Endoscopic transnasal resection of optic pathway pilocytic astrocytoma

Complications and visual outcomes following surgical resection of pediatric optic pathway/hypothalamic gliomas: a systematic review and meta-analysis

Pediatric optic pathway/hypothalamic gliomas (OPHG) pose challenges in treatment due to their location and proximity to vital structures. Surgical resection plays a key role in the management of OPHG especially when the tumor exhibits mass effect and causes symptoms. However, data regarding outcomes and complications of surgical resection for OPHG remains heterogenous. The authors performed a systematic review on pediatric OPHG in four databases: PubMed, EMBASE, Cochrane Library, and Google Scholar. We included studies that reported on the visual outcomes and complications of OPHG resection. A meta-analysis was performed and reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 26 retrospective studies were included. Seven hundred ninety-seven pediatric patients with OPHG undergoing surgical resection were examined. A diagnosis of NF1 was confirmed in 9.7%. Gross total resection was achieved in 36.7%. Intraorbital optic pathway gliomas showed a significantly higher gross total resection rate compared to those located in the chiasmatic/hypothalamic region (75.8% vs. 9.6%). Postoperatively, visual acuity improved in 24.6%, remained unchanged in 68.2%, and worsened in 18.2%. Complications included hydrocephalus (35.4%), anterior pituitary dysfunction (19.6%), and transient diabetes insipidus (29%). Tumor progression post-resection occurred in 12.8%, through a mean follow-up of 53.5 months. Surgical resection remains an essential strategy for treating symptomatic and large pediatric OPHG and can result in favorable vision outcomes in most patients. Careful patient selection is critical. Patients should be monitored for hydrocephalus development postoperatively and followed up to assess for tumor progression and adjuvant treatment necessity.

Hypothalamic Hemangioma-like Pilocytic Astrocytoma in an Adult Patient: A Systematic Review with a Focus on Differential Diagnosis and Neurological Presentation

Background: Pilocytic astrocytoma (PCA) are commonly observed as slow-growing noncancerous brain tumors in pediatric populations, but they can also occur in adults, albeit rarely. When located in diencephalic regions, particularly in the hypothalamus, they present unique diagnostic and management challenges due to their rarity and overlapping clinical and radiological features with other intracranial pathologies. This systematic review aims to provide a comprehensive understanding of hypothalamic PCA in adults, focusing on their differential diagnosis, neurological presentation, diagnostic modalities, treatment strategies. A case illustration is also described in order to better underline all the difficulties related to the diagnostic process. Material and methods: A systematic literature search was conducted in the PubMed/MEDLINE, Embase, and Scopus databases up to November 2023 to identify studies. Results: The systematic literature search identified a total of 214 articles. Following screening by title and abstract and full-text review, 12 studies were deemed eligible and are included here. Conclusions: Adult-onset PCA in diencephalic regions pose diagnostic challenges due to their rarity and overlapping features with other intracranial lesions. Advanced imaging techniques play a crucial role in diagnosis, while surgery remains the cornerstone of treatment. Multidisciplinary collaboration is essential for the optimal management and long-term follow-up of these patients.

Endoscopic Endonasal Resection of a Cavernous Malformation of the Third Ventricle: Case Report and Literature Review

BACKGROUND

 Suprasellar and third ventricle cavernous malformations (CMs) are uncommon. Conventional approaches such as interhemispheric and translamina terminalis approaches are often used to resect these lesions. Here we demonstrate the use of the endoscopic endonasal approach for a third ventricle CM.

CASE DESCRIPTION

 A 31-year-old man presented with progressive symptoms of headache and visual disturbance as well as short-term memory deficit over a 6-month period. Neurologic examination revealed bitemporal hemianopsia. Radiologic images showed a suprasellar lesion extending into the third ventricle as well as obstructive hydrocephalus. The patient was operated on using an endoscopic endonasal approach and histopathology revealed a diagnosis of CM. Transient diabetes insipidus and adrenal insufficiency were reported postoperatively.

CONCLUSION

 This report demonstrates safe resection of a third ventricle CM via the endonasal route.

Application of binasal speculum in endoscopic endonasal surgery for lesions in sellar region

Objective

This study aims to access the efficacy of the binasal speculum in endoscopic endonasal surgery by evaluating clinical outcomes and examining its utility through process-based performance measures in both surgeons and assistants.

Methods

A total of 59 patients with lesions in sellar region who underwent endoscopic endonasal surgery with the binasal speculum between September 2020 and March 2023 were included in this study. We assessed the extent of resection and documented postoperative nasal condition. Both surgeons and assistants completed post-use surveys to exam the utility of the binasal speculum and provide an overall grading.

Results

Gross total resection (GTR) was successfully achieved in 94.9% (56/59) of patients, with subtotal resection (STR) observed in 5.1% (4/59) of patients. Intraoperative cerebrospinal fluid (CSF) leakage occurred in 23.7% (14/59) of cases, and nasoseptal flap (NSF) reconstruction was required in 55.9% (33/59) of cases. The nasal airway patency rapidly recovered within 14 days in a significant majority of patients (94.9%, 56/59). Moreover, olfactory function was regained within three months postoperatively by 91.5% (54/59) of patients. The overall post-use survey mean score was 26.4. Specifically, surgeons had a mean score of 26.5, while assistants had a slightly lower mean score of 26.2. The mean overall grading for the binasal speculum was 3. Both surgeons and assistants provided a mean overall grading of 3.

Conclusion

The binasal speculum provides nasal mucosa protection and reduces the risk of an endoscopic lens clouded by mucosa or blood. It plays a crucial role in accurate guidance and facilitates the swift delivery of surgical instruments, particularly in left-blinded nasal cavities. The binasal speculum reduces the learning curve, especially for endoscopic surgeons with limited experience, while enhancing collaboration and coordination between surgeons and assistants during surgery. Both surgeons and assistants rated the overall utility of the binasal speculum as "excellent."

Endoscopic transnasal surgery in optic pathway gliomas located in the chiasma-hypothalamic region: case series of ten patients in a single-center experience and endoscopic literature review

OBJECTIVE

Optic pathway gliomas (OPGs) constitute approximately 3-5% of childhood intracranial tumors. In this study, the authors presented their experience of using the endoscopic endonasal approach to treat patients with OPG located in the chiasma-hypothalamic region and aimed to use the infrachiasmatic corridor in the endoscopic endonasal approach as an alternative to the transcranial approach in the surgical necessity of OPGs.

METHODS

We retrospectively analyzed the data of ten patients diagnosed with OPG histopathologically among 3757 cases who underwent endoscopic endonasal surgery between August 1997 and March 2021 at Kocaeli University Faculty of Medicine Pituitary Research Center and Department of Neurosurgery. Mean follow-up period 48.5 months. During the postoperative follow-up period, 3 of these 10 patients underwent reoperation due to tumor recurrence. Combined (endoscopic endonasal approach + transcranial approach) approach was applied to 2 patients in the same session. Surgical and clinical outcomes were evaluated in detail.

RESULTS

Ten patients with a mean patient age of 20.6 ± 11.4 were included in this study. The most common complaint was visual impairment. After surgery, improvement in visual impairment was observed in five patients. No increase in postoperative visual impairment was observed in any of the patients. Postoperative panhypopituitarism was not observed in any of the patients. STR resection was performed in 5 patients and NTR resection in 5 patients. No additional treatment was required during follow-up in 4 of 5 patients who underwent NTR. A total of 6 patients received postoperative radiotherapy treatment.

CONCLUSIONS

In gliomas located in the chiasma-hypothalamic region, appropriate patient selection and endoscopic endonasal surgical treatment may contribute to the elimination of symptoms due to the mass effect of the tumor. It may also contribute to keeping the disease under control with targeted adjuvant therapies by clarifying the pathological diagnosis of the lesion.

Management of Optic Pathway Glioma: A Systematic Review and Meta-Analysis

Background: OPG accounts for 3−5% of childhood central nervous system (CNS) tumors and about 2% of pediatric glial lesions. Methods: Article selection was performed by searching PubMed, Web of Science, and Cochrane databases. Results: The pooled mortality rate was 0.12 (95%CI 0.09−0.14). Due to the unrepresentative data, improved and not changed outcomes were classified as favorable outcomes and worsened as unfavorable. Meta-analyses were performed to determine the rate of clinical and radiological favorable outcomes. In terms of visual assessment, the pooled rate of a favorable outcome in chemotherapy, radiotherapy, and surgery was 0.74, 0.81, and 0.65, respectively, and the overall pooled rate of the favorable outcome was 0.75 (95%CI 0.70−0.80). In terms of radiological assessment, the rate of a favorable outcome following chemotherapy, radiotherapy, and surgery was 0.71, 0.74, and 0.67, respectively, and the overall pooled rate of the favorable outcome is 0.71 (95%CI 0.65−0.77). The subgroup analysis revealed no significant difference in the rate of clinical and radiological favorable outcomes between the different treatment modalities (p > 0.05). Conclusion: Our analyses showed that each therapeutic modality represents viable treatment options to achieve remission for these patients.

Monomodality versus Combined Therapy in Optic Pathway Gliomas—20-Year Experience from a Singapore Children’s Hospital

Introduction

The treatment of pediatric optic pathway gliomas (OPG) is challenging. At present, most centers provide individualized treatment to maximize progression free survival (PFS) and minimize morbidity. We aim to report our experience in the management of pediatric OPG, and investigate factors associated with an increased duration of remission after treatment.

Methods

This is a single-institution study approved by the hospital ethics board. A retrospective review of consecutive OPGs managed from 2000 to 2020 was performed. Patients were divided into those managed with monomodality treatment (MT) and those who received combined therapy (CT). MT included various forms of surgery, chemotherapy and radiotherapy given alone, while CT involves a combination of surgery and adjuvant chemotherapy and/or radiotherapy.

Results

Twenty-two patients were selected for this study. They had 40 treatment cycles; and a total follow up duration of 194.8 patient-years. Most of them were male (63.6%) and presented with visual deficits (72.7%). The mean age at initial presentation was 65 months and majority (86.4%) had their tumors arising directly from the optic chiasm, with 77.3% with hypothalamic extension. One patient had Neurofibromatosis type I (4.5%). The most common histological diagnosis was pilocytic astrocytoma (90.9%), followed by pilomyxoid astrocytoma (9.1%). The 5- and 10- year PFS were 46.2% and 36.4% respectively, while the 5- and 10-year OS were both 100%. When accounting for treatment type, there were 24 treatment cycles with MT (60.0%) and 16 CT (40.0%). After adjustment, treatments with MT were shown to have a shorter mean duration of remission (MT: 45 ± 49, CT: 84 ± 79 months; p = 0.007). Cox regression curve plotted after adjusting for patient’s age at treatment demonstrated a significantly longer PFS in the CT group (p = 0.037).

Conclusions

Our results suggest a significant survival benefit of CT over MT for affected patients due to the prolonged the duration of disease remission, for both primary and subsequent treatments. Nonetheless, we acknowledge that our study reflects the outcomes of treatment strategies that have evolved over time. We emphasize the need for collective efforts from a dedicated multidisciplinary team and international collaborations for better disease understanding.

Neurosurgical experience of managing optic pathway gliomas

BACKGROUND

Optic pathway gliomas (OPGs), also known as visual pathway gliomas, are debilitating tumors that account for 3-5% of all pediatric brain tumors. They are most commonly WHO grade 1 pilocytic astrocytomas and frequently occur in patients with neurofibromatosis type 1. The location of these tumors results in visual loss and blindness, endocrine and hypothalamic dysfunction, hydrocephalus, and premature death. Their involvement of the visual pathways and proximity to other eloquent brain structures typically precludes complete resection or optimal radiation dosing without incurring significant neurological injury. There are various surgical interventions that can be performed in relation to these lesions including biopsy, cerebrospinal fluid diversion, and partial or radical resection, but their role is a source of debate. This study catalogues our surgical experience and patient outcomes in order to support decision-making in this challenging pathology.

METHODS

A retrospective review of all cases of OPGs treated in a single center from July 1990 to July 2020. Data was collected on patient demographics, radiographic findings, pathology, and management including surgical interventions. Outcome data included survival, visual function, endocrine, and hypothalamic dysfunction.

RESULTS

One hundred twenty-one patients with OPG were identified, and 50 of these patients underwent a total of 104 surgical procedures. These included biopsy (31), subtotal or gross total resection (20 operations in 17 patients), cyst drainage (17), Ommaya reservoir insertion (9), or cerebrospinal fluid diversion (27). During the study period, there was 6% overall mortality, 18% hypothalamic dysfunction, 20% endocrine dysfunction, and 42% had some cognitive dysfunction. At diagnosis 75% of patients had good or moderate visual function in at least one eye, and overall, this improved to 83% at the end of the study period. In comparison the worst eye had good or moderate visual function in 56%, and this reduced to 53%. Baseline and final visual function were poorer in patients who had a surgical resection, but improvements in vision were still found-particularly in the best eye.

DISCUSSION/CONCLUSION

OPG are debilitating childhood tumor that have lifelong consequences in terms of visual function and endocrinopathies/hypothalamic dysfunction; this can result in substantial patient morbidity. Decisions regarding management and the role of surgery in this condition are challenging and include cerebrospinal fluid diversion, biopsy, and in highly select cases cystic decompression or surgical resection. In this paper, we review our own experience, outcomes, and surgical philosophy.

Treatment with endoscopic transnasal resection of hypothalamic pilocytic astrocytomas: a single-center experience

Backgrounds

Pilocytic astrocytomas (PAs) are World Health Organization (WHO) grade I tumors, which are relatively common, and are benign lesions in children. PAs could originate from the cerebellum, optic pathways, and third ventricular/hypothalamic region. Traditional various transcranial routes are used for hypothalamic PAs (HPAs). However, there are few studies on hypothalamic PAs treated through the endoscopic endonasal approach (EEA). This study reports the preliminary experience of the investigators and results with HPAs via expanded EEAs.

Methods

All patients with HPAs, undergone EEA in our hospital from 2017 to 2019, were retrospectively reviewed. The demographic data, clinical symptoms, complications, skull base reconstruction, prognosis, and endocrinological data were all recorded and analyzed in detail.

Results

Finally, five female patients were enrolled. The average age of patients was 28.6 ± 14.0. All patients had complaints about their menstrual disorder. One patient had severe bilateral visual impairment. Furthermore, only one patient suffered from severe headache due to acute hydrocephalus, although there were four patients with headache or dizziness. Four cases achieved gross-total resection, and one patient achieved subtotal resection. Furthermore, there was visual improvement in one patient (case 5), and postoperative worsening of vision in one patient (case 4). However, only one patient had postoperative intracranial infection. None of the patients experienced a postoperative CSF leak, and in situ bone flap (ISBF) techniques were used for two cases for skull base repair. In particular, ISBF combined with free middle turbinate mucosal flap was used for case 5. After three years of follow-up, three patients are still alive, two patients had no neurological or visual symptoms, or tumor recurrence, and one patient had severe hypothalamic dysfunction. Unfortunately, one patient died of severe postoperative hypothalamus reaction, which presented with coma, high fever, diabetes insipidus, hypernatremia and intracranial infection. The other patient died of recurrent severe pancreatitis at one year after the operation.

Conclusion

Although the data is still very limited and preliminary, EEA provides a direct approach to HPAs with acceptable prognosis in terms of tumor resection, endocrinological and visual outcomes. ISBF technique is safe and reliable for skull base reconstruction.