiation therapy is an effective option for management of recurrent tumors.
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Affiliation(s)
- Anne-Laure Bernat
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada; Division of Neurosurgery, University of Paris, Lariboisière Hospital, Paris, France.
| | - Pénélope Troude
- Department of Public Health Evaluation, University Paris Diderot, Paris, France
| | - Stefano Maria Priola
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada; Division of Neurosurgery, Health Sciences North, Sudbury, Ontario, Canada
| | - Ahmad Elsawy
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada; Division of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Faisal Farrash
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada; Division of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Ozgur Mete
- Department of Pathology, University Health Network, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Shereen Ezzat
- Department of Medicine, University Health Network, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Sylvia L Asa
- Department of Pathology, University Health Network, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - John De Almeida
- Department of Otolaryngology, University Health Network, Toronto, Ontario, Canada; Department of Otolaryngology, Mont Sinai Hospital, University Health Network, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Allan Vescan
- Department of Otolaryngology, University Health Network, Toronto, Ontario, Canada; Department of Otolaryngology, Mont Sinai Hospital, University Health Network, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Eric Monteiro
- Department of Otolaryngology, University Health Network, Toronto, Ontario, Canada; Department of Otolaryngology, Mont Sinai Hospital, University Health Network, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada; Departmen of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Fred Gentili
- University Health Network, Toronto, Ontario, Canada
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Fu TS, Yao CMKL, Ziai H, Monteiro E, Almeida JP, Zadeh G, Gentili F, de Almeida JR. Cost-effectiveness of endoscopic endonasal vs transcranial approaches for olfactory groove meningioma. Head Neck 2020; 43:79-88. [PMID: 32918329 DOI: 10.1002/hed.26462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 06/05/2020] [Accepted: 08/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endoscopic endonasal approaches (EEAs) have been adopted as an alternative to standard transcranial approaches for olfactory groove meningiomas (OGMs). However, the relative cost-effectiveness remains controversial. METHODS Cost-utility analysis from a societal perspective comparing EEA vs transcranial approaches for OGM was used in this study. Surgical treatment was modeled using decision analysis, and a Markov model was adopted over a 20-year horizon. Parameters were obtained from literature review. Costs were expressed in 2017 Canadian dollars. RESULTS In the base case, EEA was cost-effective compared with transcranial surgery with an incremental cost-effectiveness ratio of $33 523 ($30 475 USD)/QALY. There was a 55% likelihood that EEA was cost-effective at a willingness-to-pay of $50 000/QALY. EEA remained cost-effective at a cerebrospinal fluid leak rate below 60%, gross total resection rate above 25%, and base cost less than $66 174 ($60 158 USD). CONCLUSION EEA may be a cost-effective alternative to transcranial approaches for selected OGM.
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Affiliation(s)
- Terence S Fu
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher M K L Yao
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Hedyeh Ziai
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Eric Monteiro
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Joao Paulo Almeida
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Fred Gentili
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
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Almeida JP, Tang D, Kshettry VR, Sindwani R, Recinos PF. Endoscopic endonasal pituitary hemitransposition for resection of suprasellar and retrosellar dermoid cyst. Neurosurgical Focus: Video 2020; 2:V9. [PMID: 36284782 PMCID: PMC9542392 DOI: 10.3171/2020.4.focusvid.19959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/09/2020] [Indexed: 11/22/2022]
Abstract
This is the case of a 25-year-old woman who had had a previous rupture of a dermoid cyst and now presented with recent MRI scans suggesting further growth of her dermoid cyst. Her lesion was located in the suprasellar space and extended into the interpeduncular fossa and prepontine cistern. Considering the location of the tumor, an endoscopic pituitary hemitransposition was selected for its resection. In this video we present the technical nuances and illustrate the anatomy used for an endoscopic endonasal pituitary hemitransposition for resection of a suprasellar dermoid cyst with extension into the interpeduncular fossa. In this case, a near-total resection was achieved, with no complications and no additional hormonal deficit after surgery. The video can be found here: https://youtu.be/BHtNf5invUI.
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Affiliation(s)
- Joao Paulo Almeida
- Section of Skull Base Surgery, Department of Neurosurgery, Neurological Institute, Cleveland Clinic
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dennis Tang
- Section of Rhinology, Sinus, and Skull Base Surgery, Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic; and
| | - Varun R. Kshettry
- Section of Skull Base Surgery, Department of Neurosurgery, Neurological Institute, Cleveland Clinic
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raj Sindwani
- Section of Skull Base Surgery, Department of Neurosurgery, Neurological Institute, Cleveland Clinic
- Section of Rhinology, Sinus, and Skull Base Surgery, Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic; and
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Pablo F. Recinos
- Section of Skull Base Surgery, Department of Neurosurgery, Neurological Institute, Cleveland Clinic
- Section of Rhinology, Sinus, and Skull Base Surgery, Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic; and
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Almeida JP, Cappello Z, Borghei-Razavi H, Recinos PF, Sindwani R, Kshettry VR. Endoscopic endonasal translacerum approach for resection of petroclival chondrosarcoma. Neurosurgical Focus: Video 2020; 2:V11. [PMID: 36284791 PMCID: PMC9542297 DOI: 10.3171/2020.4.focusvid.19978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/07/2020] [Indexed: 12/02/2022]
Abstract
Petroclival chondrosarcomas are a formidable surgical challenge given the close relationship to critical neurovascular structures. The endoscopic endonasal approach can be utilized for many petroclival chondrosarcomas. However, tumors that extend to the inferior petrous apex require working behind the internal carotid artery (ICA). We present a case of a 33-year-old with a 1-year history of complete abducens palsy, with imaging showing an enhancing mass centered at the left petroclival fissure and inferior petrous apex behind the paraclival carotid artery and extending down into the nasopharynx abutting the cervical ICA. In this video, we describe the surgical steps of the endoscopic endonasal translacerum approach with ICA skeletonization and mobilization. We also highlight the relevant surgical anatomy with anatomical dissections to supplement the surgical video. The patient did well without complications. Postoperative MRI demonstrated complete resection and pathology revealed grade II chondrosarcoma. He underwent adjuvant proton beam radiotherapy. The video can be found here: https://youtu.be/80QXALJW9ME.
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Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Neurologic Institute, Cleveland Clinic, Cleveland
| | - Zachary Cappello
- Charlotte Eye, Ear, Nose and Throat Associated, Charlotte, North Carolina
| | | | - Pablo F. Recinos
- Department of Neurosurgery, Neurologic Institute, Cleveland Clinic, Cleveland
| | - Raj Sindwani
- Department of Otolaryngology, Head & Neck Institute, Cleveland Clinic, Cleveland
| | - Varun R. Kshettry
- Department of Neurosurgery, Neurologic Institute, Cleveland Clinic, Cleveland
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Almeida JP, Radovanovic I. Commentary: Transpalpebral Approach "Eyelid Incision" for Surgical Treatment of Intracerebral Aneurysms: Lessons Learned during a 10-year Experience. Oper Neurosurg (Hagerstown) 2020; 18:E66-E67. [PMID: 31420663 DOI: 10.1093/ons/opz218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/25/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Ivan Radovanovic
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
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Alves P, Marinho AV, Ferreira JA, Milner J, Freitas A, Ferreira C, Almeida JP, Martinho S, Baptista R, Martins R, Goncalves L. P320 Left atrial mechanics in moderate mitral valve disease: earlier markers of damage. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Left atrial (LA) mechanics is impaired in mitral valve disease, but it is not clear whether reservoir, conduit or contractile functions are differentially impaired in stenosis (MS) or regurgitation (MR). We aimed to study LA mechanics in patients with moderate MR or moderate MS and identify discriminators of disease.
METHODS
We conducted a prospective, observational study of 100 patients with isolated moderate MR and 100 patients with moderate MS. LA mechanics with speckle tracking echocardiography (STE) assessed LA reservoir (LA ɛsys and SRs), conduit(LAɛe, SRe), and contractile (LAɛa, SRa) functions. Left ventricle (LV) functional parameters were assessed as well, including LV ejection fraction (LVEF), LV end-diastolic diameter (LVDD) and LV global longitudinal strain (LV-GLS).
RESULTS
The mean age was 67 ± 14 years and 75% were female. Mean left ventricular ejection fraction (LVEF), LV end-diastolic diameter (LVDD), LV global longitudinal strain (LV-GLS) and systolic pulmonary artery pressure (sPAP) did not differ between MR and MS (table 1).LA indexed volume (LAVi) and LA strain did not vary between MR and MS, but strain rate did. SRs and SRe had better values in MR, whereas SRa had worse values in MR (table 1). SRe (<-0.7%) had the superior discriminative power for MR, with an area under the curve of 0.85, sensitivity of 76% and specificity of 85%.
CONCLUSIONS
LA strain rate phases were the only parameters that varied between MR and MS. Contractile phase strain rate was more impaired in MR and conduit phase strain rate in MS. This highly specific data reflect the earlier hemodynamic changes occurring in LA in the setting of mitral valve disease.
mMR mMS P value LVEF (±SD,%) 57.4 ± 6.4 59.6 ± 4.6 0.145 LV-GLS (±SD, %) -17.7 ± 4.5 -17.1 ± 3.5 0.587 sPAP (±SD, mmHg) 30.3 ± 10.5 32.4 ± 8.3 0.387 LAVi (± SD, ml/m2) 46.3 ± 6.4 48.2 ± 7.4 0.281 LAɛs (± SD, %) 15.8 ± 7.3 13.3 ± 9 0.062 LAɛe (± SD, %) 8.4 ± 4.7 7.1 ± 5.4 0.074 LAɛa (± SD, %) 6.3 ± 4.8 7.4 ± 4.5 0.081 LA SRs (± SD, %) 0.8 ± 0.4 0.6 ± 0.3 0.004 LA SRe (± SD, %) -0.9 ± 0.5 -0.5 ± 0.3 <0.001 LA SRa (± SD, %) -0.5 ± 0.4 -0.8 ± 0.5 0.007
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Affiliation(s)
- P Alves
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - A V Marinho
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - J A Ferreira
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - J Milner
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - A Freitas
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - C Ferreira
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - J P Almeida
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - S Martinho
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - R Baptista
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - R Martins
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
| | - L Goncalves
- University Hospitals of Coimbra, Cardiology, Coimbra, Portugal
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Asha MJ, Takami H, Velasquez C, Oswari S, Almeida JP, Zadeh G, Gentili F. Long-term outcomes of transsphenoidal surgery for management of growth hormone-secreting adenomas: single-center results. J Neurosurg 2019; 133:1-11. [PMID: 31604330 DOI: 10.3171/2019.6.jns191187] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/18/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Transsphenoidal surgery is advocated as the first-line management of growth hormone (GH)-secreting adenomas. Although disease control is defined by strict criteria for biochemical remission, the length of follow-up needed is not well defined in literature. In this report, the authors present their long-term remission rate and identify various predictive factors that might influence the clinical outcome. METHODS The authors conducted a single-institute retrospective analysis of all transsphenoidal procedures for GH-secreting adenomas performed from January 2000 to June 2016. The primary outcome was defined as biochemical remission according to the 2010 consensus criteria and measured at the 1-year postoperative mark as well as on the last recorded follow-up appointment.Secondary variables included recurrence rate, patterns of clinical presentation, and outcome of adjuvant therapy (including repeat surgery). Subgroup analysis was performed for patients who had biochemical or radiological "discordance"-patients who achieved biochemical remission but with incongruent insulin-like growth factor 1 (IGF-1)/GH or residual tumor on MRI. Recurrence-free survival analysis was conducted for patients who achieved remission at 1 year after surgery. RESULTS Eighty-one patients (45 female and 36 male) with confirmed acromegaly treated with transsphenoidal surgery were included. In 62 cases the patients were treated with a pure endoscopic approach and in 19 cases an endoscopically assisted microscopic approach was used.Primary biochemical remission after surgery was achieved in 59 cases (73%) at 1 year after surgery. However, only 41 patients (51%) remained in primary surgical remission (without any adjuvant treatment) at their last follow-up appointment, indicating a recurrence rate of 31% (18 of 59 patients) over the duration of follow-up (mean 100 ± 61 months). Long-term remission rates for pure endoscopic and endoscopically assisted cases were not significantly different (48% vs 52%, p = 0.6). Similarly, no significant difference in long-term remission was detected between primary surgery and repeat surgery (54% vs 33%, p = 0.22).Long-term remission was significantly influenced by extent of resection, cavernous sinus invasion (radiologically as well as surgically reported), and preoperative and early postoperative GH and IGF-1 levels (within 24-48 hours after surgery) as well as by clinical grade, with lower remission rates in patients with dysmorphic features and/or medical comorbidities (grade 2-3) compared to minimally symptomatic or silent cases (grade 1). CONCLUSIONS The long-term surgical remission rate appears to be significantly less than "early" remission rates and is highly dependent on the extent of tumor resection. The authors advocate a long-term follow-up regimen and propose a clinical grading system that may aid in predicting long-term outcome in addition to the previously reported anatomical factors. The role of repeat surgery is highlighted.
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Almeida JP, Stephens CC, Eschbacher JM, Felicella MM, Yuen KCJ, White WL, Mooney MA, Bernat AL, Mete O, Zadeh G, Gentili F, Little AS. Clinical, pathologic, and imaging characteristics of pituitary null cell adenomas as defined according to the 2017 World Health Organization criteria: a case series from two pituitary centers. Pituitary 2019; 22:514-519. [PMID: 31401793 DOI: 10.1007/s11102-019-00981-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE The 2017 World Health Organization classification of pituitary tumors redefined pituitary null cell adenomas (NCAs) by restricting this diagnostic category to pituitary tumors that are negative for pituitary transcription factors and adenohypophyseal hormones. The clinical behavior of this redefined entity has not been widely studied, and this is a major shortcoming of the classification. This study evaluated the imaging and clinical features of NCAs from two pituitary centers and compared them with those of gonadotroph adenomas (GAs). METHODS Imaging, pathologic, and clinical characteristics of NCAs and GAs were retrospectively reviewed. Tumor immunohistochemistry was performed to confirm absence of adenohypophyseal hormones and pituitary transcription factor expression. RESULTS Thirty-one NCAs were compared with 38 GAs. NCAs were more likely to invade the cavernous sinus (15/31 [48%] vs. 5/38 [13%], P = .003) and had a higher proliferative index (i.e., MIB-1 > 3%, 11/31 [35%] vs. 5/38 [13%], P = .04). Gross total resection was less likely in the NCA group (19/31 [61%] vs. 33/38 [87], P = .02). Progression-free survival was worse in the NCA cohort (5-year progression-free survival, 0.70 vs. 1.00; P = .011, by log-rank test). CONCLUSIONS Compared with GAs, NCAs are more invasive at the time of presentation and have a more aggressive clinical course. This study provides evidence that NCAs represent a distinct clinicopathologic entity with behavior that differs adversely from that of GAs. This may inform clinical decision-making, including frequency of postoperative tumor surveillance and timing of adjunctive treatments.
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Affiliation(s)
- Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Corbin C Stephens
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | | | - Kevin C J Yuen
- Department of Neuroendocrinology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - William L White
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Anne Laure Bernat
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ozgur Mete
- Laboratory Medicine Program, Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA.
- c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA.
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Voisin MR, Almeida JP, Perez-Ordonez B, Zadeh G. Recurrent Undifferentiated Carcinoma of the Sella in a Patient with Lynch Syndrome. World Neurosurg 2019; 132:219-222. [PMID: 31491579 DOI: 10.1016/j.wneu.2019.08.180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Lynch syndrome (LS) is a cancer-predisposing condition resulting from germline mutations in deoxyribonucleic acid mismatch repair genes. Patients are at high risk for a multitude of tumors, but no reports of undifferentiated sellar carcinomas have previously been described. CASE DESCRIPTION A 56-year-old female with LS due to MSH2 and MSH6 mutations presented with panhypopituitarism and a sellar mass. She was initially diagnosed with pituitary apoplexy and treated nonoperatively. The mass self-resolved. The mass recurred 2 years later, and she underwent endoscopic endonasal biopsy demonstrating an undifferentiated carcinoma of the sella with MSH2 and MSH6 loss. The tumor was negative for pituitary markers and weakly positive for p63. The patient further developed lung and bone metastases and was treated with radiation and chemotherapy. CONCLUSIONS This is the first report of an undifferentiated carcinoma of the sella. Our patient harbored a diagnosis of LS and demonstrated local tumor recurrence and aggressive systemic progression. Patients with LS should undergo close follow-up and active surveillance to detect and treat these aggressive lesions in a timely manner.
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Affiliation(s)
- Mathew Ryan Voisin
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Joao Paulo Almeida
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bayardo Perez-Ordonez
- Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Ovenden CD, Almeida JP, Oswari S, Gentili F. Pituitary abscess following endoscopic endonasal drainage of a suprasellar arachnoid cyst: Case report and review of the literature. J Clin Neurosci 2019; 68:322-328. [PMID: 31402262 DOI: 10.1016/j.jocn.2019.07.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/27/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Arachnoid cysts are uncommon lesions of the sellar region, and only rarely require decompressive surgery to treat symptoms. Pituitary abscesses are another rare lesion, and are an uncommon complication of pituitary surgery. A previously healthy 45 year old woman presented with a new finding of bitemporal hemianopsia. Magnetic resonance imaging (MRI) showed a cystic sellar lesion with suprasellar extension and compression of the optic chiasm. Endoscopic transphenoidal surgery was performed and the lesion was found to be an arachnoid cyst. She was well immediately after the operation, but 1 week later presented with headaches, fever and worsening visual acuity. MRI showed a homogenous collection in the sellar region that was compressing the chiasm. The patient was treated with antibiotics, and a second transphenoidal operation was performed, with frank pus found in the pituitary fossa. Cultures of the fluid found during the operation grew Escherichia coli and Staphylococcus lugdunensis. Her symptoms resolved after the second operation, and formal visual fields and a pituitary hormone panel were normal at this time. We report on a rare case of a pituitary abscess complicating surgery for a sellar arachnoid cyst, and discuss management of these conditions.
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Affiliation(s)
| | - Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Toronto, ON, Canada
| | - Selfy Oswari
- Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Toronto, ON, Canada
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Toronto, ON, Canada
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Marigil M, Almeida JP, Karekezi C, de Almeida JR, Gentili F. Expanded Endoscopic Endonasal Approach for Resection of Intradural Chordoma: Surgical and Anatomic Nuances: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2019; 17:E66. [PMID: 30566687 DOI: 10.1093/ons/opy385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 11/20/2018] [Indexed: 11/13/2022] Open
Abstract
The expanded endoscopic endonasal approach (EEA) has been growing as a surgical alternative for the treatment of clival chordomas because of their frequent midline location and bone erosion. The endoscopic transclival approach provides with a safer and more direct anatomic route for tumors located predominantly in the midline contributing to minimize postoperative comorbidities. In this video, we demonstrate the step-by-step technique for resection of such challenging clival pathology. This is an operative video of an extended endoscopic resection of a clival chordoma with stepwise description of the surgical technique. We present the case of a 49-yr-old man in whom, incidentally in the context of low testosterone level, a clival lesion with purely midline location with intradural extension into the ventral brainstem and occupation of the left cerebellopontine angle was discovered. The patient was submitted to an expanded endoscopic transclival approach and a macroscopic gross total resection was successfully achieved. The final pathology was compatible with a conventional chordoma. This video details the surgical anatomy of the clival region to facilitate the identification of surgical landmarks and anatomic boundaries with the goal of avoiding injury to the neurovascular structures involved in this approach. Extended endoscopic transclival surgery is a useful and safer option for the management of midline chordomas because it provides with a dissection corridor free of major neurovascular structures. Endoscopic techniques are associated with good outcomes in terms of macroscopic gross total resection and low surgical risks in these selected tumors.
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Affiliation(s)
- Miguel Marigil
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Claire Karekezi
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, Department of Surgical Oncology, Princess Margaret Cancer Center/University Health Network, Toronto, Canada
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
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Almeida JP, Sanchez MM, Karekezi C, Warsi N, Fernández-Gajardo R, Panwar J, Mansouri A, Suppiah S, Nassiri F, Nejad R, Kucharczyk W, Ridout R, Joaquim AF, Gentili F, Zadeh G. Pituitary Apoplexy: Results of Surgical and Conservative Management Clinical Series and Review of the Literature. World Neurosurg 2019; 130:e988-e999. [PMID: 31302273 DOI: 10.1016/j.wneu.2019.07.055] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Pituitary apoplexy is associated with visual, cranial nerve, and endocrine dysfunction. In this article, the results of surgical and conservative management of pituitary apoplexy in a single center are evaluated and a review of the literature is presented. METHODS A retrospective analysis was made of patients with pituitary apoplexy who underwent surgery or conservative management at our center between January 2007 and June 2017. Surgery was typically selected for patients who presented with acute deterioration of visual status and/or level of consciousness. Patients with no visual field deficit and those who had medical contraindications to undergo a surgical procedure because of previous comorbidities typically had conservative treatment. Baseline characteristics and clinical and radiologic outcomes were reviewed. A review of the literature (1990-2018) was performed according to PRISMA guidelines. Studies comparing the results of conservative and surgical management were identified. Visual, cranial nerve, and endocrine outcomes and tumor recurrence were analyzed. RESULTS Forty-nine patients (73.1%) were managed surgically and 18 (26.9%) conservatively. After careful case selection, patients underwent surgical or conservative treatment. Patients who underwent conservative treatment had fewer visual deficits. At diagnosis, visual deficit (38.8% vs. 75.5%; P = 0.008) and cranial nerve palsy (27.7% vs. 51%; P = 0.058) were less common in the conservative group. Conservative and surgical treatments had similar visual and cranial nerve improvement rates (75% vs. 58.3%, P = 0.63 and 75% vs. 69.2%, P = 1.0, respectively). In the conservative group, tumor shrinkage was observed in 76.4% of cases. The systematic review retrieved 11 studies. No significant difference between conservative and surgical treatment for clinical outcomes (visual field recovery, odds ratio [OR], 1.45; 95% confidence interval [CI], 0.72-2.92; cranial nerve recovery, OR, 2.30; 95% CI, 0.93-5.65; and hypopituitarism, OR, 1.05; 95% CI, 0.64-1.74) or tumor recurrence (OR, 0.68; 95% CI, 0.20-2.34) was observed. CONCLUSIONS A tailored approach to pituitary apoplexy, one that does not include an absolute need for surgery, is appropriate. Conservative management is appropriate in selected patients presenting without visual deficits.
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Affiliation(s)
- Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Department of Neurology, State University of Campinas (UNICAMP), Campinas, Brazil.
| | - Miguel Marigil Sanchez
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Claire Karekezi
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nebras Warsi
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Jyoti Panwar
- Department of Radiology, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Suganth Suppiah
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Romina Nejad
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Walter Kucharczyk
- Department of Radiology, University of Toronto, Toronto, Ontario, Canada
| | - Rowena Ridout
- Division of Endocrinology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrei F Joaquim
- Division of Neurosurgery, Department of Neurology, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Marigil Sanchez M, Karekezi C, Almeida JP, Kalyvas A, Castro V, Velasquez C, Gentili F. Management of Giant Pituitary Adenomas: Role and Outcome of the Endoscopic Endonasal Surgical Approach. Neurosurg Clin N Am 2019; 30:433-444. [PMID: 31471050 DOI: 10.1016/j.nec.2019.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Giant adenomas represent a significant surgical challenge. Although traditionally several transcranial and transsphenoidal microscopic approaches have had a central role in their management, in the last 2 decades here have been increasing reports of the endoscopic endonasal approach for giant adenomas, citing its improved resection rates and lower complication profile. However, its role as the preferred approach has not been fully established and there is currently a paucity of evidence-based recommendations available in the literature. This article reviews the current literature and attempts to define the role and outcomes of the endoscopic endonasal surgical approach for giant pituitary adenomas.
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Affiliation(s)
- Miguel Marigil Sanchez
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Neurosurgery, Skull Base Research Unit, Lariboisière University Hospital, 2 Rue Ambroise Paré, Paris Cedex 10 75475, France.
| | - Claire Karekezi
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Neurosurgery, Rwanda Military Hospital, Kigali, Rwanda
| | - Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Aristotelis Kalyvas
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vitor Castro
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Carlos Velasquez
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Neurological Surgery, Hospital Universitario Marques de Valdecilla and Instituto de Investigacion Marques de Valdecilla (IDIVAL), Santander, Spain
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Radovanovic I, Dehdashti AR, Turel MK, Almeida JP, Godoy BL, Doglietto F, Vescan AD, Zadeh G, Gentili F. Expanded Endonasal Endoscopic Surgery in Suprasellar Craniopharyngiomas: A Retrospective Analysis of 43 Surgeries Including Recurrent Cases. Oper Neurosurg (Hagerstown) 2019; 17:132-142. [DOI: 10.1093/ons/opy356] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 10/22/2018] [Indexed: 11/12/2022] Open
Abstract
AbstractBACKGROUNDThe role of expanded endonasal endoscopic surgery for primary and recurrent craniopharyngioma is not yet fully established.OBJECTIVETo report and evaluate our experience with the endoscopic endonasal approach (EEA) for the resection of primary and recurrent craniopharyngiomas.METHODSThis is a retrospective cohort analysis of 43 consecutive EEA procedures in 40 patients operated from September 2006 to February 2012 for suprasellar craniopharyngiomas. In 21 patients (48.8%) the disease was recurrent. We have assessed the surgical results, visual, endocrinological, and functional outcomes and resection rates in this patient cohort.RESULTSAt presentation, 31 (72.1%) patients had visual deficits, 15 patients (34.9%) complained of headaches, 25 patients (58.1%) had anterior pituitary insufficiency, and 14 (32.5%) had diabetes insipidus. Total resection was achieved in 44.2% surgeries, of which 77.3% were in primary lesions and 9.5% in recurrent lesions (P < .001). Vision improved in 92.6% patients and worsened in 2.3%. Complications other than vision were encountered in 25.6% including 9/43 cerebrospinal fluid leak, 2/43 meningitis. A total of 51.9% of patients with preoperative residual anterior pituitary function had new anterior pituitary deficiencies and 42.8% had new diabetes insipidus. There was no mortality. Six patients (14%) had recurrence of disease during the follow-up period (mean 56.8 mo), 5 of which required repeat surgery.CONCLUSIONThe EEA can be integrated in the overall management of both primary and recurrent craniopharyngiomas with good results; however, in our series recurrent surgery was associated with significantly lower rates of gross total resection.
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Affiliation(s)
- Ivan Radovanovic
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, Canada
| | - Amir R Dehdashti
- Department of Neurosurgery, Northshore University Hospital, Northwell Health, Manhasset, New York
| | - Mazda K Turel
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, Canada
| | - Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, Canada
| | - Bruno L Godoy
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, Canada
| | - Francesco Doglietto
- Instituto di Neurochirurgia, Universita di Brescia/Spedali Civili, Brescia, Italy
| | - Allan D Vescan
- Division of Otolaryngology, Faculty of Medicine, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, Canada
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, Canada
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Almeida JP, Velásquez C, Karekezi C, Marigil M, Hodaie M, Rutka JT, Bernstein M. Global neurosurgery: models for international surgical education and collaboration at one university. Neurosurg Focus 2018; 45:E5. [DOI: 10.3171/2018.7.focus18291] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVEInternational collaborations between high-income (HICs) and low- and middle-income countries (LMICs) have been developed as an attempt to reduce the inequalities in surgical care around the world. In this paper the authors review different models for international surgical education and describe projects developed by the Division of Neurosurgery at the University of Toronto in this field.METHODSThe authors conducted a review of models of international surgical education reported in the literature in the last 15 years. Previous publications on global neurosurgery reported by the Division of Neurosurgery at the University of Toronto were reviewed to exemplify the applications and challenges of international surgical collaborations.RESULTSThe most common models for international surgical education and collaboration include international surgical missions, long-term international partnerships, fellowship training models, and online surgical education. Development of such collaborations involves different challenges, including limited time availability, scarce funding/resources, sociocultural barriers, ethical challenges, and lack of organizational support. Of note, evaluation of outcomes of international surgical projects remains limited, and the development and application of assessment tools, such as the recently proposed Framework for the Assessment of International Surgical Success (FAIRNeSS), is encouraged.CONCLUSIONSActions to reduce inequality in surgical care should be implemented around the world. Different models can be used for bilateral exchange of knowledge and improvement of surgical care delivery in regions where there is poor access to surgical care. Implementation of global neurosurgery initiatives faces multiple limitations that can be ameliorated if systematic changes occur, such as the development of academic positions in global surgery, careful selection of participant centers, governmental and nongovernmental financial support, and routine application of outcome evaluation for international surgical collaborations.
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Affiliation(s)
- Joao Paulo Almeida
- 1Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Ontario, Canada; and
| | - Carlos Velásquez
- 1Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Ontario, Canada; and
- 2Hospital Universitario Marqués de Valdecilla and Fundación Instituto de Investigación Marqués de Valdecilla, Santander, Spain
| | - Claire Karekezi
- 1Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Ontario, Canada; and
| | - Miguel Marigil
- 1Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Ontario, Canada; and
| | - Mojgan Hodaie
- 1Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Ontario, Canada; and
| | - James T. Rutka
- 1Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Ontario, Canada; and
| | - Mark Bernstein
- 1Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Ontario, Canada; and
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Almeida JP, Gentili F. Letter to the Editor. Grading scale for tuberculum sellae meningiomas. Neurosurg Focus 2018; 45:E13. [DOI: 10.3171/2018.5.focus18184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Bernat AL, Priola SM, Elsawy A, Farrash F, Pasarikovski CR, Almeida JP, Lenck S, De Almeida J, Vescan A, Monteiro E, Zadeh GM, Gentili F. Recurrence of Anterior Skull Base Meningiomas After Endoscopic Endonasal Resection: 10 Years' Experience in a Series of 52 Endoscopic and Transcranial Cases. World Neurosurg 2018; 120:e107-e113. [PMID: 30077030 DOI: 10.1016/j.wneu.2018.07.210] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Although the indication of endoscopic approaches for anterior skull base meningiomas (ASBM) has been progressively refined, there remains a paucity of data on recurrence rates after resection. To analyze and compare recurrence rates of ASBM resected through endoscopic endonasal (EEE) versus transcranial (TCA) approaches. MATERIAL AND METHODS We performed a retrospective analysis of patients submitted to the EEE or TCA approach for ASBM resection from May 2006 to January 2016 in our center. Clinical, radiological, and pathology data were retrieved for analysis. Tumor size, location, surgical technique, extent of resection, and tumor grade were assessed. The 2 groups were compared to identify predictors and differences regarding tumor recurrence. RESULTS Fifty-two patients (17 olfactory groove meningioma [OGM] and 35 tuberculum sellae meningioma [TSM]) were included; 26 (6 OGM and 20 TSM) underwent EEE and 26 (13 OGM and 13 TSM) TCA, with a mean follow-up of 41 months. Gross total resection was achieved in 38 (73%) patients (18 [69%] in EEE and 20 [77%] in TCA). Eight (15%) patients presented with recurrence: 5 (19%) in the EEE group and 3 (11.5%) in the TCA group without a statistical difference (P = 0.69). Among the recurrences, gross total resection had been achieved in 1 case of each group. In the EEE group, 1 patient underwent TCA for a recurrent tumor and another patient was referred for radiosurgery. CONCLUSIONS This study has shown an overall similar recurrence rate of ASBM regardless of the technique used. However, the analysis of larger series with longer follow-up is necessary to clearly define the indications and to fully validate the efficacy of EEE.
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Affiliation(s)
- Anne-Laure Bernat
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, University Paris-Diderot, Lariboisière Hospital, Paris, France.
| | - Stefano Maria Priola
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Ahmad Elsawy
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Faisal Farrash
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Christopher R Pasarikovski
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada
| | - Joao Paulo Almeida
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada
| | - Stéphanie Lenck
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Interventional Neuroradiology, University Pierre et Marie Curie, La Pitié-Salpêtrière Hospital, Paris, France
| | - John De Almeida
- Department of Otolaryngology, UHN, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Allan Vescan
- Department of Otolaryngology, UHN, Toronto, Ontario, Canada; Department of Otolaryngology, Mount Sinai Hospital, UHN, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eric Monteiro
- Department of Otolaryngology, UHN, Toronto, Ontario, Canada; Department of Otolaryngology, Mount Sinai Hospital, UHN, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Mohammed Zadeh
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fred Gentili
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Fernández-Gajardo R, Almeida JP, Suppiah S, Witterick I, Zadeh G. Ethmoid Meningoencephalocele in a Patient with Cerebrofacial Arteriovenous Metameric Syndrome. World Neurosurg 2018; 114:1-3. [DOI: 10.1016/j.wneu.2018.02.133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/20/2018] [Accepted: 02/22/2018] [Indexed: 12/12/2022]
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Omay SB, Chen YN, Almeida JP, Ruiz-Treviño AS, Boockvar JA, Stieg PE, Greenfield JP, Souweidane MM, Kacker A, Pisapia DJ, Anand VK, Schwartz TH. Do craniopharyngioma molecular signatures correlate with clinical characteristics? J Neurosurg 2018; 128:1473-1478. [DOI: 10.3171/2017.1.jns162232] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEExome sequencing studies have recently demonstrated that papillary craniopharyngiomas (PCPs) and adamantinomatous craniopharyngiomas (ACPs) have distinct genetic origins, each primarily driven by mutually exclusive alterations: either BRAF (V600E), observed in 95% of PCPs, or CTNNB1, observed in 75%–96% of ACPs. How the presence of these molecular signatures, or their absence, correlates with clinical, radiographic, and outcome variables is unknown.METHODSThe pathology records for patients who underwent surgery for craniopharyngiomas between May 2000 and March 2015 at Weill Cornell Medical College were reviewed. Craniopharyngiomas were identified and classified as PCP or ACP. Patients were placed into 1 of 3 groups based on their genomic mutations: BRAF mutation only, CTNNB1 mutation only, and tumors with neither of these mutations detected (not detected [ND]). Demographic, radiological, and clinical variables were collected, and their correlation with each genomic group was tested.RESULTSHistology correlated strongly with mutation group. All BRAF tumors with mutations were PCPs, and all CTNNB1 with mutations and ND tumors were ACPs. Preoperative and postoperative clinical symptoms and radiographic features did not correlate with any mutation group. There was a statistically significant relationship (p = 0.0323) between the age group (pediatric vs adult) and the mutation groups. The ND group tumors were more likely to involve the sella (p = 0.0065).CONCLUSIONSThe mutation signature in craniopharyngioma is highly predictive of histology. The subgroup of tumors in which these 2 mutations are not detected is more likely to occur in children, be located in the sella, and be of ACP histology.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Theodore H. Schwartz
- Departments of 1Neurosurgery,
- 3Otolaryngology, and
- 4Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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