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Porto Sousa M, Gomes Cabral Junior S, Virgilio Ribeiro F, Nunes Pustilnik H, Yuri Ferreira M, Verly G, Pedro Bittar Sanches J, Snyder Crespo Zavala N, Muszkat Besborodco R, Vinicius Figueredo Almeida C, Oliveira LB, Batista S, Campos Gomes Pinto F, Bertani R. Good clinical outcomes and the necessity of CSF drainage in patients undergoing simultaneous biopsy and endoscopic third ventriculostomy in the region of pineal tumors: A systematic review and meta-analysis. J Clin Neurosci 2024; 126:234-244. [PMID: 38970969 DOI: 10.1016/j.jocn.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/20/2024] [Accepted: 07/01/2024] [Indexed: 07/08/2024]
Abstract
INTRODUCTION Due to their delicate and deep-seated location, tumors in the pineal region of the brain pose exceptional challenges in neurosurgical management. Highly precise procedures have become crucial to address these complexities, such as the simultaneous performance of biopsy and endoscopic third ventriculostomy (ETV). Our aim was to assess the feasibility, safety, and efficacy of simultaneous biopsy and ETV for treating patients with pineal region tumors. METHODS Medline, Embase, and Web of Science were searched for English studies from January 2000 to February 2024, following Cochrane and PRISMA guidelines. Eligible studies encompassed a minimum of four patients and examined at least one of the following outcomes: good clinical outcomes and the necessity of shunt placement. Single proportion analysis with 95% confidence intervals was conducted under a random-effects model, employing the I2 statistic to assess heterogeneity. Additionally, publication bias was evaluated using the ROBINS-I tool. RESULTS After a meticulous selection process, eighteen studies involving 390 patients were included in the analysis. Overall, good clinical outcomes were observed in 131 out of 147 patients, representing a rate of 92 % (95 % CI: 84 % to 100 %, I2 = 62 %) through random effects analysis. Subgroup analysis showed that children exhibited a notably high rate of good clinical outcomes, reaching 100 % (95 % CI: 96 % to 100 %, I2 = 0 %). Regarding the need for shunt placement, out of the 356 patients assessed, only 39 required shunt placement, yielding a rate of 8 % (95 % CI: 4 % to 12 %, I2 = 63 %). Further sub-analyses indicated shunt requirement rates of 12 % for children and 3 % for adults. Specifically focusing on adults, data from 46 patients who underwent biopsy revealed a success rate of 84 % (95 % CI: 62 % to 100 %, I2 = 81 %). Remarkably, no major complications were reported among adults, resulting in a rate of 0 % (95 % CI: 0 % to 6 %, I2 = 0 %). Additionally, low rates of mortality related to the procedure were observed in adults, with two deaths recorded among the 46 patients analyzed, resulting in a mortality rate of 1 % (95 % CI: 0 % to 7 %, I2 = 0 %). CONCLUSION In conclusion, our study aimed to assess the feasibility, safety, and efficacy of performing simultaneous biopsy and ETV for patients with pineal region tumors. We meticulously examined clinical aspects and patient outcomes, including good clinical outcomes, the requirement for shunt placement after ETV, biopsy success rates, mortality, and complications.
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Affiliation(s)
- Marcelo Porto Sousa
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | | | | | | | | | - Gabriel Verly
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | | | | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Raphael Bertani
- Department of Neurosurgery, Cerebral Hydrodynamics Group, University of São Paulo, São Paulo, Brazil
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Li Q, Zhang K, Liu H, Zhai S, Jia Y, Li T, Pan Y. Clinical effects of neuroendoscopic infratentorial supracerebellar approach surgical technique for resecting pineal tumors: a retrospective study. Neurochirurgie 2024; 70:101576. [PMID: 38908132 DOI: 10.1016/j.neuchi.2024.101576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/30/2024] [Accepted: 06/04/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE Pineal tumors are relatively rare central nervous system lesions with a predilection for the pediatric population. This article aims to explore the clinical effects of neuroendoscopic infratentorial supracerebellar approach for resecting tumors in the pineal area. METHODS This is a retrospective study that included patients who underwent neuroendoscopic infratentorial supracerebellar approach to resect nine tumors in the pineal area at the Department of Neurosurgery of the Second Hospital of Lanzhou University from December 2017 to October 2023. RESULTS The results of postoperative MRI revealed that all tumors were resected. Five patients received postoperative radiotherapy, three patients received radiotherapy along with chemotherapy, and one patient received neither radiotherapy nor chemotherapy. The pathological results showed that four patients were diagnosed with germinoma, two patients with teratoma, two patients with mixed germ cell tumors, and one patient with central neurocytoma. After surgery, one patient developed psychiatric symptoms, two patients developed binocular upward vision and diplopia, and one patient developed unstable walking and diplopia. With a follow-up of 1.7-4.8 years, all nine patients lived normally. Furthermore, none of them had tumor recurrence or death. CONCLUSION The simple neuroendoscopic infratentorial supracerebellar approach has some safety and efficacy. It is suitable for tumors in the pineal region where the disease is mainly located below the Galen vein complex.
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Affiliation(s)
- Qiang Li
- Department of Neurosurgery, Second Hospital of Lanzhou University, Lanzhou 730030, China
| | - Kai Zhang
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Hanruo Liu
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Shijia Zhai
- Department of Neurosurgery, Second Hospital of Lanzhou University, Lanzhou 730030, China.
| | - Yanfei Jia
- Department of Neurosurgery, Second Hospital of Lanzhou University, Lanzhou 730030, China.
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, Xi'an 710032, China.
| | - Yawen Pan
- Department of Neurosurgery, Second Hospital of Lanzhou University, Lanzhou 730030, China.
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Meira DA, Júnior SP, da Cunha BLB, Marques Fontes JH, Pustilnik HN, da Paz MGDS, Alcântara T, de Avellar LM. Simultaneous Single-Trajectory Endoscopic Biopsy and Third Ventriculostomy in Pineal Region Tumors: A Systematic Review and Single Arm Meta-Analysis. World Neurosurg 2024; 184:e708-e719. [PMID: 38340795 DOI: 10.1016/j.wneu.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE To assess the efficacy and surgical outcomes of the simultaneous single-trajectory endoscopic biopsy and third ventriculostomy (ETV) in pineal region tumors. METHODS A systematic review and meta-analysis adhering to Cochrane Standards and PRISMA framework were conducted. PubMed, Embase, and Web Of Science databases were searched until December 2023. Outcomes included rate of histopathologic diagnosis success, ETV success, complications, required VPS, and mortality. RESULTS Seventeen studies (N = 388) met inclusion criteria. Histopathologic diagnosis success rate was 90% for general population (95% CI: 86%-95%; I2 = 42%) and 94% for pediatric patients (95% CI: 89%-98%; I2 = 19%). ETV Success rate was 93% (95% CI: 88%-97%; I2 = 60%). An estimated risk of postoperative ETV complications was found to be 16% for the general population (95% CI: 5%-28%; I2 = 90%) and 5% for pediatric patients (95% CI: 0%-13%; I2 = 51%). The risk of requiring VPS was estimated as 2% (95% CI: 0%-4%; I2 = 39%) and for the pediatric population it was 7% (95% CI: 0%-16%; I2 = 69%). Mortality risk was found to be 1% (95% CI: 0%-3%; I2 = 0%). CONCLUSIONS Simultaneous endoscopic biopsy and ETV demonstrated high diagnostic and therapeutic success rates. The procedure's safety profile, with low mortality and complications, supports its role in treating hydrocephalus associated to pineal region tumors. Subgroup analyses revealed higher diagnostic success rates and required VPS in the pediatric population, whilst it had lower complication rates.
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Affiliation(s)
- Davi Amorim Meira
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil.
| | | | | | | | | | | | - Tancredo Alcântara
- General Hospital Roberto Santos, Neurosurgery Department, Salvador, Bahia, Brazil; Núcleo Integrado do Cérebro e Coluna, Salvador, Bahia, Brazil
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Deopujari C, Shroff K, Malineni S, Shaikh S, Mohanty C, Karmarkar V, Mittal A. Intraventricular Tumors: Surgical Considerations in Lateral and Third Ventricular Tumors. Adv Tech Stand Neurosurg 2024; 50:63-118. [PMID: 38592528 DOI: 10.1007/978-3-031-53578-9_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Management of lateral and third ventricular tumors has been a challenge for neurosurgeons. Advances in imaging and pathology have helped in a better understanding of the treatment options. Technical refinement of microsurgical technique and addition of endoscopy has enabled more radical excision of tumors, when indicated, and added more safety.A proper understanding of the pathology at various ages and treatment options is continuously evolving. Many pediatric tumors are amenable to conservative surgical methods with effective complementary treatments. However, radical surgery is required in many adults as the main treatment and for many benign tumors. Various intraventricular lesions encountered and their surgical management is reviewed here for their efficacy, safety, and outcome, encompassing changes in our practice over the last 20 years.
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Affiliation(s)
- Chandrashekhar Deopujari
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Krishna Shroff
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Suhas Malineni
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | | | - Chandan Mohanty
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Vikram Karmarkar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Amol Mittal
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
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Huang LT, Wang CX, Li T, Wang SY, Zhou Q, Tong X. Optimal therapeutic strategies for pineal region lesions. Front Neurol 2023; 14:1261054. [PMID: 38107642 PMCID: PMC10722988 DOI: 10.3389/fneur.2023.1261054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023] Open
Abstract
Background The removal of pineal region lesions are challenging, and therapeutic strategies for their removal remain controversial. The current study was conducted to identify the characteristics and the optimal therapeutic strategies for pineal region lesions. Methods This retrospective study reviewed the treatments of 101 patients with pineal region lesions, and different characteristics and therapeutic strategies were observed. Results There were no statistical differences in the total resection ratio, complications, and prognosis outcomes between the hydrocephalus group and non-hydrocephalus group, except patients in the hydrocephalus group were younger and pediatric patients had an increased level of intracranial infections. Treatments of lesions and hydrocephalus secondary to pineal region lesions were two integral parts to therapeutic strategies. For the management of lesions, germinoma or non-germinoma were diagnosed preoperatively, and resection or diagnostic radiation were chosen to deal with pineal region lesions. Endoscopic-assisted surgery provided a higher total resection rate. For the management of hydrocephalus, endoscopic third ventriculostomy (ETV) had the better therapeutic effect. Additionally, cerebrospinal fluid (CSF) diversion before radiotherapy or resection did not improve prognosis outcome, but it was necessary for patients with severe hydrocephalus. Logistical regression analysis indicated that age, lesion size, reoperation ratio, and intracranial complications were predictors of prognosis outcome. Conclusion More attention should be paid to intracranial infections in pediatric patients with hydrocephalus secondary to pineal region lesions, and CSF diversion before radiotherapy or resection did not promote prognosis outcome, but it was necessary for patients with severe hydrocephalus. Age, lesion size, reoperation ratio, and intracranial complications may be the predictors of prognosis outcome. Most importantly, the surgical algorithm for pineal region lesions which was based on preoperatively diagnosis (non-germinoma and germinoma) is useful, especially for developing countries.
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Affiliation(s)
- Li-tian Huang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Chun-xi Wang
- Department of Neurosurgery, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Tang Li
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Sheng-yong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Quan Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Xiaoguang Tong
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
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Kim YH, Phi JH, Kim SK, Wang KC. Endoscopic biopsy of pineal tumors: two burr hole trans-foramen of Monro approach and endonasal trans-tuber cinereum approach. Childs Nerv Syst 2023; 39:2367-2375. [PMID: 36112201 DOI: 10.1007/s00381-022-05654-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/16/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The pineal region is a challenging area for neurosurgeons due to its innate anatomical features, such as its deep location, surrounding large draining veins, and adjacent critical neural structures. DISCUSSION There is a high proportion of malignant tumors in the pineal gland, especially in children, and they are frequently accompanied by obstructive hydrocephalus. These cases require that surgical procedures can make a pathological diagnosis to guide further treatment strategies and immediately resolve increased intracranial pressure. Simultaneous endoscopic third ventriculostomy and biopsy have been regarded as the first-line surgical intervention before establishing a definite treatment plan. However, it is not always successful because various factors affect the surgical procedures, such as the location and extent of the tumor, degree of ventriculomegaly, location and size of the massa intermedia, and size of the foramen of Monro. CONCLUSION Here, we briefly reviewed the points to be considered in endoscopic biopsy of pineal tumors and introduced an alternative surgical procedure, the endoscopic endonasal trans-tuber cinereum approach, to surmount the anatomical hurdles.
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Affiliation(s)
- Yong Hwy Kim
- Pituitary Center, Department of Neurosurgery, Seoul National University of College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Seoul National University of College of Medicine, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Seoul National University of College of Medicine, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Kyu-Chang Wang
- Neuro-Oncology Clinic, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, Kyounggi-do, 10408, Republic of Korea.
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Deopujari C, Shroff K, Karmarkar V, Mohanty C. Neuroendoscopy in the management of pineal region tumours in children. Childs Nerv Syst 2023; 39:2353-2365. [PMID: 35665837 DOI: 10.1007/s00381-022-05561-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/24/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Pineal region tumours (PRTs) are more common in children and represent a wide variety of lesions. The practise of a radiation test dose is obsolete and a biochemical/histological diagnosis is recommended before further therapy. Many patients present with hydrocephalus. Advances in neuroendoscopic techniques have allowed safe and effective management of this obstructive hydrocephalus with an opportunity to sample cerebrospinal fluid (CSF) and obtain tissue for histopathology. Definitive surgery is required in less than a third. Endoscopic visualisation and assistance is increasingly used for radical resection, where indicated. METHODOLOGY Our experience of endoscopic surgery for paediatric PRTs from 2002 to 2021 is presented. All patients underwent MRI with contrast. Serum tumour markers were checked. If negative, endoscopic biopsy and endoscopic third ventriculostomy (ETV) were performed; and CSF collected for tumour markers and abnormal cells. For radical surgery, endoscope-assisted microsurgery procedures were performed to minimise retraction, visualise the extent of resection and confirm haemostasis. RESULTS M:F ratio was 2:1. The median age of presentation was 11 years. Raised ICP (88.88%) was the commonest mode of presentation. Nineteen patients had pineal tumours, one had a suprasellar and pineal tumour, one had disseminated disease, while six had tectal tumours. The ETB diagnosis rate was 95.45%, accuracy rate was 83.3% and ETV success rate was 86.96%. CONCLUSION Neuroendoscopy has revolutionised the management of paediatric PRTs. It is a safe and effective procedure with good diagnostic yield and allows successful concurrent CSF diversion, thereby avoiding major surgeries and shunt implantation. It is also helpful in radical resection of lesions, where indicated.
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Affiliation(s)
- Chandrashekhar Deopujari
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India, 400020.
| | - Krishna Shroff
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India, 400020
| | - Vikram Karmarkar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India, 400020
| | - Chandan Mohanty
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India, 400020
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Leone A, Colamaria A, Fochi NP, Di Napoli V, Blagia M, Sacco M, Winkler G, Spetzger U, Almerayed W, Carbone F. Concomitant, Single Burr Hole Endoscopic Third Ventriculostomy and Tumor Biopsy for Pineal Lesions: Feasibility, Safety, and Benefits. World Neurosurg 2023; 173:5-11. [PMID: 36764448 DOI: 10.1016/j.wneu.2023.01.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/11/2023]
Abstract
Obtaining a prompt diagnosis, avoiding indwelling ventriculoperitoneal shunt, and enhancing the predictive value of pathologic examinations are only some of the advantages conferred by a simultaneous third ventriculostomy and tumor biopsy in patients with pineal region tumors. The objective of this study was to retrospectively search the literature on concomitant, single burr hole endoscopic third ventriculostomy (ETV) and tumor biopsy (TB) for pineal region tumors and to analyze the feasibility, surgical safety, and benefits of these 2 combined procedures. Consequently, a comprehensive, systematic literature search was performed in compliance with the updated PRISMA 2020 guidelines within electronic databases MEDLINE/PubMed, EMBASE, PLOS, and Cochrane Library. Statistical analysis was performed with IBM SPSS 28.0.1.1(14), using Kendall's and Spearman's tests, with a P < 0.05 considered significant. A total of 25 studies were selected and included in this review, for a total of 368 patients (mean age 20.6 years; range 1-86 years; SD 17.5). More than two-thirds of the procedures were operated with a rigid endoscope and 27.6% were performed with either a flexible endoscope, a combination of the 2, or not otherwise specified. Germinoma represented the most frequent diagnosis (20.1%) followed by astrocytoma (12.9%) and pineocytoma (9.9%). The single-entry approach allowed a correct histologic diagnosis in 88.7% of the examined cases. Summing up, concomitant ETV and TB represent a valuable option for the management of non-communicating hydrocephalus and the initial assessment of pineal region tumors. The histologic confirmation rate was 88.7% in the examined cohort, with only 10% of the biopsies yielding inconclusive results.
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Affiliation(s)
- Augusto Leone
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany; Faculty of Human Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | - Maria Blagia
- Division of Neurosurgery, "Giovanni XXIII" Hospital, Bari, Italy
| | - Matteo Sacco
- Division of Neurosurgery, Policlinico "Riuniti", Foggia, Italy
| | - Gerd Winkler
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Uwe Spetzger
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Wessam Almerayed
- Department of Neurology, Klinikum Mittelbaden Rastatt, Rastatt, Germany
| | - Francesco Carbone
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany; Division of Neurosurgery, University of Foggia, Foggia, Italy
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Han L, Song Y, Fang L, Qi S. Multiple ectopic recurrent germ cell tumors after total pineal mature teratoma removal: A case report and literature review. Front Oncol 2023; 13:1094231. [PMID: 36816946 PMCID: PMC9932955 DOI: 10.3389/fonc.2023.1094231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Intracranial germ cell tumors (GCTs) are highly heterogeneous and rare, and the recurrence of mature teratomas is uncommon. There is limited data on the systematic management of multiple recurrent tumors following total teratoma removal. Herein, we report repeated relapsing GCTs with different histological subtypes and locations after en bloc total resection of a pineal mature teratoma. A 14-year-old patient underwent total resection of a tumor in the pineal region and histopathology revealed a mature cystic teratoma. Four years later, the patient experienced a recurrence of the suprasellar tumor, which occurred several times over the next eight years. The tumor was successfully eliminated after multiple surgeries, radiotherapy and chemotherapy. By the time the paper was submitted, the patient had not had a recurrence of the tumor and was in the good physical condition and leading a normal life. Based on this case, we discussed the pathogenesis of recurrent mature teratoma and the therapeutic strategy of multiple recurrent GCTs.
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Shabo E, Czech T, Nicholson JC, Mallucci C, Mottolese C, Piatelli G, Frappaz D, Murray MJ, Faure-Conter C, Garrè ML, Sarikaya-Seiwert S, Weinhold L, Haberl H, Calaminus G. Evaluation of the Perioperative and Postoperative Course of Surgery for Pineal Germinoma in the SIOP CNS GCT 96 Trial. Cancers (Basel) 2022; 14:cancers14143555. [PMID: 35884617 PMCID: PMC9323477 DOI: 10.3390/cancers14143555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/16/2022] [Accepted: 07/18/2022] [Indexed: 02/05/2023] Open
Abstract
Background: CNS germinoma, being marker-negative, are mainly diagnosed by histological examination. These tumors predominantly appear in the suprasellar and/or pineal region. In contrast to the suprasellar region, where biopsy is the standard procedure in case of a suspected germ-cell tumor to avoid mutilation to the endocrine structures, pineal tumors are more accessible to primary resection. We evaluated the perioperative course of patients with pineal germinoma who were diagnosed by primary biopsy or resection in the SIOP CNS GCT 96 trial. Methods: Overall, 235 patients had germinoma, with pineal localization in 113. The relationship between initial symptoms, tumor size, and postoperative complications was analyzed. Results: Of 111 evaluable patients, initial symptoms were headache (n = 98), hydrocephalus (n = 93), double vision (n = 62), Parinaud syndrome (n = 57), and papilledema (n = 44). There was no significant relationship between tumor size and primary symptoms. A total of 57 patients underwent primary resection and 54 underwent biopsy. Postoperative complications were reported in 43.2% of patients after resection and in 11.4% after biopsy (p < 0.008). Biopsy was significantly more commonly performed on larger tumors (p= 0.002). Conclusions: These results support the practice of biopsy over resection for histological confirmation of pineal germinoma.
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Affiliation(s)
- Ehab Shabo
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Sigmund-Freud-Straße 25, 53127 Bonn, Germany
- Correspondence: ; Tel.: +49-228-287-16521; Fax: +49-228-287-11366
| | - Thomas Czech
- Department of Neurosurgery, Medical University of Vienna, 1090 Vienna, Austria;
| | - James C. Nicholson
- Department of Paediatric Haematology and Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK;
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children’s Hospital, Liverpool L14 5AB, UK; (C.M.); (M.J.M.)
| | - Carmine Mottolese
- Neurochirurgie Pédiatrique, Hôpital Femme-Mère-Enfant, Université de Lyon, 59, Boulevard Pinel, 69003 Lyon, France;
| | - Gianluca Piatelli
- Division of Neurosurgery, Department of Neurosciences, Giannina Gaslini Children’s Hospital, 16147 Genvoa, Italy;
| | - Didier Frappaz
- Department of Pediatric Hematology and Oncology, Institut d’Hématologie et d’Oncologie Pédiatrique, 69008 Lyon, France; (D.F.); (C.F.-C.)
| | - Matthew Jonathan Murray
- Department of Neurosurgery, Alder Hey Children’s Hospital, Liverpool L14 5AB, UK; (C.M.); (M.J.M.)
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, UK
| | - Cecile Faure-Conter
- Department of Pediatric Hematology and Oncology, Institut d’Hématologie et d’Oncologie Pédiatrique, 69008 Lyon, France; (D.F.); (C.F.-C.)
| | - Maria Luisa Garrè
- Department of Pediatric Hematology-Oncology and Bone Marrow Transplantation, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy;
| | - Sevgi Sarikaya-Seiwert
- Section of Pediatric Neurosurgery, Department of Neurosurgery, Rheinische, Friedrich-Wilhelms-University, Sigmund-Freud-Straße 25, 53127 Bonn, Germany; (S.S.-S.); (H.H.)
| | - Leonie Weinhold
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, 53127 Bonn, Germany;
| | - Hannes Haberl
- Section of Pediatric Neurosurgery, Department of Neurosurgery, Rheinische, Friedrich-Wilhelms-University, Sigmund-Freud-Straße 25, 53127 Bonn, Germany; (S.S.-S.); (H.H.)
| | - Gabriele Calaminus
- Department of Pediatric Hematology and Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany;
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Dhandapani S, Jani P, Sahoo SK. Single-entry two-stage rotational outside-in technique for simultaneous ventriculostomy and pineal region biopsy using traditional ventricular endoscope: technical note and comparative review. Childs Nerv Syst 2022; 38:627-631. [PMID: 34625817 DOI: 10.1007/s00381-021-05389-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Many methods are reported for simultaneous endoscopic 3rd ventriculostomy and posterior 3rd ventricular biopsy with their pros and cons. We describe a novel single-entry two-stage rotational outside-in technique using the common 6° ventriculoscope and contrast this with others. TECHNIQUE Using a single burr hole, at the line extended from aqueduct through the larger foramen of Monro in parasagittal imaging, the ventricular endoscope is first inserted with 6° angled view anteroinferior, the tip of endoscope sheath just beyond the anterior part of the foramen, and ventriculostomy performed using flexible catheter's beveled cut end and balloon in a curvilinear trajectory using peripheral visualization. Keeping camera in the same orientation, it is then rotated 180° having 6° angled view postero-inferior, endoscope sheath traversing the posterior part of the foramen close to the posterior 3rd ventricular target, and biopsy obtained with rigid forceps. This technique overcomes some of the limitations of other methods by exploiting the flexible catheters and the rotational advantage of the 6° angle of the traditional ventriculoscope. CONCLUSION Our single burr hole two-stage rotational technique for simultaneous third ventriculostomy and posterior third ventricular biopsy seems to be an excellent alternative to other methods which can be used with both traditional 6° and greater angled ventriculoscopes without any significant deterrent.
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Affiliation(s)
- Sivashanmugam Dhandapani
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Parth Jani
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Sushant K Sahoo
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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Mission impossible: chemotherapy in the intensive care for pineal region germ cell tumor. Childs Nerv Syst 2022; 38:179-183. [PMID: 33474571 DOI: 10.1007/s00381-020-05031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Pineal region tumors are rare and a heterogenous group of primary central nervous system tumors which are primarily classified as germ cell tumors and non-germ cell tumors. Chemotherapy and radiotherapy as the primary treatment modalities have been reported to result in good outcomes. We discuss the case of a young girl who presented to our emergency department in an unconscious state and had a large lesion in the posterior third ventricular region, but without any associated hydrocephalus which could explain her stuporous state. Given the rapid decline in her sensorium, we were faced with the difficult choice between surgical decompression of the tumor and a trial of rescue chemotherapy following histopathological confirmation through biopsy. She underwent an open biopsy followed by chemotherapy in a neurosurgical intensive care unit despite her poor Karnofsky performance score. She improved after chemotherapy and her tumor decreased in size significantly over time. We highlight the role of chemotherapy administered in the neurosurgical ICU to an unconscious patient with a large chemoresponsive tumor leading to rapid shrinkage of the lesion and gradual improvement in the sensorium of the patient.
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Simultaneous single-trajectory endoscopic biopsy and third ventriculostomy in pediatric pineal region tumors. Acta Neurol Belg 2021; 121:1535-1542. [PMID: 32506355 DOI: 10.1007/s13760-020-01387-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/15/2020] [Indexed: 10/24/2022]
Abstract
Pineal region tumors have different pathological tumors and their optimal management remains controversial. Advancements in neuroendoscopy have led to the ability to simultaneously treat the hydrocephalus and obtain a tissue diagnosis. A retrospective review of 34 patients with pineal region tumors in Beijing Tiantan hospital from the year 2016 to 2018 was undertaken. A single bur hole for both procedures was used successfully in all patients. Once pathologic diagnosis is made, the subsequent management of different tumors is dependent on response to therapy, the tumor markers and original pathology. Follow-up period was 4-26 months. All 34 cases presented with hydrocephalus and increased intracranial pressure manifestations. Elevated blood tumor markers were found in seven cases. The neuroendoscopic biopsy was diagnostic in 32 samples (94.1%) and nondiagnostic (gliosis) in two patients. 21 cases were germinomas, five cases were tectal astrocytomas, two cases were pineoblastomas, two cases were non-germinomatous germ-cell tumours (NG-GCTs) and 1 case immature teratoma and glioblastoma respectively. During the follow-up period, all germinomas but one case with elevated blood α-fetoprotein received craniotomy with a final diagnosis of NG-GCT received radiotherapy and chemotherapy. Four tectal astocytomas, two pineoblastomas and two NG-GCTs received subsequent open surgery due to progressive development, the pathological data was concordant with the initial endoscopic biopsy sample. An additional VP shunt was inserted in one tectal astrocytoma who have hydrocephalus after craniotomy. Except for 18 cases of transient fever and a case with intratumoral hemorrhage, there was no other significant complications, cognitive disorder and no death. The simultaneous single-trajectory endoscopic technique permits not only to control hydrocephalus but also to obtain histological diagnosis with a low incidence of complication and higher safety. Providing meaningful pathological data, endoscopic biopsies could lead to an appropriate management decision. Especially, it is favored as an early step in the management of patients with marker-negative tumors.
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Feletti A, Fiorindi A, Lavecchia V, Boscolo-Berto R, Marton E, Macchi V, De Caro R, Longatti P, Porzionato A, Pavesi G. A light on the dark side: in vivo endoscopic anatomy of the posterior third ventricle and its variations in hydrocephalus. J Neurosurg 2021; 135:309-317. [PMID: 32619975 DOI: 10.3171/2020.4.jns20493] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 04/15/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Despite the technological advancements of neurosurgery, the posterior part of the third ventricle has always been the "dark side" of the ventricle. However, flexible endoscopy offers the opportunity for a direct, in vivo inspection and detailed description of the posterior third ventricle in physiological and pathological conditions. The purposes of this study were to describe the posterior wall of the third ventricle, detailing its normal anatomy and surgical landmarks, and to assess the effect of chronic hydrocephalus on the anatomy of this hidden region. METHODS The authors reviewed the video recordings of 59 in vivo endoscopic explorations of the posterior third ventricle to describe every identifiable anatomical landmark. Patients were divided into 2 groups based on the absence or presence of a chronic dilation of the third ventricle. The first group provided the basis for the description of normal anatomy. RESULTS The following anatomical structures were identified in all cases: adytum of the cerebral aqueduct, posterior commissure, pineal recess, habenular commissure, and suprapineal recess. Comparing the 2 groups of patients, the authors were able to detect significant variations in the shape of the adytum of the cerebral aqueduct and in the thickness of the habenular and posterior commissures. Exploration with sodium fluorescein excluded the presence of any fluorescent area in the posterior third ventricle, other than the subependymal vascular network. CONCLUSIONS The use of a flexible scope allows the complete inspection of the posterior third ventricle. The anatomical variations caused by chronic hydrocephalus might be clinically relevant, in light of the commissure functions.
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Affiliation(s)
- Alberto Feletti
- 1Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona
- 2Department of Neurosciences, Neurosurgical Unit, University of Modena
| | - Alessandro Fiorindi
- 3Neurosurgical Department, Spedali Civili, University of Brescia
- 4Neurosurgical Department, Treviso Regional Hospital, University of Padova, Treviso; and
| | | | - Rafael Boscolo-Berto
- 5Department of Neuroscience, Institute of Human Anatomy, University of Padova, Italy
| | - Elisabetta Marton
- 4Neurosurgical Department, Treviso Regional Hospital, University of Padova, Treviso; and
| | - Veronica Macchi
- 5Department of Neuroscience, Institute of Human Anatomy, University of Padova, Italy
| | - Raffaele De Caro
- 5Department of Neuroscience, Institute of Human Anatomy, University of Padova, Italy
| | - Pierluigi Longatti
- 4Neurosurgical Department, Treviso Regional Hospital, University of Padova, Treviso; and
| | - Andrea Porzionato
- 5Department of Neuroscience, Institute of Human Anatomy, University of Padova, Italy
| | - Giacomo Pavesi
- 2Department of Neurosciences, Neurosurgical Unit, University of Modena
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Schonauer C, Jannelli G, Tessitore E, May AT, Guatta R, Bartoli A. Endoscopic resection of a low-grade ependymoma of the pineal region. Surg Neurol Int 2021; 12:279. [PMID: 34221610 PMCID: PMC8248020 DOI: 10.25259/sni_250_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/08/2021] [Indexed: 11/04/2022] Open
Abstract
Background Full endoscopic resection of solid brain tumors represents a challenge for neurosurgeons. This can be achieved with modern technology and advanced surgical tools. Case Description A 23-years-old male was referred to our unit with raised intracranial pressure. Head computed tomography and magnetic resonance imaging (MRI) revealed obstructive hydrocephalus and a third ventricle lesion. Endoscopic third ventriculostomy and biopsy were performed, a left frontal external ventricular drain was left in place. A second-look surgery for endoscopic removal was planned. Decision to proceed with an endoscopic removal was supported by the following characteristics found during the first surgery: tumor exophytic, soft texture, scarce vascularity, and low-grade appearance. A rescue strategy for microscopic resection via transcallosal approach was decided. A straight trajectory to the tumor was planned with navigation. A further anterior left frontal burr-hole was performed, and the ventricular system was entered via the left frontal horn. Resection was carried out alternating laser for hemostasis and cutting, endoscopic ultrasonic aspirator, and endoscopic forceps for piecemeal resection. Laser hemostasis and cutting (1 Watt power at tip, continuous wave mode) were useful at the ventricular wall-tumor interface. Relevant landmarks guided the approach and the resection (foramen of Monro, mammillary bodies, aqueduct, pineal and suprapineal recess, and posterior commissure). The surgery was carried uneventfully. Histopathology confirmed a lowgrade ependymoma. Post-operative MRI showed residual tumor within the lower aqueduct. At 3 years follow-up, residual tumor is stable. Conclusion In selected cases, endoscopic resection for third ventricular tumors is feasible and safe, and represents a valid alternative to microsurgical approaches.
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Affiliation(s)
| | - Gianpaolo Jannelli
- Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | - Enrico Tessitore
- Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | - Adrien Thomas May
- Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | - Ramona Guatta
- Neurosurgical Unit, Lugano Regional Hospital Civico and Italian Sites, Lugano, Switzerland
| | - Andrea Bartoli
- Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
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Lateral Temporal Approach for Image-Guided Stereotactic Biopsy of Pineal Region Tumors. World Neurosurg 2020; 147:144-149. [PMID: 33307256 DOI: 10.1016/j.wneu.2020.11.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Biopsy of pineal region neoplasms is frequently accomplished by way of endoscopic transventricular access or using an image-guided, computer-assisted stereotactic approach. METHODS We evaluated a nonorthogonal lateral temporal approach for stereotactic biopsy of pineal region tumors as a variation of previously described stereotactic methods. Magnetic resonance imaging-guided frameless stereotaxy was used to plan and perform biopsies of pineal region tumors using a nonorthogonal trajectory extending from the superior or middle temporal gyri through the temporal stem, anterior to the atrium of the lateral ventricle, and posterior to the corticospinal tract. RESULTS All patients had an uncomplicated postoperative course and remained at neurologic baseline. No parenchymal or ventricular hemorrhage was present on postoperative scans. A tissue diagnosis was obtained in all patients. CONCLUSIONS This method appears to be a safe alternative to stereotactic biopsy using other trajectories and provides adequate tissue for definitive diagnosis.
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Attri G, Gosal JS, Khatri D, Das KK, Bhaisora KS, Mehrotra A, Sardhara J, Srivastava AK, Behari S, Jaiswal S, Jaiswal AK. Endoscopic Third Ventriculostomy and Simultaneous Tumor Biopsy in Pineal Region Tumors using the "Single Burr Hole" Technique: An Analysis of 34 Cases. Asian J Neurosurg 2020; 15:976-982. [PMID: 33708673 PMCID: PMC7869259 DOI: 10.4103/ajns.ajns_194_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/07/2020] [Accepted: 05/15/2020] [Indexed: 11/04/2022] Open
Abstract
Background Pineal region tumors often present with hydrocephalus. Endoscopic third ventriculostomy (ETV) and simultaneous tumor biopsy remain a minimally invasive procedure offering both diagnostic and therapeutic advantages in the management of these tumors. However, different operative techniques have been described in the literature. Aim The aim is to study the ETV success rate, diagnostic rate of simultaneous tumor biopsy, complications, and follow-up of patients of pineal region tumors managed with ETV and simultaneous tumor biopsy using the single burr hole technique. Methods The study was performed by retrospectively reviewing the records of patients of pineal region tumors managed by simultaneous ETV and tumor biopsy using a "single burr hole" technique from January 2012 to December 2019. Results Thirty-four patients (22 males and 12 females) with a mean age of 28.7 years were analyzed. ETV was successful in relieving hydrocephalus in 29 (87.8%) patients. Three patients needed a ventriculoperitoneal shunt, and one required Ommaya reservoir placement for persistent hydrocephalus. Histological diagnosis was successfully established in 26 (78.8%) patients. There were two procedure-related mortalities. Two patients underwent craniotomy and tumor excision subsequently. Radiotherapy was given to 11 patients, and 9 patients were managed by observation alone. The mean follow-up of our study was 15.8 months. Conclusions Simultaneous ETV and tumor biopsy using a single burr hole technique is a safe, minimally invasive procedure for the management of pineal region tumors.
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Affiliation(s)
- Gagandeep Attri
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | - Deepak Khatri
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | - Anant Mehrotra
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Jayesh Sardhara
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | - Sanjay Behari
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Sushila Jaiswal
- Department of Pathology, SGPGIMS, Lucknow, Uttar Pradesh, India
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Schulz M, Afshar-Bakshloo M, Koch A, Capper D, Driever PH, Tietze A, Grün A, Thomale UW. Management of pineal region tumors in a pediatric case series. Neurosurg Rev 2020; 44:1417-1427. [PMID: 32504201 PMCID: PMC8121748 DOI: 10.1007/s10143-020-01323-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/23/2020] [Accepted: 05/20/2020] [Indexed: 12/18/2022]
Abstract
Pineal region tumors commonly present with non-communicating hydrocephalus. These heterogeneous histological entities require different therapeutic regimens. We evaluated our surgical experience concerning procurance of a histological diagnosis, management of hydrocephalus, and choice of antitumoral treatment. We analyzed the efficacy of neuroendoscopic biopsy and endoscopic third ventriculocisternostomy (ETV) in patients with pineal region tumors between 2006 and 2019 in a single-center retrospective cross-sectional study with regard to diagnostic yield, hydrocephalus treatment, as well as impact on further antitumoral management. Out of 28 identified patients, 23 patients presented with untreated hydrocephalus and 25 without histological diagnosis. One patient underwent open biopsy, and 24 received a neuroendoscopic biopsy with concomitant hydrocephalus treatment if necessary. Eighteen primary ETVs, 2 secondary ETVs, and 2 ventriculoperitoneal shunts (VPSs) were performed. Endoscopic biopsy had a diagnostic yield of 95.8% (23/24) and complication rates of 12.5% (transient) and 4.2% (permanent), respectively. ETV for hydrocephalus management was successful in 89.5% (17/19) with a median follow-up of more than 3 years. Following histological diagnosis, 8 patients (28.6%) underwent primary resection of their tumor. Another 9 patients underwent later-stage resection after either adjuvant treatment (n = 5) or for progressive disease during observation (n = 4). Eventually, 20 patients received adjuvant treatment and 7 were observed after primary management. One patient was lost to follow-up. Heterogeneity of pineal region tumor requires histological confirmation. Primary biopsy of pineal lesions should precede surgical resection since less than a third of patients needed primary surgical resection according to the German pediatric brain tumor protocols. Interdisciplinary decision making upfront any treatment is warranted in order to adequately guide treatment.
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Affiliation(s)
- Matthias Schulz
- Pediatric Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Melissa Afshar-Bakshloo
- Pediatric Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Arend Koch
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - David Capper
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Pablo Hernáiz Driever
- Department of Pediatric Oncology and Hematology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anna Tietze
- Institute of Neuroradiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Arne Grün
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
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Role of endoscopic surgical biopsy in diagnoses of intraventricular/periventricular tumors: review of literature including a monocentric case series. Acta Neurol Belg 2020; 120:517-530. [PMID: 32107717 DOI: 10.1007/s13760-020-01299-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 02/09/2020] [Indexed: 12/28/2022]
Abstract
The intra- and periventricular location tumor (IPVT) of a brain remains a hard challenge for the neurosurgeon because of the deep location and eloquent anatomic associations. Due to this high risk of iatrogenic injury, many surgeons elect to perform biopsies of such lesions to establish a diagnosis. On the one hand, stereotaxic needle biopsy (SNB) is a minimally invasive procedure but with a significant risk of complications and a high risk of lack of tissue for molecular analyses for this region [Fukushima in Neurosurgery 2:110-113 (1978)]; on the other hand, the use of endoscopic intraventricular biopsy (EIB) allows for diagnosis with minimal surgical intervention [Iwamoto et al. in Ann Neurol 64(suppl. 6):628-634 (2008)]. IPVTs and related CSF pathway obstructions can be safely and effectively treated with endoscopic techniques. It is not possible to compare EIB with diagnoses made by any other method or with the established treatment. We aim to analyze the accuracy of EIB results by comparing them with results of biopsies performed later, in other methods and thereby evaluating the treatment evolution considering our personal experience. The difficulties and complications encountered are presented and compared with those reported in the literature to obtain the best review possible for this topic. A systematic review of literature was done using MEDLINE, the NIH Library, PubMed, and Google Scholar yielded 1.951 cases for EIB and 1912 for SNB, according to standard systemic review techniques. Review was conducted on 50 studies describing surgical procedures for lesions intra- and para-ventricular. The primary outcome measure was a diagnostic success. We also consider 20 patients with IPVT treated in our department. Clinical characteristics and surgical outcome were evaluated and a systematic review of the literature was performed. Overall, all our biopsies were diagnostic, with a positive histologic sample in 100% of our patients. 8 patients underwent a concurrent endoscopic third ventriculostomy. 4 patients underwent a concurrent ventriculostomy combined with septostomy. For 1 patient was necessary the only septostomy combined with biopsy. Every case has obtained a histological diagnosis. The percentage of complications was very low with only 1 case of post-operative infection and 1 case of hemorrhage. It was impossible to create a specific comparison from literature data of IPVTs between a stereotactic and endoscopic procedure, it presents only the collection of pineal gland tumor [Kelly in Neurosurgery 25(02):185-194 (1989); Quick-Weller in World Neurosurgery 96:124-128 (2016)] or unknown location of the lesion in major review [Marenco-Hillembrand et al. in Front Oncol 8:558 (2018)]. The present study aims to report our experience with the surgical management of IPVTs. The EIB sample yields an accurate histologic diagnosis tumor, with a positive histologic sample in 87, 95% of patients. The choice of the appropriate procedure should consider not only the preference and the experience of the neurosurgeon but also the several other variables as the location. While some periventricular lesions are better approached by endoscopic techniques, others are more suited for stereotactic-guided approaches. The ability to perform an EIB and relieve tumor-associated hydrocephalus by neuroendoscopy is considered to be a benefit of this procedure since this is less invasive than other treatments.
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Gao Y, Takagi K, Kato T, Shono N, Hata N. Continuum Robot With Follow-the-Leader Motion for Endoscopic Third Ventriculostomy and Tumor Biopsy. IEEE Trans Biomed Eng 2020; 67:379-390. [PMID: 31034405 PMCID: PMC7098325 DOI: 10.1109/tbme.2019.2913752] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In a combined endoscopic third ventriculostomy (ETV) and endoscopic tumor biopsy (ETB) procedure, an optimal tool trajectory is mandatory to minimize trauma to surrounding cerebral tissue. OBJECTIVE This paper presents wire-driven multi-section robot with push-pull wire. The robot is tested to attain follow-the-leader (FTL) motion to place surgical instruments through narrow passages while minimizing the trauma to tissues. METHODS A wire-driven continuum robot with six sub-sections was developed and its kinematic model was proposed to achieve FTL motion. An accuracy test to assess the robot's ability to attain FTL motion along a set of elementary curved trajectory was performed. We also used hydrocephalus ventricular model created from human subject data to generate five ETV/ETB trajectories and conducted a study assessing the accuracy of the FTL motion along these clinically desirable trajectories. RESULTS In the test with elementary curved paths, the maximal deviation of the robot was increased from 0.47 mm at 30 ° turn to 1.78 mm at 180 ° in a simple C-shaped curve. S-shaped FTL motion had lesser deviation ranging from 0.16 to 0.18 mm. In the phantom study, the greatest tip deviation was 1.45 mm, and the greatest path deviation was 1.23 mm. CONCLUSION We present the application of a continuum robot with FTL motion to perform a combined ETV/ETB procedure. The validation study using human subject data indicated that the accuracy of FTL motion is relatively high. The study indicated that FTL motion may be useful tool for combined ETV and ETB.
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Second Window Indocyanine Green (SWIG) Near Infrared Fluorescent Transventricular Biopsy of Pineal Tumor. World Neurosurg 2019; 134:196-200. [PMID: 31669685 DOI: 10.1016/j.wneu.2019.10.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/18/2019] [Accepted: 10/18/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Second Window Indocyanine Green (SWIG) is a novel technique for real-time, intraoperative tumor visualization using a high-dose infusion of indocyanine green (ICG) 24 hours before surgery. Due to pathologic diversity found in the pineal region, tissue diagnosis in patients with pineal region mass is essential to optimize further clinical management. CASE DESCRIPTION We present the case of a 75-year-old woman with known pineal region mass for 18 years, who presented with progressive classic signs and symptoms of obstructive hydrocephalus over the past 6 months. Preoperative imaging confirmed a contrast-enhancing pineal region tumor, which appeared to be obstructing the aqueduct of Sylvius, causing proximal obstructive hydrocephalus. We delivered 5 mg/kg of ICG intravenously 24 hours before the surgery. The patient underwent an endoscopic third ventriculostomy and a biopsy of the pineal lesion. The tumor demonstrated clear near-infrared fluorescence, which was distinct from surrounding third ventricle floor and ependyma. The signal-to-background ratio was 2.9. The final pathology report revealed a World Health Organization grade I pineocytoma. CONCLUSIONS We report on a novel application of near-infrared fluorescence for tumor identification of pineal region tumors, using the "SWIG technique."
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Samadian M, Maloumeh EN, Shiravand S, Ebrahimzadeh K, Sharifi G, Mousavinejad A, Rezaei O. Pineal region tumors: Long-term results of endoscopic third ventriculostomy and concurrent tumor biopsy with a single entry approach in a series of 64 cases. Clin Neurol Neurosurg 2019; 184:105418. [PMID: 31319237 DOI: 10.1016/j.clineuro.2019.105418] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/04/2019] [Accepted: 07/06/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Endoscopic third ventriculostomy and concurrent biopsy is increasingly used in management of the pineal region tumors. Our objective was to assess the results of single entry approach to surgically manage the tumors of the pineal region. PATIENTS AND METHODS A retrospective study was designed, and a series of 64 consecutive patients (31 male, 33 female) with pineal region tumor undergoing endoscopic third ventriculostomy and concurrent biopsy of the tumor was undertaken. RESULTS A total of 64 patients underwent simultaneous endoscopic third ventriculostomy and biopsy of the pineal tumors with a single entry approach. A positive initial diagnosis was established in 97% of patients. 5 patients (7%) required the insertion of an external ventricular drain which was removed in all patients after 72 h but in one case (1%) undergoing permanent VP shunt insertion. The postoperative complications were divided into two transient and permanent complications. The transient complications included intraventricular hemorrhage (18%), seizure (1 to two episodes of seizure) (5%), diabetes insipidus (3%) and meningitis (3%) all were successfully managed. The only permanent complication was memory deficits occurred in one patient (1%). There was no mortality rate in current study. CONCLUSION The results of this study support the safety and efficacy of endoscopic third ventriculostomy and concurrent biopsy of the pineal region tumors as a less invasive surgical method associated with low morbidity and mortality rate. Our data demonstrated how simultaneous endoscopic third ventriculostomy and biopsy of the pineal region tumors with a single entry approach can produce favorable results.
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Affiliation(s)
- Mohammad Samadian
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Ehsan Nazari Maloumeh
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Sepideh Shiravand
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Kaveh Ebrahimzadeh
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Guive Sharifi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Ali Mousavinejad
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Omidvar Rezaei
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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An anatomical study of the foramen of Monro: implications in management of pineal tumors presenting with hydrocephalus. Acta Neurochir (Wien) 2019; 161:975-983. [PMID: 30953154 DOI: 10.1007/s00701-019-03887-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/20/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND For pineal tumors presenting with hydrocephalus, simultaneous endoscopic third ventriculostomy (ETV) and tumor biopsy is commonly used as the initial step in management. To analyze the restriction which the foramen of Monro poses to this procedure, one must start with a detailed description of the microsurgical anatomy of the foramen in living subjects. However, the orientation and shape of the foramen of Monro make this description difficult with conventional imaging techniques. METHOD Virtual reality technology was applied on MRIs on living subject without hydrocephalus, as well as patients with hydrocephalus, to generate precise anatomical models with sub-millimeter accuracy. The morphometry of the foramen of Monro was studied in each group. In addition, displacement of the margins of the foramen was studied in detail for simultaneous ETV and pineal tumor biopsy through a single burr hole. RESULTS In 30 normal subjects, the foramen of Monro had oval-shaped openings averaging 5.23 mm2. The foramen was larger in people above age 55 (p = 0.007) and on the left side compared to the right (p = 0.002). For patients with clinical presentation of hydrocephalus, the average opening was 32.6 mm2. Simulated single burr hole simultaneous ETV and pineal tumor biopsy was performed in 10 specimens. Average displacement of the posterior and anterior margins of the foramen was 5.71 mm and 5.76 mm, respectively. However, maximum displacement reached 9.3 mm posteriorly and 10 mm anteriorly. CONCLUSIONS The foramen of Monro is an oval-shaped cylinder that changes in size and orientation in the hydrocephalic patient. If universally applied to all patients regardless of foramen and tumor size, ETV/biopsy can displace structures around the Foramen of Monro up to 1 cm, which can potentially lead to neurological damage. Careful pre-operative assessment is critical to determine if a single burr hole approach is safe.
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Amer MAI, Elatrozy HIS. Combined endoscopic third ventriculostomy and tumor biopsy in the management of pineal region tumors, safety considerations. EGYPTIAN JOURNAL OF NEUROSURGERY 2018. [DOI: 10.1186/s41984-018-0022-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Snyder R, Felbaum DR, Jean WC, Anaizi A. Supracerebellar Infratentorial Endoscopic and Endoscopic-Assisted Approaches to Pineal Lesions: Technical Report and Review of the Literature. Cureus 2017; 9:e1329. [PMID: 28690962 PMCID: PMC5501715 DOI: 10.7759/cureus.1329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The pineal gland has a deep central location, making it a surgeon's no man's land. Surgical pathology within this territory presents a unique challenge and an opportunity for employment of various surgical techniques. In modern times, the microsurgical technique has been competing with the endoscope for achieving superior surgical results. We describe two cases utilizing a purely endoscopic and an endoscopic-assisted supracerebellar infratentorial approach in accessing lesions of the pineal gland. We also discuss our early learning experience with these approaches.
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Affiliation(s)
- Rita Snyder
- Neurosurgery, Medstar Georgetown University Hospital
| | | | - Walter C Jean
- Neurosurgery, Medstar Georgetown University Hospital
| | - Amjad Anaizi
- Neurosurgery, Medstar Georgetown University Hospital
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Nagm A, Ogiwara T, Goto T, Chiba A, Hongo K. Neuroendoscopy via an Extremely Narrow Foramen of Monro: A Case Report. NMC Case Rep J 2016; 4:37-42. [PMID: 28664024 PMCID: PMC5364906 DOI: 10.2176/nmccrj.cr.2016-0157] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/18/2016] [Indexed: 11/25/2022] Open
Abstract
Herein, safe and reliable neuroendoscopic biopsy via an extremely narrow foramen of Monro (ENFM) for a non-hydrocephalic patient with hypothalamic and pineal region tumors was successfully applied. A 17-year-old boy presented with hypothalamic manifestations attributed to hypothalamic and pineal region tumors. Small ventricles were seen. Intraoperatively, to advance different diameter steerable fiberscopes via ENFM, the third ventricle was flushed to induce a moment increase in the intraventricular pressure with subsequent dilatation of FM. Postoperative course was uneventful. Histopathological studies revealed a yolk sac tumor. Adjuvant therapy was applied. Follow-up neuroimaging disclosed marvellous improvement of the condition. His symptoms gradually improved.
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Affiliation(s)
- Alhusain Nagm
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan and.,Department of Neurosurgery, Al-Azhar University Faculty of Medicine-Nasr city, Cairo, Egypt
| | - Toshihiro Ogiwara
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan and
| | - Tetsuya Goto
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan and
| | - Akihiro Chiba
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan and
| | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan and
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Eastwood KW, Bodani VP, Drake JM. Three-Dimensional Simulation of Collision-Free Paths for Combined Endoscopic Third Ventriculostomy and Pineal Region Tumor Biopsy: Implications for the Design Specifications of Future Flexible Endoscopic Instruments. Oper Neurosurg (Hagerstown) 2016; 12:231-238. [PMID: 29506110 DOI: 10.1227/neu.0000000000001177] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 10/18/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Recent innovations to expand the scope of intraventricular neuroendoscopy have focused on transitioning multiple-incision procedures into single-corridor approaches. However, the successful adoption of these combined procedures requires minimizing the unwanted torques applied to surrounding healthy structures. OBJECTIVE To define the geometry of relevant anatomical structures in endoscopic third ventriculostomy (ETV) and pineal region tumor biopsy (ETB). Second, to determine the optimal instrument shaft path required for collision-free single burr hole combined ETV/ETB. METHODS Magnetic resonance and computed tomography data from 15 pediatric patients who underwent both ETV and ETB procedures between 2006 and 2014 was segmented by using the 3DSlicer software package to create virtual 3-D patient models. Anatomical regions of interest were measured including the foramen of Monro, the massa intermedia, the floor of the third ventricle, and the tumor margin. Utilizing the MATLAB software package, virtual dexterous instruments were inserted into the models and optimal dimensions were calculated. RESULTS The diameters of the foramen of Monro, massa intermedia (anterior-posterior, superior-inferior), anterior third ventricle, and tumor margin are 6.85, 4.01, 5.05, 14.2, and 28.5 mm, respectively. The average optimal burr placement was determined to be 22.5 mm anterior to the coronal and 30 mm lateral to the sagittal sutures. Optimal flexible instrument geometries for novel instruments were calculated. CONCLUSION We have established a platform for estimating the shape of novel curved dexterous instruments for collision-free targeting of multiple intraventricular points, which is both patient and tool specific and can be integrated with image guidance. These data will aid in developing novel dexterous instruments.
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Affiliation(s)
- Kyle W Eastwood
- Institute of Biomaterials and Biomedical Engineering, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Center for Image Guided Innovation and Therapeutic Intervention (CIGITI), Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vivek P Bodani
- Institute of Biomaterials and Biomedical Engineering, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Center for Image Guided Innovation and Therapeutic Intervention (CIGITI), Hospital for Sick Children, Toronto, Ontario, Canada
| | - James M Drake
- Institute of Biomaterials and Biomedical Engineering, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Center for Image Guided Innovation and Therapeutic Intervention (CIGITI), Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
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Endoscopic Histologic Mapping of a Mixed Germ Pineal Tumor. World Neurosurg 2016; 95:625.e1-625.e5. [PMID: 27554308 DOI: 10.1016/j.wneu.2016.08.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/09/2016] [Accepted: 08/10/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND The accurate histologic diagnosis of germ cell tumors in the pineal region is a keystone for determining the best treatment strategy and prognosis. This situation poses a challenge for the neuropathologist, considering the lack of a standarized procedure to obtain biopsy samples, which results in few and small specimens, which are not suitable for diagnosis. CASE DESCRIPTION We report a case in which a pineal region mixed germ cell tumor was accurately diagnosed by performing histologic mapping through a dual burr-hole endoscopic approach. The technical pitfalls and other considerations necessary for obtaining an accurate diagnosis in this tumor subgroup are specified. In addition, the histologic analysis regarding the sampling technique used is described. CONCLUSIONS The supraorbital frontal endoscopic approach enables the surgeon to perform histologic mapping of pineal region tumors, allowing standarization of the procedure used to obtain the specimens. This approach could result in a more accurate diagnosis, especially in mixed germ cell neoplasms.
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Endoscopic Versus Stereotactic Procedure for Pineal Tumor Biopsies: Focus on Overall Efficacy Rate. World Neurosurg 2016; 92:223-228. [PMID: 27060509 DOI: 10.1016/j.wneu.2016.03.088] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 03/27/2016] [Accepted: 03/29/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The management of pineal region tumors depends on the histologic subtypes. Two minimally invasive techniques are available: endoscopic intraventricular biopsies and stereotactic biopsies. The recent Southampton and Lille series are the largest endoscopic and stereotactic series of pineal region tumors reporting both diagnosis rate and accuracy rate, respectively; we elaborated on these results in the light of other recent studies. METHODS We compared the Southampton endoscopic series with the Lille series, reflecting our 25-year experience of stereotactic biopsies, and the metadata of the literature for both approaches, as reported in the 2013 Report of the French-Speaking Society of Neurosurgery on tumors of the pineal region. RESULTS The results of the Southampton series match the endoscopic literature, in particular regarding the diagnosis rate (81.2%) and the perioperative morbidity (25.0%), and provide a rarely reported accuracy rate (78.6%), giving access to the overall efficacy rate (63.8%). The results of the Lille series match the stereotactic literature and show better results than endoscopic biopsies concerning the diagnosis rate (98.9%), accuracy rate (100%), resulting overall efficacy rate (98.9%), and perioperative morbidity (6.4%). CONCLUSIONS The Southampton and Lille series provide a unique opportunity to compare the overall efficacy rates of endoscopic and stereotactic biopsies, respectively. The stereotactic approach is safer and more effective for biopsies of pineal region tumors. To improve the safety and reliability of endoscopic biopsies, various methods have to be evaluated: alternative burr-hole strategies, use of neuronavigation, and a combination of flexible and rigid endoscopes.
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