F.10 Management of peripheral nerve sheath tumours: the Toronto Western Hospital experience

Background: We retrospectively review benign peripheral nerve sheath tumours (BPNST) managed surgically at the Toronto Western Hospital. The incidence of BPNST is classified by anatomic location and predisposition syndrome. Independent predictors of tumour recurrence and symptom resolution are identified. Methods: 175 patients with 201 tumours were eligible for analysis. Data was collected on patient age, gender, diagnosis of neurofibromatosis (NF), tumour histopathology, tumour location, tumour volume, and extent of resection. Postoperative motor, sensory and pain outcomes were dichotomized as stable/improved or worse than preoperative scores. Relationships between tumour recurrence, or symptom resolution, and predictor variables were assessed with univariate and multiple logistic regression models. Results: Among Schwannomas, subtotal resection, a diagnosis of Schwannomatosis, and larger tumour volume were associated with recurrence (p=0.012, p=0.048, p=0.049, respectively); for neurofibromas, subtotal resection and a diagnosis of NF1 were associated with recurrence (p=0.036, p=0.022, respectively). Multivariate analyses revealed subtotal resection as an independent predictor of recurrence for BPNSTs (p=0.007, OR=13.16, 95%-CI 2.34-52.63). Gross-total resection (p=0.023, OR=4.01, 95%-CI 1.21-13.22) and presence of a preoperative motor deficit (p=0.038, OR=8.06, 95%-CI 4.65-90.91) were independent predictors of stable/improved postoperative motor function for BPNSTs. Conclusions: Gross-total resection is associated with both reduced recurrence and improved postoperative motor function, and should be attempted for all eligible BPNSTs.

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The Long-term Outcome After Resection of Intraspinal Nerve Sheath Tumors

Neurosurgery ◽

10.1227/neu.0000000000000890 ◽

2015 ◽

Vol 77 (4) ◽

pp. 585-593 ◽

Cited By ~ 10

Author(s):

Charlotte Marie Halvorsen ◽

Pål Rønning ◽

John Hald ◽

Tom Børge Johannesen ◽

Frode Kolstad ◽

...

Keyword(s):

Clinical Outcome ◽

Progression Free Survival ◽

Gross Total Resection ◽

Subtotal Resection ◽

Total Resection ◽

Free Survival ◽

Nerve Sheath Tumors ◽

Nerve Sheath

Abstract BACKGROUND: The existing literature on recurrence rates and long-term clinical outcome after resection of intraspinal nerve sheath tumors is limited. OBJECTIVE: To evaluate progression-free survival, overall survival, and long-term clinical outcome in a consecutive series of 131 patients with symptomatic intraspinal nerve sheath tumors. METHODS: Medical charts were retrospectively reviewed. Surviving patients voluntarily participated in a clinical history and physical examination that focused on neurological function and current tumor status. RESULTS: Follow-up data are 100% complete; median follow-up time was 6.1 years. All patients (100%) had surgery as the first line of treatment; gross total resection was performed in 112 patients (85.5%) and subtotal resection in 19 patients (14.5%). Five-year progression-free survival was 89%. The following risk factors for recurrence were identified: neurofibroma, malignant peripheral nerve sheath tumor, subtotal resection, neurofibromatoses/schwannomatosis, and advancing age at diagnosis. More than 95% of patients had neurological function compatible with an independent life at follow-up. The rate of tumor recurrence in nonneurofibromatosis patients undergoing total resection of a single schwannoma was 3% (3/93), in comparison with a recurrence rate of 32% (12/38) in the remaining patients. CONCLUSION: Gross total resection is the gold standard treatment for patients with intraspinal nerve sheath tumors. In a time of limited health care resources, we recommend that follow-up be focused on the subgroup of patients with a high risk of recurrence. The benefit of long-term, yearly magnetic resonance imaging follow-up with respect to recurrence in nonneurofibromatosis patients undergoing gross total resection of a single schwannoma is, in our opinion, questionable.

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High-Definition 4K 3D Exoscope (ORBEYETM) in Peripheral Nerve Sheath Tumor Surgery: A Preliminary, Explorative, Pilot Study

Operative Neurosurgery ◽

10.1093/ons/opaa090 ◽

2020 ◽

Vol 19 (4) ◽

pp. 480-488

Author(s):

Ignazio G Vetrano ◽

Francesco Acerbi ◽

Jacopo Falco ◽

Antonio D’Ammando ◽

Grazia Devigili ◽

...

Keyword(s):

Peripheral Nerve ◽

Lower Limbs ◽

Gross Total Resection ◽

Nerve Sheath Tumor ◽

Tumor Surgery ◽

Total Resection ◽

Peripheral Nerve Sheath Tumors ◽

Advantages And Disadvantages ◽

Nerve Sheath ◽

Clinical Series

Abstract BACKGROUND Surgery for peripheral nerve sheath tumors aims to preserve functional fascicles achieving gross-total resection. Increasing the visualization of anatomic details helps to identify the different layers and the tumor-nerve interface. The traditional microscope can present some limitations in this type of surgery, such as its physical obstruction. OBJECTIVE To present a proof-of-concept study about exoscope-guided surgery for schwannomas of the lower limbs, to analyze the advantages and disadvantages of the 4K, high-quality, 3-dimensional (3D) imaging. METHODS We analyzed 2 consecutive surgical cases of suspected schwannomas of the lower limbs using the ORBEYE™ exoscope (Olympus). A standard operative microscope was also available in the operating room. All procedures were performed with neurophysiological monitoring, to identify functioning nerves and to localize the tumor capsule safest entry point. The cases are reported according to the PROCESS guidelines. RESULTS In both cases, we achieved a gross total resection of the schwannomas; the exoscope provided an excellent view of the anatomic details at tumor-nerve interface, as visible in intraoperative images and in the 3D-4K video supporting these findings. The surgeon's position was comfortable in both cases, although if the co-surgeon positioned himself in front of the first surgeon, the comfort was slightly reduced. The 4K monitor allowed a realistic, nontiring 3D vision for all the team. CONCLUSION The ORBEYETM, after an adequate learning curve, can represent a feasible and comfortable instrument for nerve tumor surgery, which is usually performed in a single horizontal plane. Further and wider clinical series are necessary to confirm this first impression.

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Fluorescein-guided removal of peripheral nerve sheath tumors: a preliminary analysis of 20 cases

Journal of Neurosurgery ◽

10.3171/2019.9.jns19970 ◽

2019 ◽

pp. 1-10 ◽

Cited By ~ 2

Author(s):

Ignazio G. Vetrano ◽

Francesco Acerbi ◽

Jacopo Falco ◽

Grazia Devigili ◽

Sara Rinaldo ◽

...

Keyword(s):

Peripheral Nerve ◽

Tumor Resection ◽

Gross Total Resection ◽

Light Illumination ◽

Total Resection ◽

Follicular Hyperplasia ◽

Nerve Sheath Tumors ◽

Peripheral Nerve Sheath Tumors ◽

Nerve Sheath ◽

Yellow 560

OBJECTIVEBenign peripheral nerve sheath tumors (PNSTs) include mainly schwannomas—the most common tumors arising from peripheral nerves—and neurofibromas. Due to their origin, distinguishing between functional intact nerve and the fibers from whence the PNST arose may not always be easy to perform. The introduction of intraoperative tools to better visualize these tumors could be helpful in achieving a gross-total resection. In this study, the authors present a series of patients harboring PNST in which the surgery was performed under fluorescein guidance.METHODSBetween September 2018 and February 2019, 20 consecutive patients with a total of 25 suspected PNSTs underwent fluorescein-guided surgery performed under microscopic view with a dedicated filter integrated into the surgical microscope (YELLOW 560) and with intraoperative monitoring. All patients presented with a different degree of contrast enhancement at preoperative MRI. Fluorescein was intravenously injected after intubation at a dose of 1 mg/kg. Preoperative clinical and radiological data, intraoperative fluorescein characteristics, and postoperative neurological and radiological outcomes were collected and analyzed.RESULTSSix patients were affected by neurofibromatosis or schwannomatosis. There were 14 schwannomas, 8 neurofibromas, 1 myxoma, 1 reactive follicular hyperplasia, and 1 giant cell tumor of tendon sheath. No patient experienced worsening of neurological status after surgery. No side effects related to fluorescein injection were found in this series. Fluorescein allowed an optimal intraoperative distinction between tumor and surrounding nerves in 13 of 14 schwannomas and in all neurofibromas. In 6 neurofibromas and in 1 schwannoma, the final YELLOW 560 visualization showed the presence of small tumor remnants that were not visible under white-light illumination and that could be removed, obtaining a gross-total resection.CONCLUSIONSFluorescein was demonstrated to be a feasible, safe, and helpful intraoperative adjunct to better identify and distinguish PNSTs from intact functional nerves, with a possible impact on tumor resection, particularly in diffuse neurofibromas.

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Sodium Fluorescein-Guided Gross Total Resection of Pediatric Exophytic Brainstem Glioma: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa357 ◽

2020 ◽

Author(s):

Christopher Markosian ◽

Catherine A Mazzola ◽

Luke D Tomycz

Keyword(s):

Normal Tissue ◽

Clinical Case ◽

Aminolevulinic Acid ◽

Significant Risk ◽

Gross Total Resection ◽

Subtotal Resection ◽

Sodium Fluorescein ◽

Total Resection ◽

Term Survival ◽

Patient Consent

Abstract Brainstem gliomas comprise 10% to 20% of pediatric intracranial tumors.1 Gross total resection is associated with the greatest long-term survival.1 However, due to the eloquence of surrounding brain tissue, an aggressive resection is not always achievable and can be associated with significant risk.2 Sodium fluorescein can be used to help differentiate between tumor and normal tissue.3,4 In this operative video, we demonstrate the step-by-step technique to utilize fluorescence in surgically resecting an exophytic glioma arising from the midbrain in a 16-yr-old male. Technical nuances are highlighted in this operative video, including the use of the YELLOW 560 (Zeiss) filter to differentiate fluorescent tumor from normal tissue as well as strategic splitting of the tentorium to expose the supratentorial component of the tumor. A decrease in motor potentials of the right leg during the case did not translate into neurological worsening postoperatively; at 3-mo follow-up, the patient attests to better strength and coordination on his affected side. In summary, sodium fluorescein can be used as a critical adjunctive tool for successful surgery in the case of a brainstem tumor. Alternatives to this procedure included gross total resection with 5-aminolevulinic acid, subtotal resection with chemotherapy, and active monitoring, but were not chosen due to their limitations in this clinical case.5-7 Appropriate patient consent was obtained to perform this procedure and present this clinical case and surgical video for academic purposes.

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A management strategy for intraventricular subependymal giant cell astrocytomas in tuberous sclerosis complex

Journal of Neurosurgery Pediatrics ◽

10.3171/2013.9.peds13193 ◽

2014 ◽

Vol 13 (1) ◽

pp. 21-28 ◽

Cited By ~ 12

Author(s):

David H. Harter ◽

Luigi Bassani ◽

Shaun D. Rodgers ◽

Jonathan Roth ◽

Orrin Devinsky ◽

...

Keyword(s):

Tumor Progression ◽

Tuberous Sclerosis ◽

Giant Cell ◽

Tuberous Sclerosis Complex ◽

Primary Tumor ◽

Management Strategy ◽

Gross Total Resection ◽

Subtotal Resection ◽

Total Resection ◽

Shunt Placement

Object Subependymal giant cell astrocytomas (SEGAs) are benign tumors, most commonly associated with tuberous sclerosis complex (TSC). The vast majority of these tumors arise from the lateral ependymal surface adjacent to the foramen of Monro, therefore potentially encroaching on one or both foramina, and resulting in obstructive hydrocephalus that necessitates surgical decompression. The indications for surgery, intraoperative considerations, and evolution of the authors' management paradigm are presented. Methods Patients with TSC who underwent craniotomy for SEGA resection at New York University Langone Medical Center between January 1997 and March 2011 were identified. Preoperative imaging, clinical characteristics, management decisions, operative procedures, and outcomes were reviewed. Results Eighteen patients with TSC underwent 22 primary tumor resections for SEGAs. The indication for surgery was meaningful radiographic tumor progression in 16 of 21 cases. The average age at the time of operation was 10.3 years. Average follow-up duration was 52 months (range 12–124 months). The operative approach was intrahemispheric-transcallosal in 16 cases, transcortical-transventricular in 5, and neuroendoscopic in 1. Nine tumors were on the right, 9 on the left, and 3 were bilateral. Gross-total resection was documented in 16 of 22 cases in our series, with radical subtotal resection achieved in 4 cases, and subtotal resection (STR) in 2 cases. Two patients had undergone ventriculoperitoneal shunt placement preoperatively and 7 patients required shunt placement after surgery for moderate to severe ventriculomegaly. Two patients experienced tumor progression requiring reoperation; both of these patients had initially undergone STR. Conclusions The authors present their management strategy for TSC patients with SEGAs. Select patients underwent microsurgical resection of SEGAs with acceptable morbidity. Gross-total resection or radical STR was achieved in 90.9% of our series (20 of 22 primary tumor resections), with no recurrences in this group. Approximately half of our patient series required CSF diversionary procedures. There were no instances of permanent neurological morbidity associated with surgery.

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P.041 Adult craniopharyngioma: case series, systematic review and meta-analysis

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2017.126 ◽

2017 ◽

Vol 44 (S2) ◽

pp. S24-S24

Author(s):

C Dandurand ◽

AA Sepehry ◽

MH Asadi Lari ◽

R Akagami ◽

PA Gooderham

Keyword(s):

Meta Analysis ◽

Case Series ◽

Gross Total Resection ◽

Subtotal Resection ◽

Total Resection ◽

Childhood Population ◽

Institutional Experience ◽

The Difference ◽

Meta Analyses ◽

Case Basis

Background: The optimal therapeutic approach for adult craniopharyngioma remains controversial. Some advocate for gross total resection (GTR), while others support subtotal resection followed by adjuvant radiotherapy (STR + XRT). Methods: MEDLINE (1946 to July 1st 2016) and EMBASE (1980 to June 30th 2016) were systematically reviewed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed. At our institution, from 1975 to 2013, 33 patients were treated with initial surgical resection for adult onset craniopharyngioma. 22 patients were included in the present case series. Results: Eligible studies (n=21) were identified from the literature in addition to a case series of our institutional experience. Three groups were available for analysis: GTR, STR + XRT, and STR. The rates of recurrence were 17 %, 27 % and 45%, respectively. This differs from childhood population. The difference in risk of recurrence after GTR vs. STR + XRT did not reach significance (OR: 0.63, 95% confidence interval: 0.33-1.24, P=0.18). This maybe because of low pooled sample size (n=99) who underwent STR+XRT. Conclusions: This is the first and largest meta-analysis examining rate of recurrence in adult craniopharyngioma. Thus, when safe and feasible, a goal of gross total resection should be favored. Each patient should be considered on a case-by-case basis.

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Profound hearing loss following surgery in pediatric patients with posterior fossa low-grade glioma

Neuro-Oncology Practice ◽

10.1093/nop/npx025 ◽

2017 ◽

Vol 5 (2) ◽

pp. 96-103 ◽

Cited By ~ 1

Author(s):

Yahya Ghazwani ◽

Ibrahim Qaddoumi ◽

Johnnie K Bass ◽

Shengjie Wu ◽

Jason Chiang ◽

...

Keyword(s):

Hearing Loss ◽

Posterior Fossa ◽

Extent Of Resection ◽

Tumor Location ◽

Low Grade Glioma ◽

Gross Total Resection ◽

Subtotal Resection ◽

Low Grade ◽

Total Resection ◽

Profound Hearing Loss

Abstract Background Hearing loss may occur in patients with posterior fossa low-grade glioma who undergo surgery. Methods We retrospectively reviewed 217 patients with posterior fossa low-grade glioma, including 115 for whom results of hearing tests performed after surgery and before chemotherapy or radiation therapy were available. We explored the association of UHL with age at diagnosis, sex, race, tumor location, extent of resection, posterior fossa syndrome, ventriculoperitoneal shunt placement, and histology. Results Of the 115 patients, 15 (13.0%: 11 male, 6 black, 8 white, 1 multiracial; median age 7 years [range, 1.3–17.2 years]) had profound UHL after surgery alone or before receiving ototoxic therapy. Median age at tumor diagnosis was 6.8 years (range, 0.7–14.1 years), and median age at surgery was 6.8 years (range, 0.7–14.1 years). Patients with UHL had pathology characteristic of pilocytic astrocytoma (n = 10), ganglioglioma (n = 4), or low-grade astrocytoma (n = 1). Of these 15 patients, 4 underwent biopsy, 1 underwent gross total resection, 1 underwent near-total resection, and 9 underwent subtotal resection. UHL was more frequent in black patients than in white patients (OR 7.3, P = .007) and less frequent in patients who underwent gross total resection or near-total resection than in those who underwent subtotal resection (OR 0.11, P = .02). Conclusions Children undergoing surgery for posterior fossa low-grade glioma are at risk for UHL, which may be related to race or extent of resection. These patients should receive postoperative audiologic testing, as earlier intervention may improve outcomes.

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Microsurgical Gross Total Resection of a Large Residual/Recurrent Vestibular Schwannoma via Translabyrinthine Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1669971 ◽

2018 ◽

Vol 79 (S 05) ◽

pp. S387-S388

Author(s):

Sima Sayyahmelli ◽

Joseph Roche ◽

Mustafa Baskaya

Keyword(s):

Vestibular Schwannoma ◽

Gross Total Resection ◽

Subtotal Resection ◽

Total Resection ◽

Entry Zone ◽

Stereotactic Radiation ◽

Translabyrinthine Approach ◽

History Of ◽

Microsurgical Techniques ◽

Facial Function

Although, gross total resection in large vestibular schwannomas is an ideal goal, subtotal resection is frequently performed due to lack of expertise, concerns for facial palsy, or overuse of stereotactic radiation. In this video, we present a 31-year-old man with a 7-year history of tinnitus, dizziness, and hearing loss. The patient had a subtotal resection of a 2.5 cm right-sided vestibular schwannoma via retrosigmoid craniotomy at an outside hospital. He was referred for further surgical resection due to the increased size of the tumor on surveillance magnetic resonance imagings (MRIs) and worsening symptoms. MRI showed a residual/recurrent large schwannoma with extension to the full length of the internal acoustic canal and brain stem compression. He underwent microsurgical gross total resection via a translabyrinthine approach. The facial nerve was preserved and stimulated with 0.15 mA at the brainstem entry zone. He awoke with House–Brackmann grade III facial function, with an otherwise uneventful postoperative course. In this video, microsurgical techniques and important resection steps for this residual/recurrent vestibular schwannoma are demonstrated, and nuances for microsurgical technique are discussed.The link to the video can be found at: https://youtu.be/a0ZxE41Tqzw.

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Clinical, surgical and postoperative outcome analysis of tumors occupying both posterior and middle cranial fossa

Nepal Journal of Neuroscience ◽

10.3126/njn.v18i2.33783 ◽

2021 ◽

Vol 18 (2) ◽

pp. 36-44

Author(s):

Rahul Singh ◽

Ravi Shankar Prasad ◽

Ramit Chandra Singh ◽

Kulwant Singh ◽

Anurag Sahu

Keyword(s):

Postoperative Outcome ◽

Middle Cranial Fossa ◽

Posterior Cranial Fossa ◽

Gross Total Resection ◽

Outcome Analysis ◽

Subtotal Resection ◽

Combined Approach ◽

Total Resection ◽

Trigeminal Schwannoma ◽

Cranial Fossa

Objectives: To analyse clinical, surgical and postoperative outcome perspectives of tumors occupying both middle and posterior cranial fossa. Materials and Methods: This retrospective cohort study includes 23 patients operated for tumors involving both middle and posterior cranial fossa in our department between August 2016 and August 2020. Each patient was evaluated for age, sex, co morbidities, tumour histopathology, clinical presentation, radiological characteristics, surgical and outcome characteristics. Unpaired t- test and chi-square test was used for statistical analysis. P < 0.05 was considered statistically significant. Results: The mean age was 46 years (range 40–57 years), with the majority of patients being female (56.5%). Most tumors (65.3%) were trigeminal schwannoma, with the remaining being vestibular schwannoma (21.7%), facial schwannoma (8.7%) and epidermoid (4.3%). The most commonly used surgical approach was the retrosigmoid approach (30.4%) and combined approach (30.4%). Gross total resection (GTR) was done in 14 patients while subtotal resection (STR) was done in 9 patients. STR was significantly associated (p<0.05) with persisting cranial nerve deficit and tumour progression. Midbrain compression, internal carotid artery and cavernous sinus involvement were significantly (p<0.05) associated with STR. Conclusions: Trigeminal schwannoma is the most common tumour involving both middle and posterior cranial fossa. Combined approach for such tumours is required in tumours having significant size in both middle cranial fossa and posterior cranial fossa. The intent of surgery is to achieve a gross total resection (GTR) but adhesions and involvement of critical brain structures results in STR.

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Long-term efficacy of surgical resection with or without adjuvant therapy for treatment of secondary glioblastoma in adults

Neuro-Oncology Advances ◽

10.1093/noajnl/vdaa098 ◽

2020 ◽

Vol 2 (1) ◽

Author(s):

Ruoyu Huang ◽

Guanzhang Li ◽

Yiming Li ◽

Yinyan Wang ◽

Pei Yang ◽

...

Keyword(s):

Survival Analysis ◽

Prognostic Factors ◽

Adjuvant Therapy ◽

Clinical Outcomes ◽

Cox Regression ◽

Postoperative Radiotherapy ◽

Gross Total Resection ◽

Subtotal Resection ◽

Total Resection ◽

Secondary Glioblastoma

Abstract Background There are limited studies on treatment strategies and associated clinical outcomes in patients with secondary glioblastoma (sGBM). We sought to investigate the prognostic factors and treatment decisions in a retrospective cohort of patients with sGBM. Methods One hundred and seventy-one patients with sGBM who met the screening criteria were included in this study. Kaplan–Meier survival analysis and Cox survival analysis were used to detect prognostic factors. R (v3.5.0) and SPSS software (v25.0, IBM) were used to perform statistical analyses. Results The median overall survival was 303 days (range 23–2237 days) and the median progression-free survival was 229 days (range 33–1964 days) in patients with sGBM. When assessing the relationship between adjuvant treatment outcome and extent of resection (EOR), the results showed that patients underwent gross total resection can benefit from postoperative radiotherapy and chemotherapy, but not in patients underwent subtotal resection. In addition, we also found that aggressive adjuvant therapy can significantly improve clinical outcomes of IDH1-mutated patients but no significant prognostic value for IDH1-wildtyped patients. The univariate Cox regression analyses demonstrated that EOR, adjuvant therapy, and postoperative Karnofsky Performance Scores were prognostic factors for patients with sGBM, and multivariate COX analysis confirmed that adjuvant therapy and EOR were independent prognostic factors. Conclusions For patients with sGBM, aggressive postoperative adjuvant therapy after gross total resection was recommended. However, we did not detect a benefit in IDH1-wildtype patients in our cohort.

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