MeduUoblastoma with Brain Stem Involvement: The Impact of Gross Total Resection on Outcome

Abstract Introduction The extended endoscopic approach (EEA) provides direct access for resection of tuberculum sellae (TSM) and olfactory groove meningiomas (OGM) but is associated with cerebrospinal fluid (CSF) leak in up to 25% of patients. To evaluate the impact of improved skull base reconstructive techniques, we assessed published CSF leak percentages in EEA over the last two decades. Method Random-effects meta-analyses were performed for studies published between 2004-2020. Outcomes assessed were CSF leak, gross total resection, visual improvement, intraoperative arterial injury and 30-day mortality. For the main analyses, publications were pragmatically grouped based on publication year in three categories: 2004-2010, 2011-2015, and 2016-2020. Results We included 29 studies describing 540 TSM and 115 OGM patients. CSF leak incidence dropped over time from 22% (95% CI: 6-43%) in studies published between 2004 and 2010, to 16% (95% CI: 11-23%) between 2011 and 2015, and 4% (95% CI: 1-9%) between 2016 and 2020. Outcomes of gross total resection, visual improvement, intraoperative arterial injury, and 30-day mortality remained stable over time Conclusions We report a noticeable decrease in CSF leak over time, which might be attributed to the development of reconstructive techniques (e.g., hadad bassagasteguy flap, and gasket seal), refined multilayer repair protocols, and selected lumbar drain usage.

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Extent of resection in glioblastoma: a 10-year local survival analysis

Neuro-Oncology ◽

10.1093/neuonc/noab195.049 ◽

2021 ◽

Vol 23 (Supplement_4) ◽

pp. iv19-iv19

Author(s):

Theodore Hirst ◽

Patrick McAleavey ◽

Tom Flannery

Keyword(s):

Neurological Deficit ◽

Survival Benefit ◽

Extent Of Resection ◽

Cox Proportional Hazards ◽

Partial Resection ◽

Gross Total Resection ◽

Molecular Profile ◽

Total Resection ◽

Local Survival ◽

The Impact

Abstract Aims The impact on extent of resection (EOR) in glioblastoma has been well documented. It is clear that gross-total resection (GTR) confers best overall survival (OS), however the minimum EOR required to confer a survival benefit over biopsy is debated. Recent studies favour partial resection (PR) over biopsy for IDH-wildtype, MGMT-unmethylated tumours. We describe our experiences locally with these principles in mind. Method Retrospective evaluation of a single surgeon cohort. All patients over 18 years old, undergoing a surgical treatment for histologically confirmed GBM in the stated period were included. We collected information on demographics, tumour volume, EOR, complications, adjuvant therapies, molecular profile, and OS. We used log rank tests and Cox Proportional Hazards Models to identify factors associated with OS. Results The patient and tumour characteristics of our cohort were similar to those documented in the literature. The mean age was 56.6 years. 72 patients underwent biopsy and 202 had debulking surgery. Median OS was 11 months. Of those debulked, gross-total resection was achieved in 41 patients (20%); associated median OS was 29 months. Patients receiving partial resection (defined as EOR <80%) had no clear survival benefit over patients undergoing biopsy (median OS 6 vs 5 months) but had a higher rate of post-op neurological deficit (3% vs 12%). Tumour molecular profile appeared to influence survival outcome in a manner comparable to worldwide experience. Conclusion In our experience, partial resection is not a justifiable surgical aim in the typical glioblastoma cohort. The limited benefit that it may confer over biopsy appears to be outweighed by the risk of neurological deficit that affects quality and probably quantity of life. This finding applies to our glioblastoma population in general as well as those specifically with an MGM-unmethylated tumour.

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Gross Total Resection Rates in Contemporary Glioblastoma Surgery

Neurosurgery ◽

10.1227/neu.0b013e31826d1e6b ◽

2012 ◽

Vol 71 (5) ◽

pp. 927-936 ◽

Cited By ~ 120

Author(s):

Philippe Schucht ◽

Jürgen Beck ◽

Janine Abu-Isa ◽

Lukas Andereggen ◽

Michael Murek ◽

...

Keyword(s):

Aminolevulinic Acid ◽

Complete Resection ◽

High Rate ◽

Gross Total Resection ◽

Neurological Deficits ◽

Total Resection ◽

Glioma Surgery ◽

Intraoperative Mapping ◽

Number Of Patients ◽

The Impact

Abstract BACKGROUND: Complete resection of contrast-enhancing tumor has been recognized as an important prognostic factor in patients with glioblastoma and is a primary goal of surgery. Various intraoperative technologies have recently been introduced to improve glioma surgery. OBJECTIVE: To evaluate the impact of using 5-aminolevulinic acid and intraoperative mapping and monitoring on the rate of complete resection of enhancing tumor (CRET), gross total resection (GTR), and new neurological deficits as part of an institutional protocol. METHODS: One hundred three consecutive patients underwent resection of glioblastoma from August 2008 to November 2010. Eligibility for CRET was based on the initial magnetic resonance imaging assessed by 2 reviewers. The primary end point was the number of patients with CRET and GTR. Secondary end points were volume of residual contrast-enhancing tissue and new postoperative neurological deficits. RESULTS: Fifty-three patients were eligible for GTR/CRET (n = 43 newly diagnosed glioblastoma, n = 10 recurrent); 13 additional patients received surgery for GTR/CRET-ineligible glioblastoma. GTR was achieved in 96% of patients (n = 51, no residual enhancement > 0.175 cm3); CRET was achieved in 89% (n = 47, no residual enhancement). Postoperatively, 2 patients experienced worsening of preoperative hemianopia, 1 patient had a new mild hemiparesis, and another patient sustained sensory deficits. CONCLUSION: Using 5-aminolevulinic acid imaging and intraoperative mapping/monitoring together leads to a high rate of CRET and an increased rate of GTR compared with the literature without increasing the rate of permanent morbidity. The combination of safety and resection-enhancing intraoperative technologies was likely to be the major drivers for this high rate of CRET/GTR.

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The Impact of Intraoperative Electrocorticography on Seizure Outcome After Resection of Pediatric Brain Tumors: A Cohort Study

Neurosurgery ◽

10.1093/neuros/nyy342 ◽

2018 ◽

Vol 85 (3) ◽

pp. 375-383 ◽

Cited By ~ 1

Author(s):

Faith C Robertson ◽

Nicole J Ullrich ◽

Peter E Manley ◽

Hasan Al-Sayegh ◽

Clement Ma ◽

...

Keyword(s):

Pediatric Patients ◽

Focal Cortical Dysplasia ◽

Tumor Resection ◽

Cortical Dysplasia ◽

Class I ◽

Gross Total Resection ◽

Seizure Outcome ◽

Seizure Freedom ◽

Total Resection ◽

The Impact

AbstractBACKGROUNDIntraoperative electrocorticography (ECoG) has been utilized in patients with tumor-associated seizures; however, its effectiveness for seizure control remains controversial.OBJECTIVETo evaluate clinical outcomes in pediatric patients undergoing lesionectomy with or without ECoG.METHODSPatients undergoing brain tumor resection at Boston Children's Hospital were examined retrospectively (2005-2014). Inclusion criteria involved diagnosis of a supratentorial tumor, ≥2 unequivocal seizures, and ≥6 mo follow-up. Patients with isolated cortical dysplasia or posterior fossa tumors were excluded. Logistic regression models evaluated predictors of ECoG use, and the impact of ECoG, gross total resection, and focal cortical dysplasia with tumors on seizure freedom by Engel Class and anti-epileptic drug use (AED).RESULTSA total of 119 pediatric patients were included (n = 69 males, 58%; median age, 11.3 yr). Forty-one patients (34.5%) had ECoG-guided surgery. Preoperative seizure duration and number and duration of AED use were significant predictors for undergoing ECoG. There were no differences in seizure freedom (Engel Class I) or improved Engel Score (Class I-II vs III-IV) in patients who did or did not have ECoG at 30 d, 6 mo, and 1, 2, or 5 yr. Patients undergoing ECoG required a greater number of AEDs at 6 mo (P = .01), although this difference disappeared at subsequent time intervals. Gross total resection predicted seizure freedom at 30 d and 6 mo postsurgery (P = .045).CONCLUSIONThis retrospective study, one of the largest evaluating the use of ECoG during tumor resection, suggests that ECoG does not provide improved seizure freedom compared to lesionectomy alone for children.

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Surgical treatment of ectopic recurrence of craniopharyngioma

Journal of Neurosurgery Pediatrics ◽

10.3171/2009.3.peds0948 ◽

2009 ◽

Vol 4 (2) ◽

pp. 105-112 ◽

Cited By ~ 22

Author(s):

Robert E. Elliott ◽

Yaron A. Moshel ◽

Jeffrey H. Wisoff

Keyword(s):

Surgical Treatment ◽

Local Recurrence ◽

Tumor Recurrence ◽

Radical Resection ◽

Gross Total Resection ◽

Consecutive Series ◽

Total Resection ◽

Ectopic Recurrence ◽

The Impact

Local recurrence following radical resection is one of the most common complications of pediatric craniopharyngioma. Only 28 cases of ectopic recurrence of craniopharyngioma have been reported in the literature, and only 13 cases occurred in patients originally treated as children. In this consecutive series of 86 children who underwent radical resection of primary and recurrent craniopharyngiomas, 4 patients (4.7%) experienced ectopic tumor recurrence, accounting for 27% of all recurrences after gross-total resection. The authors report on the successful surgical treatment of these 4 patients and the impact of ectopic craniopharyngioma recurrence on survival.

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Gross total resection or debulking of pituitary adenomas improves hormonal control of acromegaly by somatostatin analogs

Acta Endocrinologica ◽

10.1530/eje.1.01824 ◽

2005 ◽

Vol 152 (1) ◽

pp. 61-66 ◽

Cited By ~ 102

Author(s):

Patrick Petrossians ◽

Liliane Borges-Martins ◽

Consuelo Espinoza ◽

Adrian Daly ◽

Daniela Betea ◽

...

Keyword(s):

Pituitary Adenomas ◽

Somatostatin Analogs ◽

Tumor Resection ◽

Hormonal Control ◽

Gross Total Resection ◽

Term Therapy ◽

Total Resection ◽

Igf I ◽

Before And After ◽

The Impact

Introduction: Invasive GH-secreting pituitary adenomas are rarely cured by surgery and although long-term therapy with somatostatin analogs (SSAs) may be employed, hormonal control is achieved in only 60% of cases. The impact of tumor debulking on subsequent control of acromegaly with SSAs has not been studied previously. Methods: We studied retrospectively the response to SSA therapy in acromegalic patients before and after incomplete surgical tumor excision. A case review identified 24 acromegalic patients who had received SSA therapy for ≥1 month before and after gross total resection or debulking of adenomas. No patient received radiotherapy or combination treatment with SSAs and dopamine agonists during the study. GH and IGF-I responses to SSAs were recorded pre- and postoperatively. Postoperative SSA therapy was begun after a washout period of 1–3 months to assess the hormonal effects of the surgery alone. Results: Before preoperative SSA treatment, 24/24 (100%) patients had elevated GH levels and IGF-I levels were elevated in 19/21 (90.5%) patients with recorded values. During preoperative SSA treatment, GH and IGF-I levels were normalized in 7/24 (29.2%) and 11/24 (45.8%) patients respectively. Following postoperative washout, GH was controlled in only 3/24 (12.5%) patients, while IGF-I was controlled in 8/19 (42.1%) patients with available data. During the second SSA treatment period, normal GH levels were seen in 13/24 (54.2%) patients, while IGF-I control was noted in 18/23 (78.3%). Conclusion: Gross total tumor resection or debulking increases the likelihood of achieving biochemical disease control with SSAs in acromegalic patients with adenomas that were not amenable to complete surgical resection and in whom primary SSA therapy was unable to achieve good biochemical control.

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Adjuvant radiotherapy versus observation following gross total resection for atypical meningioma: a systematic review and meta-analysis

Radiation Oncology ◽

10.1186/s13014-021-01759-9 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Se-Woong Chun ◽

Kyung Min Kim ◽

Min-Sung Kim ◽

Ho Kang ◽

Yun-Sik Dho ◽

...

Keyword(s):

Local Recurrence ◽

Recurrence Rate ◽

Adjuvant Radiotherapy ◽

Local Recurrence Rate ◽

Meta Analysis ◽

Atypical Meningioma ◽

Gross Total Resection ◽

Survival Outcomes ◽

Total Resection ◽

The Impact

Abstract Background The impact of adjuvant radiotherapy (RT) on atypical meningioma (AM) underwent a gross total resection (GTR) remains unclear, showing conflicting results from various studies. The objective of this study was to perform an updated meta-analysis for observational studies to determine the effect of adjuvant RT after GTR on local recurrence and survival outcomes compared to observation after GTR. Methods PubMed, Embase, and Web of Science were searched to identify comparative studies that reported outcomes of adjuvant RT versus observation for AM patients after GTR. Local recurrence rate, progression-free survival (PFS), overall survival (OS), and toxicities related to RT were considered as outcomes of interest. Differences between two cohorts were estimated by calculating odds ratios (OR) for LR rate and hazard ratios (HR) for survival outcomes with 95% confidence intervals (CIs) for meta-analysis, using R version 4.0.3 software. Included studies were appraised with the Risk of Bias Assessment tool for Non-Randomized Studies. Outcome ratios were combined with the Mantel–Haenszel method and the inverse variance-weighted method, appropriately. Results Data from 30 studies involving 2904 patients (adjuvant RT: n = 737; observation: n = 2167) were eventually included. Significant reduction of local recurrence rate was seen in the adjuvant RT cohort compare to that in the observation cohort (OR 0.50; 95% CI 0.36–0.68; p < 0.0001). Pooled HRs of PFS at 1-year, 3-year, 5-year, and > 5-year revealed that adjuvant RT was superior to observation. There was no significant difference in OS between the two cohorts during any period. Most toxicities were tolerable with grade 1 or 2. There was no documented grade 5 toxicity. Conclusions For AM patients who underwent GTR, evidence suggested that adjuvant RT could potentially decrease local recurrence and improve PFS better than observation.

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SURG-10. PROGNOSTIC IMPORTANCE OF THE EXTENT OF RESECTION IN IDH-WILD TYPE GRADE II ASTROCYTOMAS ACCORDING TO PTERT MUTATION

Neuro-Oncology ◽

10.1093/neuonc/noaa215.857 ◽

2020 ◽

Vol 22 (Supplement_2) ◽

pp. ii205-ii205

Author(s):

Alessia Pellerino ◽

Francesco Bruno ◽

Antonio Silvani ◽

Tamara Ius ◽

Lorenzo Bello ◽

...

Keyword(s):

Extent Of Resection ◽

Gross Total Resection ◽

National Database ◽

Wild Type ◽

Total Resection ◽

Kaplan Meier ◽

Grade Ii ◽

Prognostic Importance ◽

The Impact

Abstract BACKGROUND IDH-wild type diffuse astrocytomas with pTERT mutation have been suggested by cIMPACT-NOW update 3 to share a poor prognosis with glioblastoma (GBM). In a previous series of the Italian Association of Neuro-Oncology, we reported that IDH-wild type grade II astrocytomas benefit from gross total resection. However, the impact of surgery in the pTERT-mutated subgroup has not been addressed so far. Here, we present our preliminary data about the impact of the extent surgery according to pTERT status. MATERIAL AND METHODS We re-analysed a national database of 122 patients with grade II IDH-wild type astrocytoma. P-TERT mutation was evaluated by gene sequencing. Kaplan-Meier curves were used for the analysis of progression-free and overall survival (PFS and OS). RESULTS Median follow-up was 33.0 months. P-TERT status was available in 40 cases and the mutation was found in 27 cases (67.5%). Patients with pTERT mutation had a significantly shorter PFS (9.4 vs 147.7 months, P < 0.001) and OS (NR vs 36.6 months, P = 0.012). Furthermore, the OS of patients with pTERT mutation, who underwent gross total resection, was significantly longer than in patients with subtotal / partial resection (37.0 vs 32.0 months, P = 0.018). Thus far, the OS of patients without pTERT mutation was not reached with either subtotal / partial or gross total resection. CONCLUSIONS IDH-wild type astrocytomas may be stratified into classes with different outcome based on the pTERT mutation. As far as we know, this is the first study that specifically investigated the importance of a gross total resection according to pTERT status in IDH-wild type grade II astrocytomas.

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Retrosigmoid Approach for Resecting a Giant Lateral Pontine Ependymoma: Two-Dimensional Operative Video

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1705158 ◽

2020 ◽

Author(s):

Hongxiang Wang ◽

Yong Yan ◽

Tao Xu ◽

Juxiang Chen

Keyword(s):

Brain Stem ◽

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Retrosigmoid Approach ◽

Gross Total Resection ◽

Neurological Deficits ◽

Ependymal Cells ◽

Total Resection ◽

Petrosal Vein ◽

Cerebellar Artery

AbstractEpendymoma is one of the most common pediatric tumors in central nervous system, for which gross total resection has been the most favorable prognostic factor.1 2 However, surgery of ependymomas located in brain stem is significantly challenging. This video demonstrates the microsurgical removal of an ependymoma originating from ependymal cells of the lateral recess of fourth ventricle via retrosigmoid approach in an 11-year-old female. The patient presented with a 6-month history of continues headache and vomiting. On examination, she had a walking instability and an emaciated body. Neuroimaging revealed a right lateral pontine lesion extending to the cerebellopontine angle region. The patient underwent a suboccipital craniotomy, followed by excellent exposure for the tumor. Petrosal vein encased by the tumor mass and close adhesion of the tumor and the initial segments of facial and acoustic nerves adjoined brain stem could be seen operatively. While preserving trigeminal nerve, facial and acoustic nerves, posterior cranial nerves, anterior inferior cerebellar artery, labyrinth artery, posterior inferior cerebellar artery, and petrosal vein, gross total resection was achieved under the careful operation along arachnoid spaces together with intratumoral decompression. The patient tolerated the procedure well without any neurological deficits. Histological examination confirmed the tumor as an ependymoma (WHO II). The cytology measurement of the cerebrospinal fluid did not find any tumor cells. Postoperative computed tomography and magnetic resonance imaging scan depicted complete resection of the tumor, and adjuvant radiotherapy was recommended. She remained symptom-free without any evidence of recurrence during the follow-up period of 1 year. Informed consent was obtained from the patient.The link to the video can be found at: https://youtu.be/sZ9GhUeltwc.

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Minimal residual calcification and recurrence after gross-total resection of craniopharyngioma in children

Journal of Neurosurgery Pediatrics ◽

10.3171/2009.1.peds08335 ◽

2009 ◽

Vol 3 (4) ◽

pp. 276-283 ◽

Cited By ~ 18

Author(s):

Robert E. Elliott ◽

Yaron A. Moshel ◽

Jeffrey H. Wisoff

Keyword(s):

Ct Scan ◽

Early Recurrence ◽

Senior Author ◽

Gross Total Resection ◽

Total Resection ◽

Time To Recurrence ◽

Preoperative Ct ◽

The Impact ◽

Minimal Residual

Object The purpose of this study was to assess the impact of minimal residual calcification without enhancing tumor on the rate of recurrence after gross-total resection (GTR) of craniopharyngioma in children. Methods Data were retrospectively collected in 86 patients younger than 21 years of age in whom 103 craniopharyngioma resections were performed by the senior author between 1986 and 2008. Forty-nine patients (27 boys and 22 girls, with a mean age of 8.6 years) fulfilled the criteria for inclusion in this study by having tumor calcification on the preoperative CT scan, undergoing GTR, and having complete postoperative CT and MR imaging and clinical follow-up. Results Thirteen patients (27%) had residual calcification (≤ 2 mm in 12 patients; 3.5 mm in 1 patient) on their postoperative CT scan. At a mean follow-up of 9.4 years (median 10 years), 2 (15%) of 13 patients with and 10 (28%) of 36 patients without residual calcification experienced tumor recurrence. There were no significant differences between these groups in terms of the duration of follow-up, time to recurrence, rate of recurrence, or recurrence-free survival. Conclusions The absence or presence of minimal residual calcification does not have an impact on the risk of recurrence after GTR in pediatric craniopharyngiomas. The authors recommend withholding irradiation or other adjuvant therapy in the setting of minimal residual calcification without enhancing tumor. Close follow-up with frequent serial imaging in all patients after GTR is imperative to identify and treat early recurrence.

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