Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas

OBJECTIVE Craniopharyngiomas can be difficult to remove completely based on their intimate relationship with surrounding visual and endocrine structures. Reoperations are not uncommon but have been associated with higher rates of complications and lower extents of resection. So radiation is often offered as an alternative to reoperation. The endonasal endoscopic transsphenoidal approach has been used in recent years for craniopharyngiomas previously removed with craniotomy. The impact of this approach on reoperations has not been widely investigated. METHODS The authors reviewed a prospectively acquired database of endonasal endoscopic resections of craniopharyngiomas over 11 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, performed by the senior authors. Reoperations were separated from first operations. Pre- and postoperative visual and endocrine function, tumor size, body mass index (BMI), quality of life (QOL), extent of resection (EOR), impact of prior radiation, and complications were compared between groups. EOR was divided into gross-total resection (GTR, 100%), near-total resection (NTR, > 95%), and subtotal resection (STR, < 95%). Univariate and multivariate analyses were performed. RESULTS Of the total 57 endonasal surgical procedures, 22 (39%) were reoperations. First-time operations and reoperations did not differ in tumor volume, radiological configuration, or patients' BMI. Hypopituitarism and diabetes insipidus (DI) were more common before reoperations (82% and 55%, respectively) compared with first operations (60% and 8.6%, respectively; p < 0.001). For the 46 patients in whom GTR was intended, rates of GTR and GTR+NTR were not significantly different between first operations (90% and 97%, respectively) and reoperations (80% and 100%, respectively). For reoperations, prior radiation and larger tumor volume had lower rates of GTR. Vision improved equally in first operations (80%) compared with reoperations (73%). New anterior pituitary deficits were more common in first operations compared with reoperations (51% vs 23%, respectively; p = 0.08), while new DI was more common in reoperations compared with first-time operations (80% vs 47%, respectively; p = 0.08). Nonendocrine complications occurred in 2 (3.6%) first-time operations and no reoperations. Tumor regrowth occurred in 6 patients (11%) over a median follow-up of 46 months and was not different between first versus reoperations, but was associated with STR (33%) compared with GTR+NTR (4%; p = 0.02) and with not receiving radiation after STR (67% vs 22%; p = 0.08). The overall BMI increased significantly from 28.7 to 34.8 kg/m2 over 10 years. Six months after surgery, there was a significant improvement in QOL, which was similar between first-time operations and reoperations, and negatively correlated with STR. CONCLUSIONS Endonasal endoscopic transsphenoidal reoperation results in similar EOR, visual outcome, and improvement in QOL as first-time operations, with no significant increase in complications. EOR is more impacted by tumor volume and prior radiation. Reoperations should be offered to patients with recurrent craniopharyngiomas and may be preferable to radiation in patients in whom GTR or NTR can be achieved.

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73. PREDICTION OF A SECOND LOCAL RECURRENCE IN SURGICALLY TREATED RECURRENT BRAIN METASTASES PATIENTS

Neuro-Oncology Advances ◽

10.1093/noajnl/vdaa073.060 ◽

2020 ◽

Vol 2 (Supplement_2) ◽

pp. ii15-ii15

Author(s):

Ishaan Tewarie ◽

Alexander Hulsbergen ◽

Manish Paranjpe ◽

Ray Jhun ◽

Arun Job ◽

...

Keyword(s):

Risk Factor ◽

Local Recurrence ◽

Tumor Volume ◽

Cox Regression ◽

Extent Of Resection ◽

Subtotal Resection ◽

Adjuvant Radiation ◽

Common Occurrence ◽

Total Resection ◽

Cox Regression Analysis

Abstract BACKGROUND Local recurrence is a common occurrence after resection or radiotherapy for brain metastasis (BM). Very little is known about the benefit of (re-)craniotomy in this scenario: does resecting the initial local recurrence (LR1) invariably lead to a second local recurrence (LR2)? This study aimed to analyze occurrence and predictors of LR2 in BM patients undergoing craniotomy for LR1. METHODS Patients were identified from a departmental database at the Brigham and Women’s Hospital, Boston, MA. Multivariable logistic regression and cox regression analysis was performed to identify predictors of binary occurrence of LR2 (yes/no) and time-to-LR2, respectively. Based on predictors, subgroup-specific prevalence of LR2 was explored. RESULTS A total of 188 patients were identified. The median age was 59.5 years and 117 patients (62.2%) were female. Treatment-wise, 64 patients (34.0%) underwent subtotal resection (STR) and 66 (35.1%) received adjuvant radiation. Eighty-one (43.1%) patients experienced LR2 at a median of 7 months after craniotomy. Occurrence of LR2 was significantly associated with STR (OR 6.88, p = 0.0008), surgery as treatment for LR1 (OR = 0.26, p = 0.03), larger tumor volume (OR = 1.14 per 1000 mm3, p = 0.01), and frontal location (OR = 5.23, p = 0.02). Shorter time-to-LR2 was associated with STR (HR = 5.31, p = 0.01) and adjuvant radiation (HR = 2.22, p = 0.03), while temporal (HR = 0.16, p = 0.03) and parietal (0.13, p = 0.03) location were associated with longer time-to-LR2. When stratifying by extent of resection, prevalence of LR2 was 32.8% after gross total resection and 57.1% after STR. CONCLUSION In this population, LR2 occurred in 43.1% of patients. STR was the strongest risk factor for LR2, while tumor size, location, surgical treatment of LR1, and receipt of adjuvant radiation may also influence subsequent recurrence.

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Preserve or sacrifice the stalk? Endocrinological outcomes, extent of resection, and recurrence rates following endoscopic endonasal resection of craniopharyngiomas

Journal of Neurosurgery ◽

10.3171/2018.6.jns18901 ◽

2019 ◽

Vol 131 (4) ◽

pp. 1163-1171 ◽

Cited By ~ 4

Author(s):

Edgar G. Ordóñez-Rubiano ◽

Jonathan A. Forbes ◽

Peter F. Morgenstern ◽

Leopold Arko ◽

Georgiana A. Dobri ◽

...

Keyword(s):

Diabetes Insipidus ◽

Extent Of Resection ◽

Endocrine Function ◽

Subtotal Resection ◽

Type I ◽

Pituitary Insufficiency ◽

Recurrence Rates ◽

Total Resection ◽

Endoscopic Endonasal ◽

Operative Notes

OBJECTIVEGross-total resection (GTR) of craniopharyngiomas (CPs) is potentially curative and is often the goal of surgery, but endocrinopathy generally results if the stalk is sacrificed. In some cases, GTR can be attempted while still preserving the stalk; however, stalk manipulation or devascularization may cause endocrinopathy and this strategy risks leaving behind small tumor remnants that can recur.METHODSA retrospective review of a prospective cohort of patients who underwent initial resection of CP using the endoscopic endonasal approach over a period of 12 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, was performed. Postresection integrity of the stalk was retrospectively assessed using operative notes, videos, and postoperative MRI. Tumors were classified based on location into type I (sellar), type II (sellar-suprasellar), and type III (purely suprasellar). Pre- and postoperative endocrine function, tumor location, body mass index, rate of GTR, radiation therapy, and complications were reviewed.RESULTSA total of 54 patients who had undergone endoscopic endonasal procedures for first-time resection of CP were identified. The stalk was preserved in 33 (61%) and sacrificed in 21 (39%) patients. GTR was achieved in 24 patients (73%) with stalk preservation and 21 patients (100%) with stalk sacrifice (p = 0.007). Stalk-preservation surgery achieved GTR and maintained completely normal pituitary function in only 4 (12%) of 33 patients. Permanent postoperative diabetes insipidus was present in 16 patients (49%) with stalk preservation and in 20 patients (95%) following stalk sacrifice (p = 0.002). In the stalk-preservation group, rates of progression and radiation were higher with intentional subtotal resection or near-total resection compared to GTR (67% vs 0%, p < 0.001, and 100% vs 12.5%, p < 0.001, respectively). However, for the subgroup of patients in whom GTR was achieved, stalk preservation did not lead to significantly higher rates of recurrence (12.5%) compared with those in whom it was sacrificed (5%, p = 0.61), and stalk preservation prevented anterior pituitary insufficiency in 33% and diabetes insipidus in 50%.CONCLUSIONSWhile the decision to preserve the stalk reduces the rate of postoperative endocrinopathy by roughly 50%, nevertheless significant dysfunction of the anterior and posterior pituitary often ensues. The decision to preserve the stalk does not guarantee preserved endocrine function and comes with a higher risk of progression and need for adjuvant therapy. Nevertheless, to reduce postoperative endocrinopathy attempts should be made to preserve the stalk if GTR can be achieved.

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Impact of Extent of Resection on Incidence of Postoperative Complications in Patients With Glioblastoma

Neurosurgery ◽

10.1093/neuros/nyz313 ◽

2019 ◽

Vol 86 (5) ◽

pp. 625-630 ◽

Cited By ~ 2

Author(s):

Dimitri Laurent ◽

Rachel Freedman ◽

Logan Cope ◽

Patricia Sacks ◽

Joe Abbatematteo ◽

...

Keyword(s):

Extent Of Resection ◽

Magnetic Resonance Images ◽

Gross Total Resection ◽

Subtotal Resection ◽

Total Resection ◽

Resection Group ◽

Patient Safety Indicators ◽

Hospital Acquired Conditions ◽

Hospital Acquired ◽

The Impact

Abstract BACKGROUND Extent of resection (EOR) is well established as correlating with overall survival in patients with glioblastoma (GBM). The impact of EOR on reported quality metrics such as patient safety indicators (PSIs) and hospital-acquired conditions (HACs) is unknown. OBJECTIVE To perform a retrospective study to evaluate possible associations between EOR and the incidence of PSIs and HACs. METHODS We queried all patients diagnosed with GBM who underwent surgical resection at our institution between January 2011 and May 2017. Pre- and postoperative magnetic resonance images were analyzed for EOR. Each chart was reviewed to determine the incidence of PSIs and HACs. RESULTS A total of 284 patients met the inclusion criteria. EOR ranged from 39.00 to 100%, with a median of 99.84% and a mean of 95.7%. There were 16 PSI, and 13 HAC, events. There were no significant differences in the rates of PSIs or HACs when compared between patients stratified by gross total resection (EOR ≥ 95%) and subtotal resection (EOR < 95%). The odds of encountering a PSI or HAC were 2.5 times more likely in the subtotal resection group compared to the gross total resection group (P = .58). After adjusting for confounders, the odds of encountering a PSI or HAC in the subtotal resection group were 3.9 times greater than for the gross total resection group (P < .05). CONCLUSION Gross total resection of GBM is associated with a decreased incidence of PSIs and HACs, as compared to subtotal resection.

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Sphenoorbital meningioma: surgical technique and outcome

Journal of Neurosurgery ◽

10.3171/2010.10.jns101128 ◽

2011 ◽

Vol 114 (5) ◽

pp. 1241-1249 ◽

Cited By ~ 37

Author(s):

Soichi Oya ◽

Burak Sade ◽

Joung H. Lee

Keyword(s):

Surgical Technique ◽

Visual Outcome ◽

Sphenoid Bone ◽

Wide Resection ◽

Tumor Control ◽

Subtotal Resection ◽

Total Resection ◽

Anterior Clinoid Process ◽

Orbital Wall

Object The aim of this study was to describe the surgical technique used for removal of sphenoorbital meningiomas in the authors' practice and to review the operative outcome. Methods Review of the senior author's practice between 1994 and 2009 revealed 39 patients (mean age 48 years) eligible for this study. Clinical presentation, surgical technique, postoperative outcome, and follow-up data are presented. Surgical technique is detailed, with an emphasis on aggressive removal consisting of drilling of the hypertrophied sphenoid bone, orbital wall, and anterior clinoid process, followed by tumor removal and a wide resection of the involved dura. A simple dural closure without reconstruction of the orbital roof or the lateral wall of the orbit is also described. Results Gross-total resection was achieved in 15 cases (38.5%), near-total resection with small residual in the cavernous sinus or periorbita in 20 cases (51.3%), and subtotal resection in 4 cases (10.3%). Postoperative complications included trigeminal hypesthesia in 9 patients, oculomotor palsy in 3 patients, and seizure in 2 patients. Seven patients had recurrence within the mean follow-up period of 40.7 months. Preoperative visual deficits were present in 21 patients (53.8%). Of these, 14 (66.7%) experienced visual recovery to normal levels postoperatively. Statistical analyses revealed preoperative severe visual deficit and sphenoid bone hypertrophy as an independent risk factor and an independent favorable factor, respectively, for a favorable visual outcome. Proptosis was resolved (≤ 2 mm) in 73.5% of the authors' patients. No patient had postoperative enophthalmos. Conclusions In the authors' practice, surgery for sphenoorbital meningiomas consists of resection of the orbital/sphenoid intraosseous, intraorbital, and intradural tumor components. The authors believe that aggressive removal of the orbital/sphenoid intraosseous tumor is critical for a favorable visual outcome and tumor control. Furthermore, satisfactory cosmetic results can be achieved with simple reconstruction techniques as described.

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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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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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Health Related Quality of Life of Children Infected with HIV in Agra Region, India

Asian Journal of Pediatric Research ◽

10.9734/ajpr/2021/v5i430180 ◽

2021 ◽

pp. 18-26

Author(s):

Abhishek Kumar ◽

Dipti Agarwal ◽

N.C. Prajapati

Keyword(s):

Quality Of Life ◽

Clinical Stage ◽

Health Related Quality ◽

Social Emotional ◽

Medical College ◽

Related Quality ◽

Health Related ◽

Valid Instrument ◽

The Impact

Objective and Methods: HIV specific health related quality of life (HRQOL) instrument based on PedQLTM4.0 generic scale was prepared and named HIV-QOL. It was validated and used to evaluate HRQOL in HIV infected children in an observational,crossectional study conducted in the Department of Pediatrics, Sarojini Naidu Medical College, Agra, India. Results:Cronbach’s alpha score > 0.7,supported acceptable internal consistency of the instrument.The correlation coefficient of more than 0.8 indicated that the instrument was valid for application. Study included 40 HIV infected children between age 8 to 18 years.Their mean scores were calculated in all four domains (viz physical, social, emotional and school functioning) and comparison of HRQOL scores was done with respect to various social and demographic parameters. CD4 counts, clinical stage of the disease and living status of the parents and anti retroviral therapy (ART) had significant influence on the HRQOL scores. Conclusion: HIV QOL is a valid instrument to assess the health related quality of life of HIV infected children in India. It can help in assessing their health status, as well as in evaluating the impact of various medical and social programmes aimed at improving their quality of life.

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Ants' Notion of Zero through the Perception of the Absence of an Odor

International Journal of Biology ◽

10.5539/ijb.v11n2p1 ◽

2019 ◽

Vol 11 (2) ◽

pp. 1

Author(s):

Marie-Claire Cammaerts ◽

Roger Cammaerts

Keyword(s):

Operant Conditioning ◽

Basic Concept ◽

Olfactory Conditioning ◽

Pleasant Odor ◽

Learning Score ◽

The Impact ◽

First Time

Workers of the ant Myrmica sabuleti can acquire the notion of ‘nothing’, i.e. a basic concept of zero, through olfactory conditioning, the best when the odor is unpleasant (onion odor) and when the response to the absence of the odor is rewarded. With a pleasant odor (lavender, rosemary or vanilla odor), the ants learn best when the response to the odor is rewarded. To our knowledge this is the first time that olfactory operant conditioning is obtained in animals by rewarding their response to ‘nothing’. The present work also points out: - the impact of the kind and quality of the cue to be learned on the animals’ learning score, - the improvement of a given learning over successive similar learning experiments, - the obtaining of a better learning when the reward is associated with the animals’ preference.

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Comparison of Outcomes following Primary and Repeat Resection of Craniopharyngioma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1735559 ◽

2021 ◽

Author(s):

Alexander A. Aabedi ◽

Jacob S. Young ◽

Ryan R. L. Phelps ◽

Ethan A. Winkler ◽

Michael W. McDermott ◽

...

Keyword(s):

Surgical Approach ◽

Residual Tumor ◽

Extent Of Resection ◽

Primary Resection ◽

Endocrine Function ◽

Surgical Approaches ◽

Subtotal Resection ◽

Limited Data ◽

Time To Recurrence ◽

Skull Base Lesions

Abstract Introduction The management of recurrent craniopharyngioma is complex with limited data to guide decision-making. Some reports suggest reoperation should be avoided due to an increased complication profile, while others have demonstrated that safe reoperation can be performed. For other types of skull base lesions, maximal safe resection followed by adjuvant therapy has replaced radical gross total resection due to the favorable morbidity profiles. Methods Seventy-one patients underwent resection over a 9-year period for craniopharyngioma and were retrospectively reviewed. Patients were separated into primary resection and reoperation cohorts and stratified by surgical approach (endonasal vs. cranial) and survival analyses were performed based on cohort and surgical approach. Results Fifty patients underwent primary resection, while 21 underwent reoperation for recurrence. Fifty endonasal transsphenoidal surgeries and 21 craniotomies were performed. Surgical approaches were similarly distributed across cohorts. Subtotal resection was achieved in 83% of all cases. There were no differences in extent of resection, visual outcomes, subsequent neuroendocrine function, and complications across cohorts and surgical approaches. The median time to recurrence was 87 months overall, and there were no differences by cohort and approach. The 5-year survival rate was 81.1% after reoperation versus 93.2% after primary resection. Conclusion Compared with primary resection, reoperation for craniopharyngioma recurrence is associated with similar functional and survival outcomes in light of individualized surgical approaches. Maximal safe resection followed by adjuvant radiotherapy for residual tumor likely preserves vision and endocrine function without sacrificing overall patient survival.

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STMO-03 ROLE OF INTRAOPERATIVE COMPUTED TOMOGRAPHY IN GLIOBLASTOMA RESECTION GUIDED BY 5-ALA

Neuro-Oncology Advances ◽

10.1093/noajnl/vdz039.083 ◽

2019 ◽

Vol 1 (Supplement_2) ◽

pp. ii18-ii19

Author(s):

Takahiro Yamauchi ◽

Ryuhei Kitai ◽

Yoshinori Shibaike ◽

Mizuki Oiwa ◽

Shintaro Yamada ◽

...

Keyword(s):

Computed Tomography ◽

Aminolevulinic Acid ◽

Residual Tumor ◽

Subtotal Resection ◽

Resection Rate ◽

Total Resection ◽

Intraoperative Computed Tomography ◽

Postoperative Mri ◽

The Impact ◽

Additional Resection

Abstract OBJECTIVE To improve resection rate, multiple operative modalities have been essential for glioblastoma (GBM) surgery. Aim of this study is to clarify the impact of intraoperative computed tomography (i-CT) for GBM surgery with 5-aminolevulinic acid photodynamic diagnosis (5-ALA PDD). METHODS Consecutive 24 patients newly diagnosed GBM were analyzed, retrospectively. To exclude 6 patients decided timing for i-CT based on neural monitoring, 18 patients performed i-CT after total resection of 5-ALA positive lesion were included, finally. RESULTS The median age was 58 years old, and average preoperative tumor volume was 47.78 cm3. Tumor locations were frontal lobe 5 (27%), parietal lobe 3 (17%), temporal lobe 9 (50%), and corpus callosum 1 (6%). Seventeen tumors (78%) harbored in eloquent area. After i-CT performed, 7 (39%) were confirmed residual tumor, and additional resections were needed. Subtotal resection (STR) was 5 and partial resection (PR) was 2 on volumetry in i-CT before additional resection. After additional resection, those cases were judged as 2 gross total resection (GTR), 4 STR and 1 PR in postoperative magnetic resonance imaging (MRI). 11 cases without additional resection were judged as 4 GTR, 3 STR and 4 PR in postoperative MRI. In 18 patients confirmed total resection of 5-ALA positive lesion, i-CT and postoperative MRI revealed 14 (78%) residual tumors. I-CT revealed 7 (50%) in all residual tumor. DISCUSSION Hemorrhage, brain edema, air, invasive lesion, and limitation of resolution of CT might make difficult to detect residual tumor. CONCLUSION I-CT may be useful to detect residual tumor even with 5-ALA and improve resection rate.

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