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Giussani C, Carrabba G, Rui CB, Chiarello G, Stefanoni G, Julita C, De Vito A, Cinalli MA, Basso G, Remida P, Citerio G, Di Cristofori A. Perilesional resection technique of glioblastoma: intraoperative ultrasound and histological findings of the resection borders in a single center experience. J Neurooncol 2023; 161:625-632. [PMID: 36690859 PMCID: PMC9992251 DOI: 10.1007/s11060-022-04232-z] [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: 07/07/2022] [Accepted: 12/29/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION The surgical goal in glioblastoma treatment is the maximal safe resection of the tumor. Currently the lack of consensus on surgical technique opens different approaches. This study describes the "perilesional technique" and its outcomes in terms of the extent of resection, progression free survival and overall survival. METHODS Patients included (n = 40) received a diagnosis of glioblastoma and underwent surgery using the perilesional dissection technique at "San Gerardo Hospital"between 2018 and 2021. The tumor core was progressively isolated using a circumferential movement, healthy brain margins were protected with Cottonoid patties in a "shingles on the roof" fashion, then the tumorwas removed en bloc. Intraoperative ultrasound (iOUS) was used and at least 1 bioptic sample of "healthy" margin of the resection was collected and analyzed. The extent of resection was quantified. Extent of surgical resection (EOR) and progression free survival (PFS)were safety endpoints of the procedure. RESULTS Thirty-four patients (85%) received a gross total resection(GTR) while 3 (7.5%) patients received a sub-total resection (STR), and 3 (7.5%) a partial resection (PR). The mean post-operative residual volume was 1.44 cm3 (range 0-15.9 cm3).During surgery, a total of 76 margins were collected: 51 (67.1%) were tumor free, 25 (32.9%) were infiltrated. The median PFS was 13.4 months, 15.3 in the GTR group and 9.6 months in the STR-PR group. CONCLUSIONS Perilesional resection is an efficient technique which aims to bring the surgeon to a safe environment, carefully reaching the "healthy" brain before removing the tumoren bloc. This technique can achieve excellent tumor margins, extent of resection, and preservation of apatient's functions.
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Affiliation(s)
- Carlo Giussani
- Department of Medicine and Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy. .,Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, MB, Italy.
| | - Giorgio Carrabba
- Department of Medicine and Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Chiara Benedetta Rui
- Department of Medicine and Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Gaia Chiarello
- Neuropathology, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, MB, 20900, Monza, Italy
| | - Giovanni Stefanoni
- Neurology, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Chiara Julita
- Radiotherapy, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Andrea De Vito
- Neuroradiology, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Maria Allegra Cinalli
- Department of Medicine and Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Gianpaolo Basso
- Department of Medicine and Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neuroradiology, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Paolo Remida
- Neuroradiology, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Giuseppe Citerio
- Department of Medicine and Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neurointensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Andrea Di Cristofori
- Department of Medicine and Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, MB, Italy
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Giambra M, Di Cristofori A, Valtorta S, Manfrellotti R, Bigiogera V, Basso G, Moresco RM, Giussani C, Bentivegna A. The peritumoral brain zone in glioblastoma: where we are and where we are going. J Neurosci Res 2023; 101:199-216. [PMID: 36300592 PMCID: PMC10091804 DOI: 10.1002/jnr.25134] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/01/2022] [Accepted: 10/01/2022] [Indexed: 12/13/2022]
Abstract
Glioblastoma (GBM) is the most aggressive and invasive primary brain tumor. Current therapies are not curative, and patients' outcomes remain poor with an overall survival of 20.9 months after surgery. The typical growing pattern of GBM develops by infiltrating the surrounding apparent normal brain tissue within which the recurrence is expected to appear in the majority of cases. Thus, in the last decades, an increased interest has developed to investigate the cellular and molecular interactions between GBM and the peritumoral brain zone (PBZ) bordering the tumor tissue. The aim of this review is to provide up-to-date knowledge about the oncogenic properties of the PBZ to highlight possible druggable targets for more effective treatment of GBM by limiting the formation of recurrence, which is almost inevitable in the majority of patients. Starting from the description of the cellular components, passing through the illustration of the molecular profiles, we finally focused on more clinical aspects, represented by imaging and radiological details. The complete picture that emerges from this review could provide new input for future investigations aimed at identifying new effective strategies to eradicate this still incurable tumor.
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Affiliation(s)
- Martina Giambra
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,PhD Program in Neuroscience, University of Milano-Bicocca, Monza, Italy
| | - Andrea Di Cristofori
- PhD Program in Neuroscience, University of Milano-Bicocca, Monza, Italy.,Division of Neurosurgery, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza, Italy
| | - Silvia Valtorta
- Department of Nuclear Medicine, San Raffaele Scientific Institute, IRCCS, Milan, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council (IBFM-CNR), Segrate, Italy.,NBFC, National Biodiversity Future Center, 90133, Palermo, Italy
| | - Roberto Manfrellotti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Division of Neurosurgery, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza, Italy
| | - Vittorio Bigiogera
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Gianpaolo Basso
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Rosa Maria Moresco
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Nuclear Medicine, San Raffaele Scientific Institute, IRCCS, Milan, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council (IBFM-CNR), Segrate, Italy
| | - Carlo Giussani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Division of Neurosurgery, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza, Italy
| | - Angela Bentivegna
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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Carrabba G, Fiore G, Di Cristofori A, Bana C, Borellini L, Zarino B, Conte G, Triulzi F, Rocca A, Giussani C, Caroli M, Locatelli M, Bertani G. Diffusion tensor imaging, intra-operative neurophysiological monitoring and small craniotomy: Results in a consecutive series of 103 gliomas. Front Oncol 2022; 12:897147. [PMID: 36176387 PMCID: PMC9513471 DOI: 10.3389/fonc.2022.897147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/14/2022] [Indexed: 11/13/2022] Open
Abstract
Diffusion tensor imaging (DTI) allows visualization of the main white matter tracts while intraoperative neurophysiological monitoring (IONM) represents the gold standard for surgical resection of gliomas. In recent years, the use of small craniotomies has gained popularity thanks to neuronavigation and to the low morbidity rates associated with shorter surgical procedures. The aim of this study was to review a series of patients operated for glioma using DTI, IONM, and tumor-targeted craniotomies. The retrospective analysis included patients with supratentorial glioma who met the following inclusion criteria: preoperative DTI, intraoperative IONM, tumor-targeted craniotomy, pre- and postoperative MRI, and complete clinical charts. The DTI was performed on a 3T scanner. The IONM included electroencephalography (EEG), transcranial (TC) and/or cortical motor-evoked potentials (MEP), electrocorticography (ECoG), and direct electrical stimulation (DES). Outcomes included postoperative neurological deficits, volumetric extent of resection (EOR), and overall survival (OS). One hundred and three patients (61 men, 42 women; mean age 54 ± 14 years) were included and presented the following WHO histologies: 65 grade IV, 19 grade III, and 19 grade II gliomas. After 3 months, only three patients had new neurological deficits. The median postoperative volume was 0cc (IQR 3). The median OS for grade IV gliomas was 15 months, while for low-grade gliomas it was not reached. In our experience, a small craniotomy and a tumor resection supported by IONM and DTI permitted to achieve satisfactory results in terms of neurological outcomes, EOR, and OS for glioma patients.
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Affiliation(s)
- Giorgio Carrabba
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
- *Correspondence: Giorgio Carrabba,
| | - Giorgio Fiore
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Andrea Di Cristofori
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
| | - Cristina Bana
- Neurophysiopathology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy
| | - Linda Borellini
- Neurophysiopathology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy
| | - Barbara Zarino
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giorgio Conte
- Neuroradiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Fabio Triulzi
- Neuroradiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Alessandra Rocca
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Carlo Giussani
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Manuela Caroli
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Marco Locatelli
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
- Department of Medical-Surgical Physiopathology and Transplantation, University of Milan, Milan, Italy
| | - Giulio Bertani
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Zhang L, Wang C, Zeng X. Risk Factors for Early Hydrocephalus on Post Unilateral Thalamic Tumor Resection. Front Surg 2022; 9:814308. [PMID: 35465419 PMCID: PMC9023863 DOI: 10.3389/fsurg.2022.814308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 03/18/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe outcome of surgical treatment for thalamic tumors is poor. Hydrocephalus is one of the most frequent postoperative complications after unilateral thalamic tumor resection. This study examined the relationship between surgical approaches, pathological grade, image characteristics, preoperative complications, extent of resection, and incidence of postoperative hydrocephalus.MethodsThe study retrospectively reviewed clinical data from 80 patients who underwent resection of thalamic tumors between 2015 and 2021. Data on patient survival and disease progression status were obtained retrospectively to calculate overall survival (OS) and progression free survival (PFS).ResultsNo patients died during the perioperative period and two patients suffered postoperative coma. Tumors were totally resected in 44 cases (55 %), subtotally resected in 21 cases (26.25 %), and partially resected in 15 cases (18.75 %). Thirty-five cases of hydrocephalus occurred within 1 month after operation(43.75%). Surgical approaches associated with hydrocephalus were as follows: hydrocephalus occurred in seven cases after trans-frontal lateral ventricle approach for tumor resection (62.9%), in 17 cases after through parieto-occipital transventricular approach tumor resection (43.58%), and in one case after trans-frontal lateral ventricle approach for tumor resection + third ventriculostomy (7.1%). Postoperative muscle strength decrease occurred in 41 patients (51.25%). Longer PFS and OS were correlated with degree of resection in patients with thalamic glioblastoma (P < 0.05) and had no relationship with hydrocephalus.ConclusionSurgical treatment of thalamic tumors is an effective therapeutic method. The incidence of postoperative hydrocephalus is not associated with tumor size, degree of tumor enhancement, peritumoral edema, tumor invasion, midline crossing, and pathological grade. The incidence of postoperative hydrocephalus was higher in patients with preoperative hydrocephalus and low resection degree, and lower in patients with endoscopic third ventriculostomy. The risk of early postoperative hydrocephalus in thalamic tumors is high. Intraoperative third ventriculostomy could reduce the incidence of early postoperative hydrocephalus. PFS and OS were longer in patients with thalamic glioblastoma with a high resection degree (P < 0.05) and were not associated with hydrocephalus.
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Affiliation(s)
- Linpeng Zhang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chen Wang
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xianwei Zeng
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- *Correspondence: Xianwei Zeng ; orcid.org/0000-0002-2501-8368
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Sihag R, Bajaj J, Yadav YR, Ratre S, Hedaoo K, Kumar A, Sinha M, Parihar V, Swamy MN. Endoscope-controlled Access to Thalamic Tumors using Tubular Brain Retractor: An Alternative Approach to Microscopic Excision. J Neurol Surg A Cent Eur Neurosurg 2021; 83:122-128. [PMID: 34144629 DOI: 10.1055/s-0041-1722966] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Surgery for thalamic lesions has been considered challenging due to their deep-seated location. Endoscopic excision of deep-seated brain tumors using tubular retractor has been shown to be safe and effective in prior studies; however, there are limited reports regarding its use for thalamic tumors. We present our experience of endoscope-controlled resection of thalamic tumors using a tubular retractor. MATERIAL AND METHODS This was a prospective observational case series done at a tertiary center specialized for endoscopic neurosurgery during the period from 2010 to 2019. Surgeries were performed under the endoscopic control using a silicon tubular retractor. Lesions were approached transcortically or trans-sulcally. Data were collected for the extent of resection, amount of blood loss, operative time, need for conversion to microscopy, and complications. RESULTS Twenty-one patients of thalamic masses of 14- to 60-year age underwent the surgeries. Pathologies ranged from grade I to IV gliomas. Gross total and near-total resection could be done in 42.85% of cases for each group. The average blood loss and operative time were164.04 ± 83.63 mL and 157.14 ± 28.70 minutes, respectively. Complications included a small brain contusion, two transient hemipareses, and one transient speech deficit. CONCLUSION Endoscopic excision of thalamic tumors using a tubular retractor was found to be a safe and effective alternative to microscopic resection.
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Affiliation(s)
- Rakesh Sihag
- Department of Neurosurgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
| | - Jitin Bajaj
- Department of Neurosurgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
| | - Yad Ram Yadav
- Department of Neurosurgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
| | - Shailendra Ratre
- Department of Neurosurgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
| | - Ketan Hedaoo
- Department of Neurosurgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
| | - Ambuj Kumar
- Department of Neurosurgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
| | - Mallika Sinha
- Department of Neurosurgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
| | - Vijay Parihar
- Department of Neurosurgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
| | - M Narayan Swamy
- Department of Neurosurgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
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Asimakidou E, Abut PA, Raabe A, Seidel K. Motor Evoked Potential Warning Criteria in Supratentorial Surgery: A Scoping Review. Cancers (Basel) 2021; 13:2803. [PMID: 34199853 PMCID: PMC8200078 DOI: 10.3390/cancers13112803] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 12/31/2022] Open
Abstract
During intraoperative monitoring of motor evoked potentials (MEP), heterogeneity across studies in terms of study populations, intraoperative settings, applied warning criteria, and outcome reporting exists. A scoping review of MEP warning criteria in supratentorial surgery was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sixty-eight studies fulfilled the eligibility criteria. The most commonly used alarm criteria were MEP signal loss, which was always a major warning sign, followed by amplitude reduction and threshold elevation. Irreversible MEP alterations were associated with a higher number of transient and persisting motor deficits compared with the reversible changes. In almost all studies, specificity and Negative Predictive Value (NPV) were high, while in most of them, sensitivity and Positive Predictive Value (PPV) were rather low or modest. Thus, the absence of an irreversible alteration may reassure the neurosurgeon that the patient will not suffer a motor deficit in the short-term and long-term follow-up. Further, MEPs perform well as surrogate markers, and reversible MEP deteriorations after successful intervention indicate motor function preservation postoperatively. However, in future studies, a consensus regarding the definitions of MEP alteration, critical duration of alterations, and outcome reporting should be determined.
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Affiliation(s)
- Evridiki Asimakidou
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Pablo Alvarez Abut
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
- Department of Neurosurgery, Clínica 25 de Mayo, 7600 Mar del Plata, Argentina
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
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Zarino B, Sirtori MA, Meschini T, Bertani GA, Caroli M, Bana C, Borellini L, Locatelli M, Carrabba G. Insular lobe surgery and cognitive impairment in gliomas operated with intraoperative neurophysiological monitoring. Acta Neurochir (Wien) 2021; 163:1279-1289. [PMID: 33236177 DOI: 10.1007/s00701-020-04643-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND For a long time, surgery of insular gliomas was considered at high risk for postoperative cognitive deficits, but recent studies highlighted the feasibility of the surgical approach. The aims of our study were to investigate the presence of language impairment before and after surgery and the relationship between language impairment and tumor volume preoperatively and extent of resection (EOR) 3 months after surgery. METHODS Thirty-five patients with insular gliomas underwent an extensive language assessment before and few days after surgery, and after 3 months. Intraoperative neurophysiological monitoring (IOM) and brain mapping with direct electrical stimulation (DES) were used in all the cases; 8 patients underwent awake craniotomy. Statistical analysis was performed on the language tests administered. RESULTS Patients with pure left insular lesion showed language impairment before and after surgery. Overall, patients with a left lesion showed a drop of performance after surgery followed by a partial recovery. Moreover, when the tumor involved the insula and adjacent networks, we observed a more severe deficit. No correlations were found between tumor volume, EOR, and language impairment. CONCLUSIONS Left insular lobe is an important hub in language networks; its involvement determines pre- and postsurgical deficits, together with the involvement of white matter connections. Tumor volume and EOR are not risk factors per se directly related to language functioning. Surgery of insular gliomas is possible with a pre- and intraoperative extensive study of the patient with IOM and awake surgery, and encouraged by the trend of cognitive recovery highlighted.
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Affiliation(s)
- Barbara Zarino
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy.
| | - Martina Andrea Sirtori
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Tommaso Meschini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulio Andrea Bertani
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy
| | - Manuela Caroli
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy
| | - Cristina Bana
- Neuropathophysilogy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Linda Borellini
- Neuropathophysilogy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Locatelli
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giorgio Carrabba
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy
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Giammattei L, Starnoni D, Benes V, Froelich S, Cossu G, Borsotti F, Májovsky M, Sufianov AA, Fava A, di Russo P, Elbabaa SK, González-López P, Messerer M, Daniel RT. Extreme Lateral Supracerebellar Infratentorial Approach: Surgical Anatomy and Review of the Literature. World Neurosurg 2021; 147:89-104. [PMID: 33333288 DOI: 10.1016/j.wneu.2020.12.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The extreme lateral supracerebellar infratentorial (ELSI) approach has the potential to access several distinct anatomical regions that are otherwise difficult to reach. We have illustrated the surgical anatomy through cadaveric dissections and provided an extensive review of the literature to highlight the versatility of this approach, its limits, and comparisons with alternative approaches. METHODS The surgical anatomy of the ELSI has been described using 1 adult-injected cadaveric head. Formalized noninjected brain specimens were also dissected to describe the brain parenchymal anatomy of the region. An extensive review of the literature was performed according to each targeted anatomical region. Illustrative cases are also presented. RESULTS The ELSI approach allows for wide exposure of the middle and posterolateral incisural spaces with direct access to centrally located intra-axial structures such as the splenium, pulvinar, brainstem, and mesial temporal lobe. In addition, for skull base extra-axial tumors such as petroclival meningiomas, the ELSI approach represents a rapid and adequate method of access without the use of extensive skull base approaches. CONCLUSIONS The ELSI approach represents one of the most versatile approaches with respect to its ability to address several anatomical regions centered at the posterior and middle incisural spaces. For intra-axial pathologies, the approach allows for access to the central core of the brain with several advantages compared with alternate approaches that frequently involve significant brain retraction and cortical incisions. In specific cases of skull base lesions, the ELSI approach is an elegant alternative to traditionally used skull base approaches, thereby avoiding approach-related morbidity.
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Affiliation(s)
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Vladimir Benes
- Department of Neurosurgery, Charles University and Military University Hospital, Prague, Czech Republic
| | | | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Francois Borsotti
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Martin Májovsky
- Department of Neurosurgery, Charles University and Military University Hospital, Prague, Czech Republic
| | - Albert A Sufianov
- Department of Neurosurgery, Federal Centre of Neurosurgery, Tyumen, Russia; Department of Neurosurgery, Sechenov University, Moscow, Russia
| | - Arianna Fava
- Department of Neurosurgery, Lariboisière Hospital, Paris, France
| | - Paolo di Russo
- Department of Neurosurgery, Lariboisière Hospital, Paris, France
| | - Samer K Elbabaa
- Department of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Pablo González-López
- Department of Neurosurgery, Hospital General Universitario de Alicante, Alicante, Spain
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland; Department of Neurosurgery, Sechenov University, Moscow, Russia; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
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Campanella R, Guarnaccia L, Caroli M, Zarino B, Carrabba G, La Verde N, Gaudino C, Rampini A, Luzzi S, Riboni L, Locatelli M, Navone SE, Marfia G. Personalized and translational approach for malignant brain tumors in the era of precision medicine: the strategic contribution of an experienced neurosurgery laboratory in a modern neurosurgery and neuro-oncology department. J Neurol Sci 2020; 417:117083. [PMID: 32784071 DOI: 10.1016/j.jns.2020.117083] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/16/2020] [Accepted: 08/04/2020] [Indexed: 12/20/2022]
Abstract
Personalized medicine (PM) aims to optimize patient management, taking into account the individual traits of each patient. The main purpose of PM is to obtain the best response, improving health care and lowering costs. Extending traditional approaches, PM introduces novel patient-specific paradigms from diagnosis to treatment, with greater precision. In neuro-oncology, the concept of PM is well established. Indeed, every neurosurgical intervention for brain tumors has always been highly personalized. In recent years, PM has been introduced in neuro-oncology also to design and prescribe specific therapies for the patient and the patient's tumor. The huge advances in basic and translational research in the fields of genetics, molecular and cellular biology, transcriptomics, proteomics, and metabolomics have led to the introduction of PM into clinical practice. The identification of a patient's individual variation map may allow to design selected therapeutic protocols that ensure successful outcomes and minimize harmful side effects. Thus, clinicians can switch from the "one-size-fits-all" approach to PM, ensuring better patient care and high safety margin. Here, we review emerging trends and the current literature about the development of PM in neuro-oncology, considering the positive impact of innovative advanced researches conducted by a neurosurgical laboratory.
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Affiliation(s)
- Rolando Campanella
- Laboratory of Experimental Neurosurgery and Cell Therapy, Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Guarnaccia
- Laboratory of Experimental Neurosurgery and Cell Therapy, Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Manuela Caroli
- Laboratory of Experimental Neurosurgery and Cell Therapy, Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Zarino
- Laboratory of Experimental Neurosurgery and Cell Therapy, Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Carrabba
- Laboratory of Experimental Neurosurgery and Cell Therapy, Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Chiara Gaudino
- Department of Neuroradiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Angela Rampini
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Laura Riboni
- Department of Medical Biotechnology and Translational Medicine, LITA-Segrate, University of Milan, Milan, Italy
| | - Marco Locatelli
- Laboratory of Experimental Neurosurgery and Cell Therapy, Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Aldo Ravelli" Research Center, Milan, Italy; Department of Medical-Surgical Physiopathology and Transplantation, University of Milan, Milan, Italy
| | - Stefania Elena Navone
- Laboratory of Experimental Neurosurgery and Cell Therapy, Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Aldo Ravelli" Research Center, Milan, Italy.
| | - Giovanni Marfia
- Laboratory of Experimental Neurosurgery and Cell Therapy, Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Aldo Ravelli" Research Center, Milan, Italy; Clinical Pathology Unit, Istituto di Medicina Aerospaziale "A. Moosso", Aeronautica Militare, Milan, Italy
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Wang T, Long Q, Gao T. Letter: Thalamic Glioblastoma: Clinical Presentation, Management Strategies, and Outcomes. Neurosurgery 2019; 84:E288. [PMID: 30770537 DOI: 10.1093/neuros/nyz009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tianwei Wang
- Department of Neurosurgery Xi'an Central Hospital Xi'an Jiaotong University School of Medicine Xi'an, Shaanxi, China
| | - Qianfa Long
- Department of Neurosurgery Xi'an Central Hospital Xi'an Jiaotong University School of Medicine Xi'an, Shaanxi, China
| | - Ting Gao
- Department of Pediatric Xi'an Jiaotong University Affiliated Children's Hospital, Xi'an Shaanxi, China
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11
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Wu B, Tang C, Wang Y, Li Z, Hu S, Hua W, Li W, Huang S, Ma J, Zhang Y. High-grade thalamic gliomas: Microsurgical treatment and prognosis analysis. J Clin Neurosci 2017; 49:56-61. [PMID: 29248381 DOI: 10.1016/j.jocn.2017.12.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 10/29/2017] [Accepted: 12/03/2017] [Indexed: 12/28/2022]
Abstract
This retrospective study is aimed to investigate the efficacy of microsurgical treatment for high-grade thalamic gliomas, and to analyze the relevant prognosis. From May 2011 to Aug 2015, 49 patients with thalamic gliomas underwent microsurgical resection, and received chemotherapy and radiotherapy postoperatively. The postoperative symptoms and complications were documented, and the overall survival (OS) and the progression-free survival (PFS) data were collected. The prognostic factors were evaluated by univariate and multivariate analyses. Finally, there was no perioperative death. Twenty cases, 24 cases and 5 cases were achieved subtotal resection (>90%), partial resection (70-90%) and less than partial resection (<70%) respectively. All patients' pathological diagnosis was confirmed. The symptoms were improved in 32 cases, unchanged in 11 cases, and worsen in 6 cases. Postoperative complications were absent in 9 cases. The 6-month, 12-month, and 24-month OS were 71.4%, 38.9%, and 12.1% respectively; corresponding PFS were 66.6%, 27.1%, and 10.2% respectively. The median OS time and PFS time were 9.0 months (95% CI 6.9-11.1) and 9.0 months (95% CI 6.6-11.4) respectively. Multivariate analysis revealed extent of resection were independent prognostic factors for OS (p < .05), patients with postoperative adjuvant chemotherapy and radiotherapy had a significant prolonged OS (p < .001) and PFS (p < .001). The study shows that the short-term efficacy of microsurgery for high-grade thalamic gliomas is satisfactory. Microsurgery can effectively alleviate patients' symptoms and improve life quality. Postoperative adjuvant chemotherapy and radiotherapy are helpful for prolonging the survival time.
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Affiliation(s)
- Biwu Wu
- Department of Neurosurgery, The 5th People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Chao Tang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yang Wang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhiqi Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Shukun Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Wei Hua
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Wengang Li
- Department of Neurosurgery, The 5th People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Shan Huang
- Department of Neurosurgery, The 5th People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Junfeng Ma
- Department of Neurosurgery, The 5th People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Yi Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
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12
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Lee RP, Foster KA, Lillard JC, Klimo P, Ellison DW, Orr B, Boop FA. Surgical and molecular considerations in the treatment of pediatric thalamopeduncular tumors. J Neurosurg Pediatr 2017; 20:247-255. [PMID: 28686121 PMCID: PMC5839469 DOI: 10.3171/2017.4.peds16668] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Thalamopeduncular tumors are a group of pediatric low-grade gliomas that arise at the interface of the thalamus and brainstem peduncle. They typically occur within the first 2 decades of life, presenting with progressive spastic hemiparesis. Treatment strategies, including surgical intervention, have varied significantly. The authors present their experience in the treatment of 13 children, ages 2-15 years, with non-neurofibromatosis-related pilocytic astrocytomas located in the thalamopeduncular region. METHODS Between 2003 and 2016, 13 children presenting with progressive spastic hemiparesis due to a pilocytic astrocytoma at the interface of the thalamus and cerebral peduncles were identified. Medical records were reviewed retrospectively for clinical, radiological, pathological, and surgical data. Formalin-fixed, paraffin-embedded tissue was obtained for 12 cases and tested for KIAA1549-BRAF fusion and BRAF V600E point mutation. RESULTS On preoperative diffusion tensor imaging tractography (performed in 12 patients), the ipsilateral corticospinal tract was displaced laterally in 1 case (8.3%), medially in 1 case (8.3%), anterolaterally in 10 cases (83%), and posteriorly in no cases. Ten patients underwent resection via a transtemporal, transchoroidal approach, which was chosen to avoid further damage to motor function in cases of tumors that caused anterolateral or medial corticospinal tract displacement. With this approach, complications included hemianopia, oculomotor palsy, and tremor at a rate of 50%. Among the 12 patients with obtainable follow-up (mean 50.9 months), none received adjuvant therapy, and only 2 (17%) experienced recurrence or progression. KIAA1549-BRAF fusions were present in 10 cases (83%), while BRAF V600E was absent (0%). The 2 fusion-negative tumors had clinical features atypical for the series, including multi-focality and infiltration. CONCLUSIONS Transcortical, transchoroidal resection of thalamopeduncular tumors through the middle temporal gyrus allows for a high rate of gross-total resection and cure. Diffuse tensor tractography is a critical component of the preoperative planning process to determine the location of white matter tracts in proximity. Molecular status may correlate with clinical features, and the presence of BRAF lesions offers an additional target for future novel therapeutics.
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Affiliation(s)
- Ryan P. Lee
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kimberly A. Foster
- Department of Neurosurgery, Le Bonheur Children’s Hospital, Memphis, Tennessee,Division of Neurosurgery, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Jock C. Lillard
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, Le Bonheur Children’s Hospital, Memphis, Tennessee,Division of Neurosurgery, St. Jude Children’s Research Hospital, Memphis, Tennessee,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
| | - David W. Ellison
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Brent Orr
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Frederick A. Boop
- Department of Neurosurgery, Le Bonheur Children’s Hospital, Memphis, Tennessee,Division of Neurosurgery, St. Jude Children’s Research Hospital, Memphis, Tennessee,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
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13
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Endoscopic management of a low-grade thalamic glioma: a safe alternative to open microsurgery? Acta Neurochir (Wien) 2017; 159:1237-1240. [PMID: 28236182 DOI: 10.1007/s00701-017-3120-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 02/15/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite considerable advances in preoperative and intraoperative imaging and neuronavigation, resection of thalamic gliomas remains challenging. Although both endoscopic biopsy and third ventriculostomy (ETV) for the treatment of secondary hydrocephalus are commonly performed, endoscopic resection of thalamic gliomas has been very sparsely described. METHOD We report and illustrate the surgical procedure and patient's outcome after full endoscopic resection of a thalamic glioma and to discuss this approach as an alternative to open microsurgery. RESULTS In 2016, a 56-year-old woman presented with disorientation, dysphasia and right facial hypaesthesia in our department. Cranial magnetic resonance imaging revealed a left thalamic lesion and subsequent hydrocephalus. Initially, hydrocephalus was treated by ETV but forceps biopsy was not diagnostic. However, metabolism in 18F-fluoroethyl-L-tyrosine positron emission tomography indicated glioma. Subsequently, endoscopic and neuronavigation-guided tumour resection was performed using a <1 cm2, trans-sulcal approach through the left posterior horn of the lateral ventricle. While visibility was poor using the intraoperative microscope, neuroendoscopy provided excellent visualisation and allowed safe tumour debulking. Neither haemorrhage from the tumour or collapse of the cavity compromised endoscopic resection. CONCLUSIONS In accordance with one previously published case of endoscopic resection of a thalamic glioma, no surgery-related complications were observed. Although this remains to be determined in larger series, endoscopic resection of these lesions might be a safe and feasible alternative to biopsy or open surgery. Future studies should also aim to identify patients specifically eligible for these approaches.
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Distant recurrences limit the survival of patients with thalamic high-grade gliomas after successful resection. Neurosurg Rev 2016; 40:469-477. [PMID: 27987035 DOI: 10.1007/s10143-016-0804-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 11/09/2016] [Accepted: 12/06/2016] [Indexed: 02/07/2023]
Abstract
The indications of surgery for thalamic high-grade gliomas are not well established. The present study investigated the outcome of 21 patients treated by surgery and reports the high incidence of distant recurrences including disseminations after successful removal. Twenty-one patients with thalamic high-grade gliomas not invading the pyramidal tract or midbrain underwent cytoreductive surgery at our institute from June 1997 to August 2015. Surgery was performed with the aid of a neuronavigation system, electrophysiological monitoring, and fluorescence navigation. Tumor histology included 12 cases of the World Health Organization grade III and nine cases of grade IV. Gross total resection was achieved in six cases, subtotal in 13, and partial in two. Motor weakness accompanied by sensory disturbance deteriorated immediately after surgery in 13 patients. However, five patients were determined to show deterioration at 2 months after surgery. Postoperative radiation and chemotherapy were given to every patient, and median progression-free survival of patients with grade III and IV tumors was 12.1 and 7.0 months, respectively. Median overall survival of patients with grade III and IV tumors was 25.6 and 12.6 months, respectively. High incidence of distant recurrences was found, with distant lesions at recurrence in 13 of 19 patients with recurrence, suggesting the life-restricting factor in these patients. Thalamic high-grade glioma without invasion into the pyramidal tract and brainstem can be considered as a candidate for surgical resection. Distant lesion limits the survival of patients after successful resection.
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