Minimally Invasive Targeted Therapy for Glioblastoma: Laser Interstitial Thermal Therapy

OBJECTIVEMagnetic resonance–guided laser interstitial thermal therapy (MRgLITT) is a novel, minimally invasive treatment for the surgical treatment of epilepsy. In this paper, the authors report on clinical outcomes for a series of pediatric patients with tuberous sclerosis complex (TSC) and medication-refractory epileptogenic cortical tubers.METHODSA retrospective chart review was performed at SUNY Upstate Golisano Children’s Hospital in Syracuse, New York. The authors included all cases involving pediatric patients (< 18 years) who underwent MRgLITT for ablation of epileptogenic cortical tubers between February 2013 and November 2015.RESULTSSeven patients with cortical tubers were treated (4 female and 3 male). The patients’ average age was 6.6 years (range 2–17 years). Two patients had a single procedure, and 5 patients had staged procedures. The mean time between procedures in the staged cases was 6 months. All of the patients had a meaningful reduction in seizure frequency as reported by Engel and ILAE seizure outcome classifications, and most (71.4%) of the patients experienced a reduction in AED burden. Three of the 4 patients who presented with neuropsychiatric symptoms had some improvement in these domains after laser ablation. No perioperative complications were noted. The mean duration of follow-up was 19.3 months (range 4–49 months).CONCLUSIONSLaser ablation represents a minimally invasive alternative to resective epilepsy surgery and is an effective treatment for refractory epilepsy due to cortical tubers.

Download Full-text

Laser interstitial thermal therapy as a novel treatment modality for brain tumors in the thalamus and basal ganglia

Photonics and Lasers in Medicine ◽

10.1515/plm-2013-0053 ◽

2014 ◽

Vol 3 (2) ◽

Cited By ~ 5

Author(s):

Jason L. Schroeder ◽

Symeon Missios ◽

Gene H. Barnett ◽

Alireza Mohammad Mohammadi

Keyword(s):

Surgical Treatment ◽

Basal Ganglia ◽

Magnetic Resonance ◽

Brain Tumors ◽

Minimally Invasive ◽

Thermal Therapy ◽

Neurological Deficits ◽

Tumor Cell Death ◽

Primary Tumors ◽

Laser Interstitial Thermal Therapy

AbstractIntroduction:Deep-seated hemispheric brain tumors pose unique challenges for surgical treatment. These tumors are often considered inoperable and when surgery is undertaken significant, serious, morbidity and even mortality may complicate the outcome. Laser interstitial thermal therapy (LITT) is a minimally invasive alternative to traditional open surgery that affects tumor cell death by producing a zone of thermal tissue damage that can be monitored and controlled with the aid of real-time magnetic resonance thermography.Subjects and methods:A retrospective review of six patients treated with LITT at the Cleveland Clinic between 5/2011 and 8/2013 was performed. We evaluated clinical patient data and pre-, intra-, and post-operative magnetic resonance imaging (MRI) data for correlation.Results:Six patients were treated with a total of eight separate LITT procedures for their thalamic (n=5) or basal ganglia (n=1) tumors. All tumors were histologically malignant and five were primary tumors. Pre- and post-operative neurological deficits were recorded. The two patients that underwent multiple procedures were retreated for different reasons – one due to insufficient coverage and the other due to tumor recurrence. Sustained post-operative neurological deficits were observed after three procedures and one patient died within 2 days of surgery from a thalamic hemorrhage.Conclusions:LITT is a minimally invasive surgical treatment that can lead to successful ablation of tumors of the thalamus or basal ganglia. However, this treatment has the potential for neurological morbidity or even mortality and as such further studies are needed to evaluate the true risk vs. reward potential for LITT with regard to treating deep-seated tumors.

Download Full-text

Laser interstitial thermal therapy of the spine: technical aspects

Neurosurgical FOCUS ◽

10.3171/2018.4.focusvid.17732 ◽

2018 ◽

Vol 44 (videosuppl2) ◽

pp. V3 ◽

Cited By ~ 1

Author(s):

Nelson Moussazadeh ◽

Linton T. Evans ◽

Roxana Grasu ◽

Laurence D. Rhines ◽

Claudio E. Tatsui

Keyword(s):

Minimally Invasive ◽

Trajectory Planning ◽

Thermal Therapy ◽

Spinal Tumors ◽

Technical Aspects ◽

Laser Interstitial Thermal Therapy ◽

Link Type ◽

Effective Use

Spinal laser interstitial thermal therapy has been developed as a minimally invasive modality to treat epidural spinal tumors percutaneously. The safe and effective use of this technology requires meticulous preoperative trajectory planning and an intraoperative workflow incorporating navigation and MR thermography. Instrumented stabilization can be performed during the same operation if needed. Operative considerations and technical aspects are reviewed.The video can be found here: https://youtu.be/P--frsag6gU.

Download Full-text

Prolonged survival after laser interstitial thermal therapy in glioblastoma

Surgical Neurology International ◽

10.25259/sni_174_2021 ◽

2021 ◽

Vol 12 ◽

pp. 228

Author(s):

A. Basit Khan ◽

Carlos Kamiya Matsuoka ◽

Sungho Lee ◽

Maryam Rahman ◽

Ganesh Rao

Keyword(s):

Brain Tumor ◽

Minimally Invasive ◽

Surgical Resection ◽

Thermal Therapy ◽

Case Description ◽

Newly Diagnosed ◽

Laser Interstitial Thermal Therapy ◽

Minimally Invasive Surgical ◽

Surgical Option ◽

Primary Malignant Brain Tumor

Background: Glioblastoma (GBM) is the most common primary malignant brain tumor in adults. Management includes surgical resection followed by chemoradiation, and prognosis remains poor. Surgical resection is not possible for some deep-seated or eloquent tumors. Laser interstitial thermal therapy (LITT) has emerged as a new, minimally invasive surgical option for deep-seated GBM. Case Description: We report a case of newly diagnosed thalamic GBM managed with LITT followed by radiation and chemotherapy. Conclusion: The patient remains well at 50-month post-LITT, indicating a potentially unique durability of LITT treatment in GBM.

Download Full-text

SURG-25. LASER INTERSTITIAL THERMAL THERAPY (LITT) FOR INTRACRANIAL LESIONS: A SINGLE- INSTITUTIONAL SERIES, OUTCOMES AND REVIEW OF THE LITERATURE

Neuro-Oncology ◽

10.1093/neuonc/noz175.1025 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi244-vi245

Author(s):

Rocco Dabecco ◽

Alexander Yu ◽

Tulika Ranjan ◽

Linda Xu ◽

Khaled Aziz

Keyword(s):

Minimally Invasive ◽

Brain Metastases ◽

Metastatic Disease ◽

Progression Free Survival ◽

Treatment Method ◽

Thermal Therapy ◽

Minimally Invasive Treatment ◽

Invasive Treatment ◽

Laser Interstitial Thermal Therapy

Abstract INTRODUCTION Laser interstitial thermal therapy (LITT) is a minimally invasive treatment method that provides surgeons with cytoreductive techniques to treat neurosurgical conditions such as primary brain neoplasms, brain metastases, radiation necrosis, and epileptogenic lesions, many of which are located in operative corridors that would be difficult to address via open surgical or are amenable via minimally invasive approaches. Although the use of lasers is not a new concept in neurosurgery, advances in technology have enabled surgeons to perform laser treatment with the aid of real-time MRI thermography as a guide. In this report, we present our institutional series and outcomes of patients treated with LITT for 8 glial neoplasms 12 brain metastases. METHODS We retrospectively evaluated 20 patients (7 male, 13 female; age range, 28–77 years) who underwent LITT at one or more targets from 2015–2019. RESULTS In our series, all patients included had prior craniotomy for either primary glioma or metastatic disease. Mean extent of ablation (EOA) was 98% on post-op MRI. Mean progression free survival varied depending on the intracranial pathology, with the glioma cohort (5 months (SDD: 3.51)) demonstrating worse outcomes than metastatic disease (8.2 months (SDD: 4.83)). Only 1 patient experienced immediate post-operative morbidity, 1 patient experienced post-operative mortality secondary to hemorrhage. Mean follow-up was 9.7 months (SDD: 5.35), with one patient lost to follow up immediately post-procedure and excluded from the study. Average hospitalization was 2.4 days (SDD: 1.0). Mean overall survival, post-diagnosis of intracranial lesion, is more favorable for metastatic lesions (48 months (SDD: 27.14)), as compared to primary glial neoplasms (31 months SDD: 11.63)). CONCLUSION Laser interstitial thermal therapy (LITT) is a safe, minimally invasive treatment method that provides surgeons with cytoreductive techniques to treat neurosurgical conditions. In properly selected patients, this modality offers improved survival outcomes in conjunction with other salvage therapies.

Download Full-text

Laser interstitial thermal therapy followed by minimal-access transsulcal resection for the treatment of large and difficult to access brain tumors

Neurosurgical FOCUS ◽

10.3171/2016.8.focus16233 ◽

2016 ◽

Vol 41 (4) ◽

pp. E14 ◽

Cited By ~ 25

Author(s):

James Wright ◽

Jessey Chugh ◽

Christina Huang Wright ◽

Fernando Alonso ◽

Alia Hdeib ◽

...

Keyword(s):

Minimally Invasive ◽

Tumor Volume ◽

Malignant Tumors ◽

Progression Free Survival ◽

Extent Of Resection ◽

Neurological Complications ◽

Thermal Therapy ◽

Neurological Deficits ◽

Laser Interstitial Thermal Therapy ◽

Surgeon Experience

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

Download Full-text

Intracerebral laser interstitial thermal therapy followed by tumor resection to minimize cerebral edema

Neurosurgical FOCUS ◽

10.3171/2016.7.focus16224 ◽

2016 ◽

Vol 41 (4) ◽

pp. E13 ◽

Cited By ~ 17

Author(s):

Sindhura Pisipati ◽

Kyle A. Smith ◽

Kushal Shah ◽

Koji Ebersole ◽

Roukoz B. Chamoun ◽

...

Keyword(s):

Minimally Invasive ◽

Cerebral Edema ◽

Tumor Resection ◽

Mass Effect ◽

Postoperative Management ◽

Thermal Therapy ◽

Neurological Deficits ◽

Invasive Approach ◽

Laser Interstitial Thermal Therapy ◽

Cavitron Ultrasonic Surgical Aspirator

OBJECTIVE Laser interstitial thermal therapy (LITT) is used in numerous neurosurgical applications including lesions that are difficult to resect. Its rising popularity can be attributed to its minimally invasive approach, improved accuracy with real-time MRI guidance and thermography, and enhanced control of the laser. One of its drawbacks is the possible development of significant edema, which contributes to extended hospital stays and often necessitates hyperosmolar or steroid therapy. Here, the authors discuss the use of minimally invasive craniotomy to resect tissue ablated with LITT in attempt to minimize cerebral edema. METHODS Five patients with glioblastoma multiforme prospectively underwent LITT followed by resection. The LITT was performed with the aid of an MR-compatible skull-mounted frame in the MRI suite. Ablated tumor was then resected via small craniotomy by using the NICO Myriad system or cavitron ultrasonic surgical aspirator. Postoperative management involved dexamethasone administration slowly tapered over several weeks. RESULTS The use of resection following LITT, as compared with open resection or LITT alone, did not extend the hospital stay except in 1 patient who required 3-day inpatient management of edema with a trapped ventricle. No new neurological deficits were encountered, although 1 patient developed seizures postoperatively. No increase in infection rates was identified. CONCLUSIONS Resection of ablated tumor is a viable option to reduce the incidence of neurological deficits due to edema following LITT. This approach appears to mitigate cerebral edema by increasing available volume for mass effect and reducing the tissue burden that may promote an inflammatory response.

Download Full-text

Validation of corpus callosotomy after laser interstitial thermal therapy: a multimodal approach

Journal of Neurosurgery ◽

10.3171/2018.4.jns172588 ◽

2019 ◽

Vol 131 (4) ◽

pp. 1095-1105 ◽

Cited By ~ 4

Author(s):

Kurt R. Lehner ◽

Erin M. Yeagle ◽

Miklos Argyelan ◽

Zoltán Klimaj ◽

Victor Du ◽

...

Keyword(s):

Diffusion Tensor Imaging ◽

Minimally Invasive ◽

Evoked Potentials ◽

Functional Mri ◽

Diffusion Tensor ◽

Thermal Therapy ◽

Corpus Callosotomy ◽

Laser Interstitial Thermal Therapy ◽

Clinical Series ◽

Mri Guided

ObjectiveDisconnection of the cerebral hemispheres by corpus callosotomy (CC) is an established means to palliate refractory generalized epilepsy. Laser interstitial thermal therapy (LITT) is gaining acceptance as a minimally invasive approach to treating epilepsy, but this method has not been evaluated in clinical series using established methodologies to assess connectivity. The goal in this study was to demonstrate the safety and feasibility of MRI-guided LITT for CC and to assess disconnection by using electrophysiology- and imaging-based methods.MethodsRetrospective chart and imaging review was performed in 5 patients undergoing LITT callosotomy at a single center. Diffusion tensor imaging and resting functional MRI were performed in all patients to assess anatomical and functional connectivity. In 3 patients undergoing simultaneous intracranial electroencephalography monitoring, corticocortical evoked potentials and resting electrocorticography were used to assess electrophysiological correlates.ResultsAll patients had generalized or multifocal seizure onsets. Three patients with preoperative evidence for possible lateralization underwent stereoelectroencephalography depth electrode implantation during the perioperative period. LITT ablation of the anterior corpus callosum was completed in a single procedure in 4 patients. One complication involving misplaced devices required a second procedure. Adequacy of the anterior callosotomy was confirmed using contrast-enhanced MRI and diffusion tensor imaging. Resting functional MRI, corticocortical evoked potentials, and resting electrocorticography demonstrated functional disconnection of the hemispheres. Postcallosotomy monitoring revealed lateralization of the seizures in all 3 patients with preoperatively suspected occult lateralization. Four of 5 patients experienced > 80% reduction in generalized seizure frequency. Two patients undergoing subsequent focal resection are free of clinical seizures at 2 years. One patient developed a 9-mm intraparenchymal hematoma at the site of entry and continued to have seizures after the procedure.ConclusionsMRI-guided LITT provides an effective minimally invasive alternative method for CC in the treatment of seizures associated with drop attacks, bilaterally synchronous onset, and rapid secondary generalization. The disconnection is confirmed using anatomical and functional neuroimaging and electrophysiological measures.

Download Full-text

Magnetic resonance imaging–guided laser interstitial thermal therapy for previously treated hypothalamic hamartomas

Neurosurgical FOCUS ◽

10.3171/2016.7.focus16218 ◽

2016 ◽

Vol 41 (4) ◽

pp. E8 ◽

Cited By ~ 22

Author(s):

Anthony M. Burrows ◽

W. Richard Marsh ◽

Gregory Worrell ◽

David A. Woodrum ◽

Bruce E. Pollock ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Minimally Invasive ◽

Thermal Therapy ◽

Seizure Freedom ◽

Resonance Imaging ◽

Gelastic Seizures ◽

Laser Interstitial Thermal Therapy ◽

Hypothalamic Hamartomas

OBJECTIVE Hypothalamic hamartomas (HHs) are associated with gelastic seizures and the development of medically refractory epilepsy. Magnetic resonance imaging–guided laser interstitial thermal therapy (MRg-LITT) is a minimally invasive ablative treatment that may have applicability for these deep-seated lesions. Here, the authors describe 3 patients with refractory HHs who they treated with MRg-LITT. METHODS An institutional review board–approved prospective database of patients undergoing Visualase MRg-LITT was retrospectively reviewed. Demographic and historical medical data, including seizure and medication histories, previous surgeries, procedural details, and surgical complications, along with radiological interpretation of the HHs, were recorded. The primary outcome was seizure freedom, and secondary outcomes included medication reduction, seizure frequency, operative morbidity, and clinical outcome at the latest follow-up. RESULTS All 3 patients in the multi-institutional database had developed gelastic seizures related to HH at the ages of 7, 7, and 9 years. They presented for further treatment at 25, 28, and 48 years of age, after previous treatments with stereotactic radiosurgery in all cases and partial hamartoma resection in one case. One ablation was complicated by a small tract hemorrhage, which was stable on postoperative imaging. One patient developed hyponatremia and experienced weight gain, which were respectively managed with fluid restriction and counseling. At the most recent follow-up at a mean of 21 months (range 1–32 months), one patient was seizure free while another had meaningful seizure reduction. Medication was reduced in one case. CONCLUSIONS Adults with gelastic seizures despite previous treatments can undergo MRg-LITT with reasonable safety and efficacy. This novel therapy may provide a minimally invasive alternative for primary and recurrent HH as the technique is refined.

Download Full-text

Early outcomes of stereoelectroencephalography followed by MR-guided laser interstitial thermal therapy: a paradigm for minimally invasive epilepsy surgery

Neurosurgical FOCUS ◽

10.3171/2018.6.focus18209 ◽

2018 ◽

Vol 45 (3) ◽

pp. E8 ◽

Cited By ~ 14

Author(s):

Kelsey Cobourn ◽

Islam Fayed ◽

Robert F. Keating ◽

Chima O. Oluigbo

Keyword(s):

Minimally Invasive ◽

Pediatric Patients ◽

Focal Cortical Dysplasia ◽

Pediatric Population ◽

Outcome Data ◽

Thermal Therapy ◽

Laser Interstitial Thermal Therapy ◽

The Mean ◽

Seizure Foci

OBJECTIVEStereoelectroencephalography (sEEG) and MR-guided laser interstitial thermal therapy (MRgLITT) have both emerged as minimally invasive alternatives to open surgery for the localization and treatment of medically refractory lesional epilepsy. Although some data are available about the use of these procedures individually, reports are almost nonexistent on their use in conjunction. The authors’ aim was to report early outcomes regarding efficacy and safety of sEEG followed by MRgLITT for localization and ablation of seizure foci in the pediatric population with medically refractory lesional epilepsy.METHODSA single-center retrospective review of pediatric patients who underwent sEEG followed by MRgLITT procedures was performed. Demographic, intraoperative, and outcome data were compiled and analyzed.RESULTSFour pediatric patients with 9 total lesions underwent sEEG followed by MRgLITT procedures between January and September 2017. The mean age at surgery was 10.75 (range 2–21) years. Two patients had tuberous sclerosis and 2 had focal cortical dysplasia. Methods of stereotaxy consisted of BrainLab VarioGuide and ROSA robotic guidance, with successful localization of seizure foci in all cases. The sEEG procedure length averaged 153 (range 67–235) minutes, with a mean of 6 (range 4–8) electrodes and 56 (range 18–84) contacts per patient. The MRgLITT procedure length averaged 223 (range 179–252) minutes. The mean duration of monitoring was 6 (range 4–8) days, and the mean total hospital stay was 8 (range 5–11) days. Over a mean follow-up duration of 9.3 (range 5.1–16) months, 3 patients were seizure free (Engel class I, 75%), and 1 patient saw significant improvement in seizure frequency (Engel class II, 25%). There were no complications.CONCLUSIONSThese early data demonstrate that sEEG followed by MRgLITT can be used safely and effectively to localize and ablate epileptogenic foci in a minimally invasive paradigm for treatment of medically refractory lesional epilepsy in pediatric populations. Continued collection of data with extended follow-up is needed.

Download Full-text