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Rechberger JS, Power EA, DeCuypere M, Daniels DJ. Evolution of neurosurgical advances and nuances in medulloblastoma therapy. Childs Nerv Syst 2024; 40:1031-1044. [PMID: 38112693 DOI: 10.1007/s00381-023-06239-x] [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: 10/07/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023]
Abstract
Medulloblastoma, the most common malignant brain tumor in children, presents a complex treatment challenge due to its propensity for infiltrative growth within the posterior fossa and its potential attachment to critical anatomical structures. Central to the management of medulloblastoma is the surgical resection of the tumor, which is a key determinant of patient prognosis. However, the extent of surgical resection (EOR), ranging from gross total resection (GTR) to subtotal resection (STR) or even biopsy, has been the subject of extensive debate and investigation within the medical community. Today, the impact of neurosurgical EOR on the prognosis of medulloblastoma patients remains a complex and evolving area of investigation. The conflicting findings in the literature, the challenges posed by critical surrounding anatomical structures, the potential for surgical complications and neurologic morbidity, and the nuanced interactions with molecular subgroups all contribute to the complexity of this issue. As the field continues to advance, the imperative to strike a delicate balance between maximizing resection and preserving quality of life remains central to the management of medulloblastoma patients.
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Affiliation(s)
- Julian S Rechberger
- Department of Neurologic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Erica A Power
- Department of Neurologic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Loyola Stritch School of Medicine, Maywood, IL, 60153, USA
| | - Michael DeCuypere
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, 55905, USA.
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Begley SL, McBriar JD, Pelcher I, Schulder M. Intraoperative MRI: A Review of Applications Across Neurosurgical Specialties. Neurosurgery 2024:00006123-990000000-01101. [PMID: 38530004 DOI: 10.1227/neu.0000000000002933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/30/2024] [Indexed: 03/27/2024] Open
Abstract
Intraoperative MRI (iMRI) made its debut to great fanfare in the mid-1990s. However, the enthusiasm for this technology with seemingly obvious benefits for neurosurgeons has waned. We review the benefits and utility of iMRI across the field of neurosurgery and present an overview of the evidence for iMRI for multiple neurosurgical disciplines: tumor, skull base, vascular, pediatric, functional, and spine. Publications on iMRI have steadily increased since 1996, plateauing with approximately 52 publications per year since 2011. Tumor surgery, especially glioma surgery, has the most evidence for the use of iMRI contributing more than 50% of all iMRI publications, with increased rates of gross total resection in both adults and children, providing a potential survival benefit. Across multiple neurosurgical disciplines, the ability to use a multitude of unique sequences (diffusion tract imaging, diffusion-weighted imaging, magnetic resonance angiography, blood oxygenation level-dependent) allows for specialization of imaging for various types of surgery. Generally, iMRI allows for consideration of anatomic changes and real-time feedback on surgical outcomes such as extent of resection and instrument (screw, lead, electrode) placement. However, implementation of iMRI is limited by cost and feasibility, including the need for installation, shielding, and compatible tools. Evidence for iMRI use varies greatly by specialty, with the most evidence for tumor, vascular, and pediatric neurosurgery. The benefits of real-time anatomic imaging, a lack of radiation, and evaluation of surgical outcomes are limited by the cost and difficulty of iMRI integration. Nonetheless, the ability to ensure patients are provided by a maximal yet safe treatment that specifically accounts for their own anatomy and highlights why iMRI is a valuable and underutilized tool across multiple neurosurgical subspecialties.
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Affiliation(s)
- Sabrina L Begley
- Department of Neurosurgery, Brain Tumor Center, Lake Success, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Joshua D McBriar
- Department of Neurosurgery, Brain Tumor Center, Lake Success, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Isabelle Pelcher
- Department of Neurosurgery, Brain Tumor Center, Lake Success, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Michael Schulder
- Department of Neurosurgery, Brain Tumor Center, Lake Success, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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Wu O, Clift GW, Hilliard S, Ip M. Evaluating the use of intraoperative magnetic resonance imaging in paediatric brain tumour resection surgeries: a literature review. J Med Radiat Sci 2023; 70:479-490. [PMID: 37434551 PMCID: PMC10715358 DOI: 10.1002/jmrs.707] [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: 10/15/2022] [Accepted: 07/02/2023] [Indexed: 07/13/2023] Open
Abstract
Brain tumours are the most common solid neoplasm in children, posing a significant challenge in oncology due to the limited range of treatment. Intraoperative magnetic resonance imaging (iMRI) has recently emerged to aid surgical intervention in neurosurgery resection with the potential to delineate tumour boundaries. This narrative literature review aimed to provide an updated evaluation of the clinical implementation of iMRI in paediatric neurosurgical resection, with an emphasis on the extent of brain tumour resection, patient outcomes and its drawbacks. Databases including MEDLINE, PubMed, Scopus and Web of Science were used to investigate this topic with key terms: paediatric, brain tumour, and iMRI. Exclusion criteria included literature comprised of adult populations and the use of iMRI in neurosurgery in the absence of brain tumours. The limited body of research evaluating the clinical implementation of iMRI in paediatric cohorts has been predominantly positive. Current evidence demonstrates the potential for iMRI use to increase rates of gross total resection (GTR), assess the extent of resection, and improve patient outcomes, such as progression-free survival. Limitations regarding the use of iMRI include prolonged operation times and complications associated with head immobilisation devices. iMRI has the potential to aid in the achievement of maximal brain tumour resection in paediatric patients. Future prospective randomised controlled trials are necessary to determine the clinical significance and benefits of using iMRI during neurosurgical resection for clinical management of brain neoplasms in children.
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Affiliation(s)
- Olivia Wu
- Discipline of Medical Radiation Sciences, Sydney School of Health SciencesThe University of SydneySydneyNew South WalesAustralia
| | - Georgina Williamson Clift
- Discipline of Medical Radiation Sciences, Sydney School of Health SciencesThe University of SydneySydneyNew South WalesAustralia
| | - Sonia Hilliard
- Discipline of Medical Radiation Sciences, Sydney School of Health SciencesThe University of SydneySydneyNew South WalesAustralia
| | - Miranda Ip
- Discipline of Medical Radiation Sciences, Sydney School of Health SciencesThe University of SydneySydneyNew South WalesAustralia
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Bsat S, Alshareef M, Pazniokas J, Handler MH. Technical evolution of pediatric neurosurgery: the evolution of intraoperative imaging. Childs Nerv Syst 2023; 39:2605-2611. [PMID: 37518061 DOI: 10.1007/s00381-023-06040-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: 06/01/2023] [Accepted: 06/17/2023] [Indexed: 08/01/2023]
Abstract
Imaging has always been fundamental to neurosurgery, and its evolution over the last century has made a dramatic transformation in the ability of neurosurgeons to define pathology and preserve normal tissue during their operations. In the mid-70 s, the development of computerized cross-sectional imaging with CT scan and subsequently MRI have revolutionized the practice of neurosurgery. Later, further advances in computer technology and medical engineering have allowed the combination of many modalities to bring them into the operating theater. This evolution has allowed real-time intraoperative imaging, in the hope of helping neurosurgeons achieve accuracy, maximal safe resection, and the implementation of minimally invasive techniques in brain and spine pathologies. Augmented reality and robotic technologies are also being applied as useful intra-operative techniques that will improve surgical planning and outcomes in the future. In this article, we will review imaging modalities and provide our institutional perspective on how we have integrated them into our practice.
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Affiliation(s)
- Shadi Bsat
- Department of Neurological Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | - Mohammed Alshareef
- Department of Neurological Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | - Julia Pazniokas
- Department of Neurological Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael H Handler
- Department of Neurological Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
- Children's Hospital Colorado, Aurora, CO, USA.
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Huisman TAGM, Patel R, Kralik S, Desai NK, Meoded A, Chen K, Weiner HL, Curry DJ, Lequin M, Kranendonk M, Orman G, Jallo G. Advances in Imaging Modalities for Pediatric Brain and Spinal Cord Tumors. Pediatr Neurosurg 2023; 58:240-258. [PMID: 37604135 DOI: 10.1159/000531998] [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: 05/20/2022] [Accepted: 07/05/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Neuroimaging has evolved from anatomical imaging toward a multi-modality comprehensive anatomical and functional imaging in the past decades, important functional data like perfusion-weighted imaging, permeability imaging, diffusion-weighted imaging (DWI), and diffusion tensor imaging (DTI), tractography, metabolic imaging, connectomics, event-related functional imaging, resting state functional imaging, and much more is now being offered. SUMMARY Precision diagnostics has proven to be essential for precision treatment. Many minimal invasive techniques have been developed, taking advantage of digital subtraction angiography and interventional neuroradiology. Furthermore, intraoperative CT and/or MRI and more recently MR-guided focused ultrasound have complemented the diagnostic and therapeutic armamentarium. KEY MESSAGES In the current manuscript, we discuss standard imaging sequences including advanced techniques like DWI, DTI, susceptibility-weighted imaging, and 1H magnetic resonance spectroscopy, various perfusion weighted imaging approaches including arterial spin labeling, dynamic contrast enhanced imaging, and dynamic susceptibility contrast imaging. Pre-, intra, and postoperative surgical imaging including visualize imaging will be discussed. The value of connectomics will be presented for its value in neuro-oncology. Minimal invasive therapeutic possibilities of interventional neuroradiology and image-guided laser ablation and MR-guided high-intensity-focused ultrasound will be presented for treatment of pediatric brain and spinal cord tumors. Finally, a comprehensive review of spinal cord tumors and matching neuropathology has been included.
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Affiliation(s)
- Thierry A G M Huisman
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Rajan Patel
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Stephen Kralik
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Nilesh K Desai
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Avner Meoded
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Karen Chen
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Howard L Weiner
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maarten Lequin
- Department of Radiology, Wilhelmina Children's Hospital and Princess Maxima Center for Pediatric Oncology University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mariette Kranendonk
- Department of Pathobiology, Princess Maxima Center for Pediatric Oncology University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gunes Orman
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA,
| | - George Jallo
- Department of Neurosurgery, Institute for Brain Protection Sciences, Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
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Frassanito P, Stifano V, Bianchi F, Tamburrini G, Massimi L. Enhancing the Reliability of Intraoperative Ultrasound in Pediatric Space-Occupying Brain Lesions. Diagnostics (Basel) 2023; 13:diagnostics13050971. [PMID: 36900115 PMCID: PMC10000977 DOI: 10.3390/diagnostics13050971] [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: 01/30/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Intraoperative ultrasound (IOUS) may aid the resection of space-occupying brain lesions, though technical limits may hinder its reliability. METHODS IOUS (MyLabTwice®, Esaote, Italy) with a microconvex probe was utilized in 45 consecutive cases of children with supratentorial space-occupying lesions aiming to localize the lesion (pre-IOUS) and evaluate the extent of resection (EOR, post-IOUS). Technical limits were carefully assessed, and strategies to enhance the reliability of real-time imaging were accordingly proposed. RESULTS Pre-IOUS allowed us to localize the lesion accurately in all of the cases (16 low-grade gliomas, 12 high-grade gliomas, eight gangliogliomas, seven dysembryoplastic neuroepithelial tumors, five cavernomas, and five other lesions, namely two focal cortical dysplasias, one meningioma, one subependymal giant cell astrocytoma, and one histiocytosis). In 10 deeply located lesions, IOUS with hyperechoic marker, eventually coupled with neuronavigation, was useful to plan the surgical route. In seven cases, the administration of contrast ensured a better definition of the vascular pattern of the tumor. Post-IOUS allowed the evaluation of EOR reliably in small lesions (<2 cm). In large lesions (>2 cm) assessing EOR is hindered by the collapsed surgical cavity, especially when the ventricular system is opened, and by artifacts that may simulate or hide residual tumors. The main strategies to overcome the former limit are inflation of the surgical cavity through pressure irrigation while insonating, and closure of the ventricular opening with Gelfoam before insonating. The strategies to overcome the latter are avoiding the use of hemostatic agents before IOUS and insonating through normal adjacent brain instead of corticotomy. These technical nuances enhanced the reliability of post-IOUS, with a total concordance to postoperative MRI. Indeed, the surgical plan was changed in about 30% of cases, as IOUS showed a residual tumor that was left behind. CONCLUSION IOUS ensures reliable real-time imaging in the surgery of space-occupying brain lesions. Limits may be overcome with technical nuances and proper training.
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Affiliation(s)
- Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Vito Stifano
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Institute of Neurosurgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-0630154587
| | - Federico Bianchi
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Institute of Neurosurgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gianpiero Tamburrini
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Institute of Neurosurgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Luca Massimi
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Institute of Neurosurgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Becerra V, Hinojosa J, Candela S, Culebras D, Alamar M, Armero G, Echaniz G, Artés D, Munuera J, Muchart J. The impact of 1.5-T intraoperative magnetic resonance imaging in pediatric tumor surgery: Safety, utility, and challenges. Front Oncol 2023; 12:1021335. [PMID: 36686826 PMCID: PMC9846736 DOI: 10.3389/fonc.2022.1021335] [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: 08/17/2022] [Accepted: 12/05/2022] [Indexed: 01/06/2023] Open
Abstract
Objective In this study, we present our experience with 1.5-T high-field intraoperative magnetic resonance imaging (ioMRI) for different neuro-oncological procedures in a pediatric population, and we discuss the safety, utility, and challenges of this intraoperative imaging technology. Methods A pediatric consecutive-case series of neuro-oncological surgeries performed between February 2020 and May 2022 was analyzed from a prospective ioMRI registry. Patients were divided into four groups according to the surgical procedure: intracranial tumors (group 1), intraspinal tumors (group 2), stereotactic biopsy for unresectable tumors (group 3), and catheter placement for cystic tumors (group 4). The goal of surgery, the volume of residual tumor, preoperative and discharge neurological status, and postoperative complications related to ioMRI were evaluated. Results A total of 146 procedures with ioMRI were performed during this period. Of these, 62 were oncology surgeries: 45 in group 1, two in group 2, 10 in group 3, and five in group 4. The mean age of our patients was 8.91 years, with the youngest being 12 months. ioMRI identified residual tumors and prompted further resection in 14% of the cases. The mean time for intraoperative image processing was 54 ± 6 min. There were no intra- or postoperative security incidents related to the use of ioMRI. The reoperation rate in the early postoperative period was 0%. Conclusion ioMRI in pediatric neuro-oncology surgery is a safe and reliable tool. Its routine use maximized the extent of tumor resection and did not result in increased neurological deficits or complications in our series. The main limitations included the need for strict safety protocols in a highly complex surgical environment as well as the inherent limitations on certain patient positions with available MR-compatible headrests.
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Affiliation(s)
- Victoria Becerra
- Department of Neurosurgery, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain,*Correspondence: Victoria Becerra,
| | - José Hinojosa
- Department of Neurosurgery, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Santiago Candela
- Department of Neurosurgery, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Diego Culebras
- Department of Neurosurgery, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Mariana Alamar
- Department of Neurosurgery, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Georgina Armero
- Department of Pediatrics, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Gastón Echaniz
- Department of Anesthesiology, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - David Artés
- Department of Anesthesiology, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Josep Munuera
- Diagnostic Imaging Department, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain,Diagnostic and Therapeutic Imaging, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Jordi Muchart
- Diagnostic Imaging Department, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain,Diagnostic and Therapeutic Imaging, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
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Jellema PEJ, Wijnen JP, De Luca A, Mutsaerts HJMM, Obdeijn IV, van Baarsen KM, Lequin MH, Hoving EW. Advanced intraoperative MRI in pediatric brain tumor surgery. Front Physiol 2023; 14:1098959. [PMID: 37123260 PMCID: PMC10134397 DOI: 10.3389/fphys.2023.1098959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction: In the pediatric brain tumor surgery setting, intraoperative MRI (ioMRI) provides "real-time" imaging, allowing for evaluation of the extent of resection and detection of complications. The use of advanced MRI sequences could potentially provide additional physiological information that may aid in the preservation of healthy brain regions. This review aims to determine the added value of advanced imaging in ioMRI for pediatric brain tumor surgery compared to conventional imaging. Methods: Our systematic literature search identified relevant articles on PubMed using keywords associated with pediatrics, ioMRI, and brain tumors. The literature search was extended using the snowball technique to gather more information on advanced MRI techniques, their technical background, their use in adult ioMRI, and their use in routine pediatric brain tumor care. Results: The available literature was sparse and demonstrated that advanced sequences were used to reconstruct fibers to prevent damage to important structures, provide information on relative cerebral blood flow or abnormal metabolites, or to indicate the onset of hemorrhage or ischemic infarcts. The explorative literature search revealed developments within each advanced MRI field, such as multi-shell diffusion MRI, arterial spin labeling, and amide-proton transfer-weighted imaging, that have been studied in adult ioMRI but have not yet been applied in pediatrics. These techniques could have the potential to provide more accurate fiber tractography, information on intraoperative cerebral perfusion, and to match gadolinium-based T1w images without using a contrast agent. Conclusion: The potential added value of advanced MRI in the intraoperative setting for pediatric brain tumors is to prevent damage to important structures, to provide additional physiological or metabolic information, or to indicate the onset of postoperative changes. Current developments within various advanced ioMRI sequences are promising with regard to providing in-depth tissue information.
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Affiliation(s)
- Pien E. J. Jellema
- Department of Pediatric Neuro-Oncology, Princess Máxima Centre for Pediatric Oncology, Utrecht, Netherlands
- Centre for Image Sciences, University Medical Centre Utrecht, Utrecht, Netherlands
- *Correspondence: Pien E. J. Jellema,
| | - Jannie P. Wijnen
- Centre for Image Sciences, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Alberto De Luca
- Centre for Image Sciences, University Medical Centre Utrecht, Utrecht, Netherlands
- Department of Neurology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Henk J. M. M. Mutsaerts
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Amsterdam Neuroscience, Brain Imaging, Amsterdam, Netherlands
| | - Iris V. Obdeijn
- Centre for Image Sciences, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Kirsten M. van Baarsen
- Department of Pediatric Neuro-Oncology, Princess Máxima Centre for Pediatric Oncology, Utrecht, Netherlands
- Department of Neurosurgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Maarten H. Lequin
- Department of Pediatric Neuro-Oncology, Princess Máxima Centre for Pediatric Oncology, Utrecht, Netherlands
- Department of Radiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Eelco W. Hoving
- Department of Pediatric Neuro-Oncology, Princess Máxima Centre for Pediatric Oncology, Utrecht, Netherlands
- Department of Neurosurgery, University Medical Centre Utrecht, Utrecht, Netherlands
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Intraoperative MRI versus intraoperative ultrasound in pediatric brain tumor surgery: is expensive better than cheap? A review of the literature. Childs Nerv Syst 2022; 38:1445-1454. [PMID: 35511271 DOI: 10.1007/s00381-022-05545-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The extent of brain tumor resection (EOR) is a fundamental prognostic factor in pediatric neuro-oncology in association with the histology. In general, resection aims at gross total resection (GTR). Intraoperative imaging like intraoperative US (iOUS) and MRI have been developed in order to find any tumoral remnant but with different costs. Aim of our work is to review the current literature in order to better understand the differences between costs and efficacy of MRI and iOUS to evaluate tumor remnants intraoperatively. METHODS We reviewed the existing literature on PubMed until 31st December 2021 including the sequential keywords "intraoperative ultrasound and pediatric brain tumors", "iUS and pediatric brain tumors", "intraoperative magnetic resonance AND pediatric brain tumors", and "intraoperative MRI AND pediatric brain tumors. RESULTS A total of 300 papers were screened through analysis of title and abstract; 254 were excluded. After selection, a total of 23 articles were used for this systematic review. Among the 929 patients described, a total of 349(38%) of the cases required an additional resection after an iMRI scan. GTR was measured on 794 patients (data of 69 patients lost), and it was achieved in 552(70%) patients. In case of iOUS, GTR was estimated in 291 out of 379 (77%) cases. This finding was confirmed at the post-operative MRI in 256(68%) cases. CONCLUSIONS The analysis of the available literature demonstrates that expensive equipment does not always mean better. In fact, for the majority of pediatric brain tumors, iOUS is comparable to iMRI in estimating the EOR.
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10
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Hamilton KM, Malcolm JG, Desai S, Reisner A, Chern JJ. The Utility of Intraoperative Magnetic Resonance Imaging in the Resection of Cerebellar Hemispheric Pilocytic Astrocytomas: A Cohort Study. Oper Neurosurg (Hagerstown) 2022; 22:187-191. [PMID: 35147577 DOI: 10.1227/ons.0000000000000112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The mainstay of treatment for cerebellar pilocytic astrocytomas in the pediatric population is surgery. The use of intraoperative magnetic resonance imaging (iMRI) as a surgical adjunct may lower the likelihood of reoperation. Studies have examined iMRI in heterogenous tumor populations, but few have looked at single pathologies. OBJECTIVE To compare iMRI vs non-iMRI for hemispheric cerebellar pilocystic astrocytomas, specifically looking at revision surgeries and residual disease in follow-up. METHODS Retrospective review of medical records for 60 sequential patients with cerebellar hemispheric pilocytic astrocytoma at a single institution was conducted. Thirty-two patients with cerebellar pilocytic astrocytoma underwent surgery without iMRI, whereas 28 patients underwent surgical resection with iMRI. All patients had at least 3-year follow-up. RESULTS There were no significant differences between the patient populations in age, tumor size, or need for cerebrospinal fluid diversion between groups. Operative time was shorter without iMRI (without iMRI 4.4 ± 1.3 hours, iMRI 6.1 ± 1.5, P = .0001). There was no significant difference in the patients who had repeat surgery within 30 days (9% without iMRI, 0% iMRI, P = .25), residual disease at 3 months (19% without iMRI, 14% iMRI, P = .78), or underwent a second resection beyond 30 days (9% without iMRI, 4% iMRI, P = .61). There were more total reoperations in the group without iMRI, although this did not reach significance (19% vs 4%, P = .11). CONCLUSION For hemispheric cerebellar pilocytic astrocytomas, iMRI tended to leave less residual and fewer reoperations; however, neither of these outcomes achieved statistical significance leaving utilization to be determined by the surgeon.
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Affiliation(s)
- Kimberly M Hamilton
- Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - James G Malcolm
- Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Sona Desai
- Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Andrew Reisner
- Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Joshua J Chern
- Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
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11
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Singh AK, Sheikh AI, Pandey TK, Chabbra DK. Congenital Mobile Atlantoaxial Dislocation with Cervicomedullary Astrocytoma in Pediatric Patient. Neurol India 2021; 69:194-197. [PMID: 33642301 DOI: 10.4103/0028-3886.310076] [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] [Indexed: 11/04/2022]
Abstract
Congenital mobile atlantoaxial dislocation with cervicomedullary astrocytoma has never been described. We present a case of a 7-year-old male child who presented to us with gradually progressive spastic quadriparesis following a fall from table. His lateral radiograph and magnetic resonance images showed mobile atlantoaxial dislocation with intramedullary heterogeneously enhancing cervicomedullary mass. The patient underwent suboccipital craniectomy with C1-4 laminectomy. Tumor was pinkish grey, tenacious with ill-defined plane and cyst at poles. C1-C2 fusion was done using C1 lateral mass and C2 pars screw and rod system with onlay bone graft. Histopathology revealed pilocytic astrocytoma. At the time of discharge, the patient showed improvement in spasticity. Postoperative lateral radiograph showed reduced atlantoaxial dislocation with stable construct.
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Affiliation(s)
- Ajay Kumar Singh
- Department of Neurosurgery, Vivekananda Polyclinic and Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India
| | - Adiba I Sheikh
- Department of Neurosurgery, Vivekananda Polyclinic and Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India
| | - Tarun Kumar Pandey
- Department of Neurosurgery, Vivekananda Polyclinic and Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India
| | - Devender Kumar Chabbra
- Department of Neurosurgery, Vivekananda Polyclinic and Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India
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12
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Comparison of intraoperative and post-operative 3-T MRI performed at 24-72 h following brain tumour resection in children. Neuroradiology 2021; 63:1367-1376. [PMID: 33629130 DOI: 10.1007/s00234-021-02671-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Intraoperative MRI (ioMRI) is a valuable tool aiding paediatric brain tumour resection. There is no published evidence comparing the effectiveness of the final intraoperative MRI and early post-operative (24-72 h) MRI as baseline scans following brain tumour resection. We aimed to evaluate whether the final ioMRI scan could serve as the post-operative baseline scan after paediatric brain tumour resections. METHODS This prospective study compared the final ioMRI scan with the immediate post-operative MRI scan performed 24-72 h post-surgery. We included 20 patients aged 6.6-21 years undergoing brain tumour resection using ioMRI and were suitable for MRI scan without general anaesthesia. The scans were independently evaluated by experienced local and external paediatric neuroradiologists. Identical sequences in the final ioMRI and the 24-72-h MRI were compared to assess the extent of resection, imaging characteristics of residual tumour, the surgical field, extent of surgically induced contrast enhancement, and diffusion abnormalities. RESULTS In 20 patients undergoing intraoperative and early post-operative MRI, there was no difference between ioMRI and 24-72-h post-op scans in identifying residual tumour. Surgically induced contrast enhancement was similar in both groups. There were more abnormalities on diffusion imaging and a greater degree of oedema around the surgical cavity on the 24-72-h scan. CONCLUSION The final 3-T ioMRI scan may be used as a baseline post-operative scan provided standard imaging guidelines are followed and is evaluated jointly by the operating neurosurgeon and neuroradiologist. Advantages of final ioMRI as a baseline scan are identified.
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13
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Eibl T, Hammer A, Yakubov E, Blechschmidt C, Kalisch A, Steiner HH. Medulloblastoma in adults - reviewing the literature from a surgeon's point of view. Aging (Albany NY) 2021; 13:3146-3160. [PMID: 33497354 PMCID: PMC7880386 DOI: 10.18632/aging.202568] [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: 08/03/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
Medulloblastoma is a common primary brain tumor in children but it is a rare cancer in adult patients. We reviewed the literature, searching PubMed for articles on this rare tumor entity, with a focus on tumor biology, advanced neurosurgical opportunities for safe tumor resection, and multimodal treatment options. Adult medulloblastoma occurs at a rate of 0.6 per one million people per year. There is a slight disparity between male and female patients, and patients with a fair skin tone are more likely to have a medulloblastoma. Patients present with cerebellar signs and signs of elevated intracranial pressure. Diagnostic efforts should consist of cerebral MRI and MRI of the spinal axis. Cerebrospinal fluid should be investigated to look for tumor dissemination. Medulloblastoma tumors can be classified as classic, desmoplastic, anaplastic, and large cell, according to the WHO tumor classification. Molecular subgroups include WNT, SHH, group 3, and group 4 tumors. Further molecular analyses suggest that there are several subgroups within the four existing subgroups, with significant differences in patient age, frequency of metastatic spread, and patient survival. As molecular markers have started to play an increasing role in determining treatment strategies and prognosis, their importance has increased rapidly. Treatment options include microsurgical tumor resection and radiotherapy and, in addition, chemotherapy that respects the tumor biology of individual patients offers targeted therapeutic approaches. For neurosurgeons, intraoperative imaging and tumor fluorescence may improve resection rates. Disseminated disease, residual tumor after surgery, lower radiation dose, and low Karnofsky performance status are all suggestive of a poor outcome. Extraneural spread occurs only in very few cases. The reported 5-year-survival rates range between 60% and 80% for all adult medulloblastoma patients.
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Affiliation(s)
- Thomas Eibl
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Alexander Hammer
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Eduard Yakubov
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Cristiane Blechschmidt
- Department of Neuropathology, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Alexander Kalisch
- Department of Oncology, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
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14
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Sotardi ST, Degnan AJ, Liu CA, Mecca PL, Serai SD, Smock RD, Victoria T, White AM. Establishing a magnetic resonance safety program. Pediatr Radiol 2021; 51:709-715. [PMID: 33871724 PMCID: PMC8054505 DOI: 10.1007/s00247-020-04910-y] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/03/2020] [Accepted: 11/09/2020] [Indexed: 11/24/2022]
Abstract
Establishing a magnetic resonance (MR) safety program is crucial to ensuring the safe MR imaging of pediatric patients. The organizational structure includes a core safety council and broader safety committee comprising all key stakeholders. These groups work in synchrony to establish a strong culture of safety; create and maintain policies and procedures; implement device regulations for entry into the MR setting; construct MR safety zones; address intraoperative MR concerns; guarantee safe scanning parameters, including complying with specific absorption rate limitations; adhere to national regulatory body guidelines; and ensure appropriate communication among all parties in the MR environment. Perspectives on the duties of the safety council members provide important insight into the organization of program oversite. Ultimately, the collective dedication and vigilance of all MR staff are crucial to the success of a safety program.
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Affiliation(s)
- Susan T. Sotardi
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Andrew J. Degnan
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Chang Amber Liu
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA USA
| | - Patricia L. Mecca
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Suraj D. Serai
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - R. Daniel Smock
- Department of Radiology, Children’s Mercy Hospital, Kansas City, MO USA
| | - Teresa Victoria
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Ammie M. White
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
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15
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Shah AS, Yahanda AT, Sylvester PT, Evans J, Dunn GP, Jensen RL, Honeycutt J, Cahill DP, Sutherland GR, Oswood M, Shah M, Abram SR, Rich KM, Dowling JL, Leuthardt EC, Dacey RG, Kim AH, Zipfel GJ, Limbrick DD, Smyth MD, Leonard J, Chicoine MR. Using Histopathology to Assess the Reliability of Intraoperative Magnetic Resonance Imaging in Guiding Additional Brain Tumor Resection: A Multicenter Study. Neurosurgery 2020; 88:E49-E59. [PMID: 32803226 DOI: 10.1093/neuros/nyaa338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 05/24/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Intraoperative magnetic resonance imaging (iMRI) is a powerful tool for guiding brain tumor resections, provided that it accurately discerns residual tumor. OBJECTIVE To use histopathology to assess how reliably iMRI may discern additional tumor for a variety of tumor types, independent of the indications for iMRI. METHODS A multicenter database was used to calculate the odds of additional resection during the same surgical session for grade I to IV gliomas and pituitary adenomas. The reliability of iMRI for identifying residual tumor was assessed using histopathology of tissue resected after iMRI. RESULTS Gliomas (904/1517 cases, 59.6%) were more likely than pituitary adenomas (176/515, 34.2%) to receive additional resection after iMRI (P < .001), but these tumors were equally likely to have additional tissue sent for histopathology (398/904, 44.4% vs 66/176, 37.5%; P = .11). Tissue samples were available for resections after iMRI for 464 cases, with 415 (89.4%) positive for tumor. Additional resections after iMRI for gliomas (361/398, 90.7%) were more likely to yield additional tumor compared to pituitary adenomas (54/66, 81.8%) (P = .03). There were no significant differences in resection after iMRI yielding histopathologically positive tumor between grade I (58/65 cases, 89.2%; referent), grade II (82/92, 89.1%) (P = .98), grade III (72/81, 88.9%) (P = .95), or grade IV gliomas (149/160, 93.1%) (P = .33). Additional resection for previously resected tumors (122/135 cases, 90.4%) was equally likely to yield histopathologically confirmed tumor compared to newly-diagnosed tumors (293/329, 89.0%) (P = .83). CONCLUSION Histopathological analysis of tissue resected after use of iMRI for grade I to IV gliomas and pituitary adenomas demonstrates that iMRI is highly reliable for identifying residual tumor.
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Affiliation(s)
- Amar S Shah
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - John Evans
- Washington University School of Medicine, St. Louis, Missouri
| | - Gavin P Dunn
- Washington University School of Medicine, St. Louis, Missouri
| | - Randy L Jensen
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | | | | | - Mark Oswood
- University of Minnesota, Minneapolis, Minnesota.,Allina Health, Minneapolis, Minnesota
| | - Mitesh Shah
- Goodman Campbell and Indiana University, Indianapolis, Indiana
| | | | - Keith M Rich
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Ralph G Dacey
- Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Matthew D Smyth
- Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey Leonard
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
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16
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Wach J, Banat M, Borger V, Vatter H, Haberl H, Sarikaya-Seiwert S. Intraoperative MRI-guided Resection in Pediatric Brain Tumor Surgery: A Meta-analysis of Extent of Resection and Safety Outcomes. J Neurol Surg A Cent Eur Neurosurg 2020; 82:64-74. [PMID: 32968998 DOI: 10.1055/s-0040-1714413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The objective of this meta-analysis was to analyze the impact of intraoperative magnetic resonance imaging (iMRI) on pediatric brain tumor surgery with regard to the frequency of histopathologic entities, additional resections secondary to iMRI, rate of gross total resections (GTR) in glioma surgery, extent of resection (EoR) in supra- and infratentorial compartment, surgical site infections (SSIs), and neurologic outcome after surgery. METHODS MEDLINE/PubMed Service was searched for the terms "intraoperative MRI," "pediatric," "brain," "tumor," "glioma," and "surgery." The review produced 126 potential publications; 11 fulfilled the inclusion criteria, including 584 patients treated with iMRI-guided resections. Studies reporting about patients <18 years, setup of iMRI, surgical workflow, and extent of resection of iMRI-guided glioma resections were included. RESULTS IMRI-guided surgery is mainly used for pediatric low-grade gliomas. The mean rate of GTR in low- and high-grade gliomas was 78.5% (207/254; 95% confidence interval [CI]: 64.6-89.7, p < 0.001). The mean rate of GTR in iMRI-assisted low-grade glioma surgery was 74.3% (35/47; 95% CI: 61.1-85.5, p = 0.759). The rate of SSI in surgery assisted by iMRI was 1.6% (6/482; 95% CI: 0.7-2.9). New onset of transient postoperative neurologic deficits were observed in 37 (33.0%) of 112 patients. CONCLUSION IMRI-guided surgery seems to improve the EoR in pediatric glioma surgery. The rate of SSI and the frequency of new neurologic deficits after IMRI-guided surgery are within the normal range of pediatric neuro-oncologic surgery.
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Affiliation(s)
- Johannes Wach
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Mohammad Banat
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Hannes Haberl
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
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17
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Yahanda AT, Patel B, Shah AS, Cahill DP, Sutherland G, Honeycutt J, Jensen RL, Rich KM, Dowling JL, Limbrick DD, Dacey RG, Kim AH, Leuthardt EC, Dunn GP, Zipfel GJ, Leonard JR, Smyth MD, Shah MV, Abram SR, Evans J, Chicoine MR. Impact of Intraoperative Magnetic Resonance Imaging and Other Factors on Surgical Outcomes for Newly Diagnosed Grade II Astrocytomas and Oligodendrogliomas: A Multicenter Study. Neurosurgery 2020; 88:63-73. [DOI: 10.1093/neuros/nyaa320] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/24/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Few studies use large, multi-institutional patient cohorts to examine the role of intraoperative magnetic resonance imaging (iMRI) in the resection of grade II gliomas.
OBJECTIVE
To assess the impact of iMRI and other factors on overall survival (OS) and progression-free survival (PFS) for newly diagnosed grade II astrocytomas and oligodendrogliomas.
METHODS
Retrospective analyses of a multicenter database assessed the impact of patient-, treatment-, and tumor-related factors on OS and PFS.
RESULTS
A total of 232 resections (112 astrocytomas and 120 oligodendrogliomas) were analyzed. Oligodendrogliomas had longer OS (P < .001) and PFS (P = .01) than astrocytomas. Multivariate analyses demonstrated improved OS for gross total resection (GTR) vs subtotal resection (STR; P = .006, hazard ratio [HR]: .23) and near total resection (NTR; P = .02, HR: .64). GTR vs STR (P = .02, HR: .54), GTR vs NTR (P = .04, HR: .49), and iMRI use (P = .02, HR: .54) were associated with longer PFS. Frontal (P = .048, HR: 2.11) and occipital/parietal (P = .003, HR: 3.59) locations were associated with shorter PFS (vs temporal). Kaplan-Meier analyses showed longer OS with increasing extent of surgical resection (EOR) (P = .03) and 1p/19q gene deletions (P = .02). PFS improved with increasing EOR (P = .01), GTR vs NTR (P = .02), and resections above STR (P = .04). Factors influencing adjuvant treatment (35.3% of patients) included age (P = .002, odds ratio [OR]: 1.04) and EOR (P = .003, OR: .39) but not glioma subtype or location. Additional tumor resection after iMRI was performed in 105/159 (66%) iMRI cases, yielding GTR in 54.5% of these instances.
CONCLUSION
EOR is a major determinant of OS and PFS for patients with grade II astrocytomas and oligodendrogliomas. Intraoperative MRI may improve EOR and was associated with increased PFS.
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Affiliation(s)
- Alexander T Yahanda
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Bhuvic Patel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Amar S Shah
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel P Cahill
- Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Garnette Sutherland
- Department of Neurological Surgery, University of Calgary School of Medicine, Calgary, Canada
| | - John Honeycutt
- Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas
| | - Randy L Jensen
- Department of Neurological Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Joshua L Dowling
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - David D Limbrick
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gavin P Dunn
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Jeffrey R Leonard
- Department of Neurological Surgery, Ohio State University College of Medicine, Columbus, Ohio
| | - Matthew D Smyth
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Mitesh V Shah
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Steven R Abram
- Department of Neurological Surgery, St. Thomas Hospital, Nashville, Tennessee
| | - John Evans
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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18
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Lahiff MN, Ghali MGZ. The Ethical Dilemma in the Surgical Management of Low Grade Gliomas According to the Variable Availability of Resources and Surgeon Experience. Asian J Neurosurg 2020; 15:266-271. [PMID: 32656117 PMCID: PMC7335147 DOI: 10.4103/ajns.ajns_296_19] [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: 09/26/2019] [Accepted: 12/20/2019] [Indexed: 11/04/2022] Open
Abstract
Low grade gliomas (LGGs) affect young individuals in the prime of life. Management may alternatively include biopsy and observation or surgical resection. Recent evidence strongly favors maximal and supramaximal resection of LGGs in optimizing survival metrics. Awake craniotomy with cortical mapping and electrical stimulation along with other preoperative and intraoperative surgical adjuncts, including intraoperative magnetic resonance and diffusion tensor imaging, facilitates maximization of resection and eschews precipitating neurological deficits. Intraoperative imaging permits additional resection of identified residual to be completed within the same surgical session, improving extent of resection and consequently progression free and overall survival. These resources are available in only a few centers throughout the United States, raising an ethical dilemma as to where patients harboring LGGs should most appropriately be treated.
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Affiliation(s)
- Marshall Norman Lahiff
- School of Law, University of Miami, Miami, Florida, USA.,Walton Lantaff Schoreder and Carson LLP, Miami, Florida, USA
| | - Michael George Zaki Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, Philadelphia, Pennsylvania, USA.,Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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19
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Eight-Year Experience With 3-T Intraoperative MRI Integration in Focal Pediatric Epilepsy Surgery: Impact on Extent of Resection, Residual Volumes, and Seizure Outcomes. AJR Am J Roentgenol 2020; 214:1343-1351. [DOI: 10.2214/ajr.19.22336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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20
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Multani KM, Balasubramaniam A, Rajesh BJ, Kumar MS, Manohara N, Kumar A. Utility and pitfalls of high field 3 tesla intraoperative MRI in neurosurgery: A single centre experience of 100 cases. Neurol India 2020; 68:413-418. [PMID: 32415017 DOI: 10.4103/0028-3886.284359] [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] [Indexed: 11/04/2022]
Abstract
Objective In India, few centers are using 1.5 Tesla intraoperative MRI systems. We are using a 3 Tesla iMRI system. We share our initial experience of 3T iMRI in neurosurgical procedures with evaluation of its utility and pitfalls. Methods A prospective observational study conducted between August 2017 to July 2018 at Yashoda Hospital, Secunderabad. All patients undergoing iMRI guided resection of intracranial SOL were included. Results First 100 patients with various intracranial SOLs were included. The mean time required in shifting and image acquisition was 85.6 minutes in first 20 cases which was reduced to 37.4 minutes in next the next cases. Primary GTR was achieved in 44% cases, and residues were detected in 56%, secondary GTR was achieved in 37% cases, and surgery was discontinued in 19%. Maximum residues were detected in intraaxial sols and pituitary macroadenomas. No major iMRI associated complications were seen, minor issues involving transportation and minor contact burns were seen in 4 cases, insignificant anesthetic procedure related complications in 19 cases. Conclusion As per our experience iMRI is an excellent tool to guide and improve the extent of safe resection by 37% in brain tumor surgeries. Good image quality, less time for image acquisition was observed advantages of 3T system. iMRI success depends on multidepartment coordinated teamwork and multiple iterations of the process to smoothen the workflow.
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Affiliation(s)
- Kartik Manoj Multani
- Department of Neurosurgery, Yashoda Superspeciality Hospital, Secunderabad, Telangana, India
| | - Anandh Balasubramaniam
- Department of Neurosurgery, Yashoda Superspeciality Hospital, Secunderabad, Telangana, India
| | | | - Maila Sharath Kumar
- Department of Neurosurgery, Yashoda Superspeciality Hospital, Secunderabad, Telangana, India
| | - Nitin Manohara
- Department of Neuroanesthesia, Yashoda Superspeciality Hospital, Secunderabad, Telangana, India
| | - Anjani Kumar
- Department of Radiodiagnosis, Yashoda Superspeciality Hospital, Secunderabad, Telangana, India
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21
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A Multi-Institutional Analysis of Factors Influencing Surgical Outcomes for Patients with Newly Diagnosed Grade I Gliomas. World Neurosurg 2019; 135:e754-e764. [PMID: 31901497 DOI: 10.1016/j.wneu.2019.12.156] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 12/25/2019] [Accepted: 12/26/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the impact of intraoperative magnetic resonance imaging (iMRI), extent of resection (EOR), and other factors on overall survival (OS) and progression-free survival (PFS) for patients with newly diagnosed grade I gliomas. METHODS A multicenter database was queried to identify patients with grade I gliomas. Retrospective analyses assessed the impact of patient, treatment, and tumor characteristics on OS and PFS. RESULTS A total of 284 patients underwent treatment for grade I gliomas, including 248 resections (205 with iMRI, 43 without), 23 biopsies, and 13 laser interstitial thermal therapy treatments. Log-rank analyses of Kaplan-Meier plots showed improved 5-year OS (P = 0.0107) and PFS (P = 0.0009) with increasing EOR, and a trend toward improved 5-year OS for patients with lower American Society of Anesthesiologists score (P = 0.0528). Greater EOR was associated with significantly increased 5-year PFS for pilocytic astrocytoma (P < 0.0001), but not for ganglioglioma (P = 0.10) or dysembryoplastic neuroepithelial tumor (P = 0.57). Temporal tumors (P = 0.04) and location of "other" (P = 0.04) were associated with improved PFS, and occipital/parietal tumors (P = 0.02) were associated with decreased PFS compared with all other locations. Additional tumor resection was performed after iMRI in 49.7% of cases using iMRI, which produced gross total resection in 64% of these additional resection cases. CONCLUSIONS Patients with grade I gliomas have extended OS and PFS, which correlates positively with increasing EOR, especially for patients with pilocytic astrocytoma. iMRI may increase EOR, indicated by the rate of gross total resection after iMRI use but was not independently associated with increased OS or PFS.
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22
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Low SYY, Lim EHL, Loh LE, Mok YH, Siow YN, Ng LP, Seow WT, Kirollos RW, Low DCY. Use of an Offsite Intraoperative MRI Operating Theater for Pediatric Brain Tumor Surgery: Experience from a Singapore Children's Hospital. World Neurosurg 2019; 135:e28-e35. [PMID: 31655229 DOI: 10.1016/j.wneu.2019.10.083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Intraoperative magnetic resonance imaging (iMRI) has been recognized as a useful adjunct for brain tumor surgery in pediatric patients. There is minimal data on the use of an offsite intraoperative magnetic resonance imaging operating theater (iMRI OT), whereby vehicle transfer of patients is involved. The primary aim of this study is to validate the feasibility of perioperative patient transfer to use an offsite iMRI OT for patients with pediatric brain tumor. Secondary objectives include the assessment of tumor resection efficacy and perioperative outcomes in our patient cohort. METHODS This is a retrospective, single-institution clinical study of prospectively collected data from Singapore's largest children hospital. Variables of interest include issues encountered during interhospital transfer, achievement of surgical aims, length of stay in hospital, and postoperative complications. Our findings were compared with results of related studies published in the literature. RESULTS From January 1, 2009 to December 31, 2018, a total of 35 pediatric operative cases were performed in our offsite iMRI OT. Within this cohort, 24 of these were brain tumor surgery cases. For all the patients in this study, use of the iMRI OT influenced intraoperative decisions. Average ambulance transport time from parent hospital to the iMRI OT was 30.5 minutes, and from iMRI OT back to the parent hospital after surgery was 27.7 minutes. The average length of hospitalization stay was 7.9 days per patient. There were no ferromagnetic accidents during perioperative iMRI scanning and no airway/hemodynamic incidents in patients encountered during interhospital transfer. CONCLUSIONS In our local context, the use of interhospital transfers for access to iMRI OT is a safe and feasible option in ensuring good patient outcomes for a select group of patients with pediatric brain tumors.
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Affiliation(s)
- Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore.
| | - Evangeline H L Lim
- Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Lik Eng Loh
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Yew Nam Siow
- Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore
| | - Ramez W Kirollos
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore
| | - David C Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore
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Day EL, Scott RM. The utility of intraoperative MRI during pediatric brain tumor surgery: a single-surgeon case series. J Neurosurg Pediatr 2019; 24:577-583. [PMID: 31443079 DOI: 10.3171/2019.6.peds1998] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to evaluate the utility of intraoperative MRI (ioMRI) during brain tumor excision in pediatric patients and to suggest guidelines for its future use. METHODS All patients who underwent brain tumor surgery by the senior author at Boston Children's Hospital using ioMRI between 2005 and 2009 were included in this retrospective review of hospital records and the neurosurgeon's operative database. Prior to the review, the authors defined the utility of ioMRI into useful and not useful categories based on how the technology affected operative management. They determined that ioMRI was useful if it 1) effectively guided the extent of resection; 2) provided a baseline postoperative scan during the same anesthesia session; or 3) demonstrated or helped to prevent an intraoperative complication. The authors determined that ioMRI was not useful if 1) the anatomical location of the tumor had precluded a tumor's total resection, even though the surgeon had employed ioMRI for that purpose; 2) the tumor's imaging characteristics prevented an accurate assessment of resection during intraoperative imaging; 3) the surgeon deemed the technology not required for tumor resection; or 4) the intraoperative MR images were uninterpretable for technical reasons. Follow-up data provided another gauge of the long-term benefit of ioMRI to the patient. RESULTS A total of 53 brain tumor patients were operated on using ioMRI, 6 of whom had a second ioMRI procedure during the study period. Twenty-six patients were female, and 27 were male. The mean follow-up was 4.8 ± 3.85 years (range 0-12 years). By the criteria outlined above, ioMRI technology was useful in 38 (64.4%) of the 59 cases, most frequently for its help in assessing extent of resection. CONCLUSIONS Intraoperative MRI technology was useful in the majority of brain tumor resections in this series, especially in those tumors that were contrast enhancing and located largely within accessible areas of the brain. The percentage of patients for whom ioMRI is useful could be increased by preoperatively evaluating the tumor's imaging characteristics to determine if ioMRI would accurately assess the extent of tumor resection, and by the surgeon's preoperative understanding that use of the ioMRI will not lead to resection of an anatomically unresectable tumor. The ioMRI can prove useful in unresectable tumors if specific operative goals are defined preoperatively.
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Abstract
PURPOSE OF REVIEW This review discusses the evidence base behind current and emerging strategies of management of intracranial and spinal ependymomas in children, with a particular focus on aspects of surgical techniques, challenges and complications. RECENT FINDINGS The cornerstone of management remains maximal safe resective surgery, which has repeatedly been shown to correlate with improved survival. This is followed by focal conformal radiotherapy, although good results using proton beam therapy, with the potential for diminished side effects, are emerging. The role of chemotherapy remains largely unproven for paediatric ependymoma. Despite optimal management strategies, many children with ependymoma suffer from tumour recurrence. The standard of care for paediatric ependymoma comprises surgery and radiotherapy. Results of ongoing clinical trials will help shape its management in order to leverage our increasingly sophisticated understanding of the genetic drivers behind these tumours into survival benefit for this challenging group of patients.
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Affiliation(s)
- Sebastian M Toescu
- Developmental Imaging and Biophysics Section, UCL-GOS Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.,Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.
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25
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Karsy M, Akbari SH, Limbrick D, Leuthardt EC, Evans J, Smyth MD, Strahle J, Leonard J, Cheshier S, Brockmeyer DL, Bollo RJ, Kestle JR, Honeycutt J, Donahue DJ, Roberts RA, Hansen DR, Riva-Cambrin J, Sutherland G, Gallagher C, Hader W, Starreveld Y, Hamilton M, Duhaime AC, Jensen RL, Chicoine MR. Evaluation of pediatric glioma outcomes using intraoperative MRI: a multicenter cohort study. J Neurooncol 2019; 143:271-280. [PMID: 30977059 DOI: 10.1007/s11060-019-03154-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/19/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The use of intraoperative MRI (iMRI) during treatment of gliomas may increase extent of resection (EOR), decrease need for early reoperation, and increase progression-free and overall survival, but has not been fully validated, particularly in the pediatric population. OBJECTIVE To assess the accuracy of iMRI to identify residual tumor in pediatric patients with glioma and determine the effect of iMRI on decisions for resection, complication rates, and other outcomes. METHODS We retrospectively analyzed a multicenter database of pediatric patients (age ≤ 18 years) who underwent resection of pathologically confirmed gliomas. RESULTS We identified 314 patients (mean age 9.7 ± 4.6 years) with mean follow-up of 48.3 ± 33.6 months (range 0.03-182.07 months) who underwent surgery with iMRI. There were 201 (64.0%) WHO grade I tumors, 57 (18.2%) grade II, 24 (7.6%) grade III, 9 (2.9%) grade IV, and 23 (7.3%) not classified. Among 280 patients who underwent resection using iMRI, 131 (46.8%) had some residual tumor and underwent additional resection after the first iMRI. Of the 33 tissue specimens sent for pathological analysis after iMRI, 29 (87.9%) showed positive tumor pathology. Gross total resection was identified in 156 patients (55.7%), but this was limited by 69 (24.6%) patients with unknown EOR. CONCLUSIONS Analysis of the largest multicenter database of pediatric gliomas resected using iMRI demonstrated additional tumor resection in a substantial portion of cases. However, determining the impact of iMRI on EOR and outcomes remains challenging because iMRI use varies among providers nationally. Continued refinement of iMRI techniques for use in pediatric patients with glioma may improve outcomes.
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Affiliation(s)
- Michael Karsy
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - S Hassan Akbari
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - David Limbrick
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - John Evans
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew D Smyth
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jennifer Strahle
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey Leonard
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Samuel Cheshier
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | | | - Robert J Bollo
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - John R Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - John Honeycutt
- Department of Neurosurgery, Cook Children's Neurosciences, Forth Worth, TX, USA
| | - David J Donahue
- Department of Neurosurgery, Cook Children's Neurosciences, Forth Worth, TX, USA
| | - Richard A Roberts
- Department of Neurosurgery, Cook Children's Neurosciences, Forth Worth, TX, USA
| | - Daniel R Hansen
- Department of Neurosurgery, Cook Children's Neurosciences, Forth Worth, TX, USA
| | - Jay Riva-Cambrin
- Department of Neurosurgery, University of Calgary, Calgary, AB, Canada
| | | | - Clair Gallagher
- Department of Neurosurgery, University of Calgary, Calgary, AB, Canada
| | - Walter Hader
- Department of Neurosurgery, University of Calgary, Calgary, AB, Canada
| | - Yves Starreveld
- Department of Neurosurgery, University of Calgary, Calgary, AB, Canada
| | - Mark Hamilton
- Department of Neurosurgery, University of Calgary, Calgary, AB, Canada
| | - Ann-Christine Duhaime
- Department of Neurosurgery, Massachusetts General Hospital for Children, Boston, MA, USA
| | - Randy L Jensen
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA. .,Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
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Schroeck H, Welch TL, Rovner MS, Johnson HA, Schroeck FR. Anesthetic challenges and outcomes for procedures in the intraoperative magnetic resonance imaging suite: A systematic review. J Clin Anesth 2018; 54:89-101. [PMID: 30415150 DOI: 10.1016/j.jclinane.2018.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 09/28/2018] [Accepted: 10/28/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Hybrid operating room suites with intraoperative magnetic resonance imaging enable image guided surgery in a fully functional operating room environment. While this environment creates challenges to anesthetic care, the effects on anesthetic adverse events and outcomes are largely unknown. This systematic scoping review aims to map the existing knowledge about anesthetic care in advanced imaging hybrid operating rooms. METHODS A broad-based literature search was performed using the PubMed (Medline), Embase, Cochrane Library, Web of Science, and Google Scholar databases. References published in English between January 1994 and August 2017 were included. Quality of evidence was assessed using the GRADE guidelines. RESULTS Forty-seven manuscripts were eligible for data collection. Adverse events were heterogeneously defined across 17 manuscripts and occurred in 0 to 100% (quality of evidence mostly very low). Monitoring difficulty was reported in 4 manuscripts of very low data quality. Interference between the magnet and the electrocardiogram was investigated in 2 manuscripts (quality of evidence low and very low, respectively). None of the reported events appeared to result in long-term patient harm. Author recommendations or a narrative review of the literature were provided in 40 manuscripts. Common safety concerns included lower equipment reliability, inaccessibility of the patient and airway, and the relative isolation of the suite (in relationship to other anesthesia care areas). Most authors also emphasized the importance of safety checklists, protocols, and provider training. DISCUSSION While intraoperative magnetic resonance imaging hybrid operating rooms are increasingly utilized, the existing literature does not allow estimating adverse event rates in this location. Prospective studies quantifying the effect of the environment on anesthesia outcomes are lacking. Despite this, there is a broad consensus regarding the anesthetic and safety concerns. More research is needed to inform practice standards and training requirements for this challenging environment.
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Affiliation(s)
- Hedwig Schroeck
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, USA; Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Tasha L Welch
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Michelle S Rovner
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, 165 Ashley Avenue, Suite 525CH, Charleston, SC 29425, USA.
| | - Heather A Johnson
- Biomedical Libraries, Dartmouth College, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Florian R Schroeck
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, USA; White River Junction VA Medical Center, 215 N Main Street, White River Junction, VT 05009, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, USA.
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Ross WA, Hill WM, Hoang KB, Laarakker AS, Mann BP, Codd PJ. Automating neurosurgical tumor resection surgery: Volumetric laser ablation of cadaveric porcine brain with integrated surface mapping. Lasers Surg Med 2018; 50:1017-1024. [DOI: 10.1002/lsm.23000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Weston A. Ross
- Department of Mechanical Engineering and Materials Science; Duke University; Durham North Carolina
| | - Westin M. Hill
- Department of Mechanical Engineering and Materials Science; Duke University; Durham North Carolina
| | - Kimberly B. Hoang
- Department of Neurosurgery; University of Colorado Denver; Aurora Colorado
| | - Avra S. Laarakker
- Department of Neurosurgery; University of Colorado Denver; Aurora Colorado
| | - Brian P. Mann
- Department of Mechanical Engineering and Materials Science; Duke University; Durham North Carolina
| | - Patrick J. Codd
- Department of Neurosurgery; Duke University School of Medicine; Durham North Carolina
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Parikh KA, Venable GT, Orr BA, Choudhri AF, Boop FA, Gajjar AJ, Klimo P. Pineoblastoma-The Experience at St. Jude Children's Research Hospital. Neurosurgery 2018; 81:120-128. [PMID: 28327927 DOI: 10.1093/neuros/nyx005] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 01/20/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Pineoblastomas are rare, supratentorial, primitive neuroectodermal tumors. OBJECTIVE To document outcomes with multimodal therapy and evaluate the impact that the degree of surgical resection has on outcome. METHODS A departmental brain tumor database was queried to identify all patients with pathologically proven pineoblastoma who were treated from January 1997 to June 2015 at St. Jude Children's Research Hospital. For each patient, we recorded demographic, pathological, radiological, surgical, and clinical follow-up data. The effect of degree of surgical resection on survival outcomes was analyzed. RESULTS Forty-one patients (21 male, 20 female) treated for pineoblastoma were identified. The median age at diagnosis was 5.5 years (range 0.4-28.1) and the median follow-up was 34.5 months. Nineteen patients experienced tumor relapse with a median progression-free survival of 11.3 months, and 18 ultimately succumbed to their disease. Patients who died or experienced treatment failure were younger (median, 2.69 vs 6.5 years, P = .026) and more likely to have metastatic disease at diagnosis (12 [63.2%] vs 5 [22.7%], P = .012). When analyzing only patients 5 years of age or older with focal disease at presentation, those who had a gross total resection or near-total resection-compared with subtotal resection or biopsy-had greater overall survival (75.18 vs 48.57 months), with no patients dying as a result of their cancer. CONCLUSION Poor prognostic variables for children with pineoblastoma include young age, metastatic disease at presentation, and tumor relapse. For patients older than 5 years with focal disease, maximal tumor resection should be the goal.
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Affiliation(s)
- Kara A Parikh
- School of Medicine, Louisiana State University Health Science Center, New Orleans, Louisiana.,Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Garrett T Venable
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Brent A Orr
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Asim F Choudhri
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.,Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Frederick A Boop
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.,Semmes Murphey Clinic, Memphis, Tennessee
| | - Amar J Gajjar
- Department of Oncology, Division of NeuroOncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.,Semmes Murphey Clinic, Memphis, Tennessee
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Tejada S, Avula S, Pettorini B, Henningan D, Abernethy L, Mallucci C. The impact of intraoperative magnetic resonance in routine pediatric neurosurgical practice-a 6-year appraisal. Childs Nerv Syst 2018; 34:617-626. [PMID: 29460065 DOI: 10.1007/s00381-018-3751-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 02/04/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND The intraoperative magnetic resonance scanner (ioMR) was introduced in our unit in 2009, and has been used routinely since then. OBJECTIVE This study aims to describe indications, radiological features, and clinical outcomes of the patients operated on with ioMRI and analyze our experience. METHODS A retrospective analysis of a prospective surgical database has been performed, including surgical procedure, intent, radiological reports, need for second-look surgery, and complications, supplemented by further review of the clinical notes and the scans. RESULTS From 2009 to 2015, 255 surgical procedures with ioMR were performed: 175 were craniotomies for tumor excision, 65 were epilepsy related, and 15 were biopsies or cyst drainages. The mean age was 9.4 years. One ioMR was performed in 79.5% patients; the mean duration of the MR was 41 min. In 172 cases (67.4%), no actions followed the ioMR. When the aim of the surgery was debulking of the tumor, the percentage of patients in which the ioMR was followed by resection was higher than when complete resection was the aim (56 vs 27.5%). The complication rate was not increased when compared with our previous results (infection 1%, neurological deficits 12%). CONCLUSION This is the largest published series of ioMRI-aided pediatric neurosurgery to date. We have demonstrated that it can be used safely and routinely in pediatric neurosurgical procedures at any age, assisting the surgeon in achieving the best extent of resection and aiding in intra-operative decision-making for tumor- and non-tumor-related intracranial pathology.
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Affiliation(s)
- Sonia Tejada
- Department of Neurosurgery, Clínica Universidad de Navarra, Calle Pio XII, 36, 31008, Pamplona, Spain.
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation, Liverpool, UK
| | - Benedetta Pettorini
- Department of Neurosurgery, Alder Hey Children's NHS Foundation, Liverpool, UK
| | - Dawn Henningan
- Department of Neurosurgery, Alder Hey Children's NHS Foundation, Liverpool, UK
| | - Laurence Abernethy
- Department of Radiology, Alder Hey Children's NHS Foundation, Liverpool, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children's NHS Foundation, Liverpool, UK
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30
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Intraoperative 3 tesla magnetic resonance imaging: Our experience in tumors. RADIOLOGIA 2018. [DOI: 10.1016/j.rxeng.2018.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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31
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García-Baizán A, Tomás-Biosca A, Bartolomé Leal P, Domínguez P, García de Eulate Ruiz R, Tejada S, Zubieta J. Resonancia magnética intraoperatoria de 3 teslas: Nuestra experiencia en patología tumoral. RADIOLOGIA 2018; 60:136-142. [DOI: 10.1016/j.rx.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 11/01/2017] [Accepted: 12/03/2017] [Indexed: 10/18/2022]
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32
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Choudhri AF, Siddiqui A, Klimo P. Pediatric Cerebellar Tumors: Emerging Imaging Techniques and Advances in Understanding of Genetic Features. Magn Reson Imaging Clin N Am 2017; 24:811-821. [PMID: 27742118 DOI: 10.1016/j.mric.2016.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cerebellar tumors are the most common group of solid tumors in children. MR imaging provides an important role in characterization of these lesions, surgical planning, and postsurgical surveillance. Preoperative imaging can help predict the histologic subtype of tumors, which can provide guidance for surgical planning. Beyond histology, pediatric brain tumors are undergoing new classification schemes based on genetic features. Intraoperative MR imaging has emerged as an important tool in the surgical management of pediatric brain tumors. Effective understanding of the imaging features of pediatric cerebellar tumors can benefit communication with neurosurgeons and neuro-oncologists and can improve patient management.
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Affiliation(s)
- Asim F Choudhri
- Department of Radiology, University of Tennessee Health Science Center, 848 Adams Ave, Memphis, TN 38103, USA; Department of Neurosurgery, University of Tennessee Health Science Center, 847 Monroe Avenue, Memphis, TN 38163, USA; Department of Ophthalmology, University of Tennessee Health Science Center, 930 Madison Avenue, Memphis, TN 38163, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA.
| | - Adeel Siddiqui
- Department of Radiology, University of Tennessee Health Science Center, 848 Adams Ave, Memphis, TN 38103, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, 847 Monroe Avenue, Memphis, TN 38163, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA; Division of Neurosurgery, St. Jude's Children's Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA; Semmes Murphey Neurologic & Spine Institute, 6325 Humphreys Boulevard, Memphis, TN 38120, USA
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Giordano M, Samii A, Lawson McLean AC, Bertalanffy H, Fahlbusch R, Samii M, Di Rocco C. Intraoperative magnetic resonance imaging in pediatric neurosurgery: safety and utility. J Neurosurg Pediatr 2017; 19:77-84. [PMID: 27791707 DOI: 10.3171/2016.8.peds15708] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of high-field intraoperative MRI has been largely studied for the treatment of intracranial tumors in adult patients. In this study, the authors investigated the safety, advantages, and limitations of high-field iMRI for cranial neurosurgical procedures in pediatric patients, with particular attention to craniopharyngiomas and gliomas. METHODS The authors performed 82 surgical procedures in patients under 16 years of age (range 0.8-15 years) over an 8-year period (2007-2014) using iMRI. The population was divided into 3 groups based on the condition treated: sellar region tumors (Group 1), gliomas (Group 2), and other pathological entities (Group 3). The patients' pre- and postoperative neurological status, the presence of residual tumor, the number of intraoperative scans, and complications were evaluated. RESULTS In Group 1, gross-total resection (GTR) was performed in 22 (88%) of the procedures and subtotal resection (STR) in 3 (12%). In Group 2, GTR, STR, and partial resection (PR) were performed, respectively, in 15 (56%), 7 (26%), and 5 (18%) of the procedures. In Group 3, GTR was performed in 28 (93%) and STR in 2 (7%) of the procedures. In cases of craniopharyngioma (Group 1) and glioma (Group 2) in which a complete removal was planned, iMRI allowed localization of residual lesions and attainment of the surgical goal through further resection, respectively, in 18% and 27% of the procedures. Moreover, in gliomas the resection could be extended from partial to subtotal in 50% of the cases. In 17% of the patients in Group 3, iMRI enabled the identification and further removal of tumor remnants. There was no intra- or postoperative complication related to the use of iMRI despite special technical difficulties in smaller children. CONCLUSIONS In this study, the use of iMRI in children proved to be safe. It was most effective in increasing the extent of tumor resection, especially in patients with low-grade gliomas and craniopharyngiomas. The most prominent disadvantage of high-field iMRI was the limitation with respect to operative positioning due to the configuration of the surgical table.
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Affiliation(s)
- Mario Giordano
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and
| | - Amir Samii
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and.,Leibniz Institute for Neurobiology, Magdeburg, Germany
| | | | - Helmut Bertalanffy
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and
| | - Rudolf Fahlbusch
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and
| | - Madjid Samii
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and
| | - Concezio Di Rocco
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and
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34
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Roder C, Breitkopf M, Ms, Bisdas S, Freitas RDS, Dimostheni A, Ebinger M, Wolff M, Tatagiba M, Schuhmann MU. Beneficial impact of high-field intraoperative magnetic resonance imaging on the efficacy of pediatric low-grade glioma surgery. Neurosurg Focus 2016; 40:E13. [PMID: 26926053 DOI: 10.3171/2015.11.focus15530] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative MRI (iMRI) is assumed to safely improve the extent of resection (EOR) in patients with gliomas. This study focuses on advantages of this imaging technology in elective low-grade glioma (LGG) surgery in pediatric patients. METHODS The surgical results of conventional and 1.5-T iMRI-guided elective LGG surgery in pediatric patients were retrospectively compared. Tumor volumes, general clinical data, EOR according to reference radiology assessment, and progression-free survival (PFS) were analyzed. RESULTS Sixty-five patients were included in the study, of whom 34 had undergone conventional surgery before the iMRI unit opened (pre-iMRI period) and 31 had undergone surgery with iMRI guidance (iMRI period). Perioperative data were comparable between the 2 cohorts, apart from larger preoperative tumor volumes in the pre-iMRI period, a difference without statistical significance, and (as expected) significantly longer surgeries in the iMRI group. According to 3-month postoperative MRI studies, an intended complete resection (CR) was achieved in 41% (12 of 29) of the patients in the pre-iMRI period and in 71% (17 of 24) of those in the iMRI period (p = 0.05). Of those cases in which the surgeon was postoperatively convinced that he had successfully achieved CR, this proved to be true in only 50% of cases in the pre-iMRI period but in 81% of cases in the iMRI period (p = 0.055). Residual tumor volumes on 3-month postoperative MRI were significantly smaller in the iMRI cohort (p < 0.03). By continuing the resection of residual tumor after the intraoperative scan (when the surgeon assumed that he had achieved CR), the rate of CR was increased from 30% at the time of the scan to 85% at the 3-month postoperative MRI. The mean follow-up for the entire study cohort was 36.9 months (3-79 months). Progression-free survival after surgery was noticeably better for the entire iMRI cohort and in iMRI patients with postoperatively assumed CR, but did not quite reach statistical significance. Moreover, PFS was highly significantly better in patients with CRs than in those with incomplete resections (p < 0.001). CONCLUSIONS Significantly better surgical results (CR) and PFS were achieved after using iMRI in patients in whom total resections were intended. Therefore, the use of high-field iMRI is strongly recommended for electively planned LGG resections in pediatric patients.
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Affiliation(s)
| | | | - Ms
- Departments of 1 Neurosurgery and
| | | | | | | | - Martin Ebinger
- University Children's Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Markus Wolff
- University Children's Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | | | - Martin U Schuhmann
- Departments of 1 Neurosurgery and.,Section of Pediatric Neurosurgery; and
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35
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Giordano M, Arraez C, Samii A, Samii M, Di Rocco C. Neurosurgical tools to extend tumor resection in pediatric hemispheric low-grade gliomas: iMRI. Childs Nerv Syst 2016; 32:1915-22. [PMID: 27659833 DOI: 10.1007/s00381-016-3177-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 07/05/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The treatment of low-grade gliomas (LGGs) in pediatric age is still controversial. However, most authors report longer life expectancy in case of completely removed cerebral gliomas. Intraoperative magnetic resonance imaging (iMRI) is increasingly utilized in the surgical management of intra-axial tumor in adults following the demonstration of its effectiveness. In this article, we analyze the management of LGG using iMRI focusing on its impact on resection rate and its limits in the pediatric population. METHODS We performed review of the literature regarding the treatment of LGG using iMRI focusing on its impact on resection rate and its limits in the pediatric population. Some exemplary cases are also described. RESULTS Intraoperative MRI allowed extension of tumor resection after the depiction of residual tumor at the intraoperative imaging control from 21 to 52 % of the cases in the published series. Moreover, the early reoperation rate was significantly lower when compared with the population treated without this tool (0 % vs 7-14 %). Some technical difficulties have been described in literature regarding the use of iMRI in the pediatric population especially for positioning due to the structure of the headrest coil designed for adult patients. CONCLUSION The analysis of the literature and our own experience with iMRI in children indicates significant advantages in the resection of LGG offered by the technique. All these advantages are obtained without elongation of the surgical times or increased risk for complications, namely infection. The main limit for a wider diffusion of iMRI for the pediatric neurosurgical center is the cost required, for acquisition of the system, especially for high-field magnet, and the environmental and organizational changes necessary for its use.
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Affiliation(s)
- Mario Giordano
- Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany.
| | - Cinta Arraez
- Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany
| | - Amir Samii
- Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany
| | - Madjid Samii
- Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany
| | - Concezio Di Rocco
- Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany
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Choudhri AF, Siddiqui A, Klimo P. Pediatric Cerebellar Tumors: Emerging Imaging Techniques and Advances in Understanding of Genetic Features. Neuroimaging Clin N Am 2016; 26:459-69. [PMID: 27423803 DOI: 10.1016/j.nic.2016.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cerebellar tumors are the most common group of solid tumors in children. MR imaging provides an important role in characterization of these lesions, surgical planning, and postsurgical surveillance. Preoperative imaging can help predict the histologic subtype of tumors, which can provide guidance for surgical planning. Beyond histology, pediatric brain tumors are undergoing new classification schemes based on genetic features. Intraoperative MR imaging has emerged as an important tool in the surgical management of pediatric brain tumors. Effective understanding of the imaging features of pediatric cerebellar tumors can benefit communication with neurosurgeons and neuro-oncologists and can improve patient management.
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Affiliation(s)
- Asim F Choudhri
- Department of Radiology, University of Tennessee Health Science Center, 848 Adams Ave, Memphis, TN 38103, USA; Department of Neurosurgery, University of Tennessee Health Science Center, 847 Monroe Avenue, Memphis, TN 38163, USA; Department of Ophthalmology, University of Tennessee Health Science Center, 930 Madison Avenue, Memphis, TN 38163, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA.
| | - Adeel Siddiqui
- Department of Radiology, University of Tennessee Health Science Center, 848 Adams Ave, Memphis, TN 38103, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, 847 Monroe Avenue, Memphis, TN 38163, USA; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA; Division of Neurosurgery, St. Jude's Children's Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA; Semmes Murphey Neurologic & Spine Institute, 6325 Humphreys Boulevard, Memphis, TN 38120, USA
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Klimo P, Nesvick CL, Broniscer A, Orr BA, Choudhri AF. Malignant brainstem tumors in children, excluding diffuse intrinsic pontine gliomas. J Neurosurg Pediatr 2016; 17:57-65. [PMID: 26474099 DOI: 10.3171/2015.6.peds15166] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Malignant tumors of the brainstem, excluding classic diffuse intrinsic pontine gliomas (DIPGs), are a very rare, heterogeneous group of neoplasms that have been infrequently described in the literature. In this paper, the authors present their experiences with treating these unique cancers. METHODS A retrospective chart review was conducted to identify eligible cases over a 15-year period. All tumors involving the pons were, by consensus, felt not to be DIPGs based on their neuroimaging features. Demographic information, pathological specimens, neuroimaging characteristics, surgical and nonsurgical management plans, and survival data were gathered for analysis. RESULTS Between January 2000 and December 2014, 29 patients were identified. The mean age at diagnosis was 8.4 years (range 2 months to 25 years), and 17 (59%) patients were male. The most common presenting signs and symptoms were cranial neuropathies (n = 24; 83%), hemiparesis (n = 12; 41%), and ataxia or gait disturbance (n = 10; 34%). There were 18 glial and 11 embryonal tumors. Of the glial tumors, 5 were radiation-induced and 1 was a malignant transformation of a previously known low-grade tumor. Surgical intervention consisted of biopsy alone in 12 patients and some degree of resection in another 15 patients. Two tumors were diagnosed postmortem. The median overall survival for all patients was 196 days (range 15 to 3999 days). There are currently 5 (17%) patients who are still alive: 1 with an anaplastic astrocytoma and the remaining with embryonal tumors. CONCLUSIONS In general, malignant non-DIPG tumors of the brainstem carry a poor prognosis. However, maximal cytoreductive surgery may be an option for select patients with focal tumors. Long-term survival is possible in patients with nonmetastatic embryonal tumors after multimodal treatment, most importantly maximal resection.
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Affiliation(s)
- Paul Klimo
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital;,Departments of 2 Surgery.,Semmes-Murphey Neurologic & Spine Institute;,Departments of 4 Neurosurgery
| | - Cody L Nesvick
- University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Brent A Orr
- Pathology, St. Jude Children's Research Hospital
| | - Asim F Choudhri
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital;,Departments of 4 Neurosurgery.,Radiology, University of Tennessee Health Science Center; and
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Millward CP, Perez Da Rosa S, Avula S, Ellenbogen JR, Spiteri M, Lewis E, Didi M, Mallucci C. The role of early intra-operative MRI in partial resection of optic pathway/hypothalamic gliomas in children. Childs Nerv Syst 2015. [PMID: 26216059 DOI: 10.1007/s00381-015-2830-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Optic pathway/hypothalamic gliomas (OPHGs) are generally benign but situated in an exquisitely sensitive brain region. They follow an unpredictable course and are usually impossible to resect completely. We present a case series of 10 patients who underwent surgery for OPHGs with the aid of intra-operative MRI (ioMRI). The impact of ioMRI on OPHG resection is presented, and a role for ioMRI in partial resection is discussed. METHODS Ten patients with OPHGs managed surgically utilising ioMRI at Alder Hey Children's Hospital between 2010 and 2013 were retrospectively identified. Demographic and relevant clinical data were obtained. MRI was used to estimate tumour volume pre-operatively and post-resection. If ioMRI demonstrated that further resection was possible, second-look surgery, at the discretion of the operating surgeon, was performed, followed by post-operative imaging to establish the final status of resection. Tumour volume was estimated for each MR image using the MRIcron software package. RESULTS Control of tumour progression was achieved in all patients. Seven patients had, on table, second-look surgery with significant further tumour resection following ioMRI without any surgically related mortality or morbidity. The median additional quantity of tumour removed following second-look surgery, as a percentage of the initial total volume, was 27.79% (range 11.2-59.2%). The final tumour volume remaining with second-look surgery was 23.96 vs. 33.21% without (p = 0.1). CONCLUSIONS OPHGs are technically difficult to resect due to their eloquent location, making them suitable for debulking resection only. IoMRI allows surgical goals to be reassessed intra-operatively following primary resection. Second-look surgery can be performed if possible and necessary and allows significant quantities of extra tumour to be resected safely. Although the clinical significance of additional tumour resection is not yet clear, we suggest that ioMRI is a safe and useful additional tool, to be combined with advanced neuronavigation techniques for partial tumour resection.
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Affiliation(s)
- Christopher Paul Millward
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
| | - Sandra Perez Da Rosa
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK
- Pediatric Neurosurgery Department, Carlos Haya Hospital, University of Málaga, Avenida Carlos Haya, 29010, Málaga, Spain
| | - Shivaram Avula
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK
| | - Jonathan R Ellenbogen
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK
| | - Michaela Spiteri
- Centre for Vision Speech and Signal Processing, Department of Electronic Engineering, University of Surrey, Guildford, Surrey, GU2 7XH, UK
| | - Emma Lewis
- Centre for Vision Speech and Signal Processing, Department of Electronic Engineering, University of Surrey, Guildford, Surrey, GU2 7XH, UK
| | - Mo Didi
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK
| | - Conor Mallucci
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK
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Tallen G, Resch A, Calaminus G, Wiener A, Leiss U, Pletschko T, Friedrich C, Langer T, Grabow D, Driever PH, Kortmann RD, Timmermann B, Pietsch T, Warmuth-Metz M, Bison B, Thomale UW, Krauss J, Mynarek M, von Hoff K, Ottensmeier H, Frühwald M, Kramm CM, Temming P, Müller HL, Witt O, Kordes U, Fleischhack G, Gnekow A, Rutkowski S. Strategies to improve the quality of survival for childhood brain tumour survivors. Eur J Paediatr Neurol 2015; 19:619-39. [PMID: 26278499 DOI: 10.1016/j.ejpn.2015.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 07/05/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Tumours of the central nervous system (CNS) are the most frequent solid tumours and the second most frequent type of cancer in children and adolescents. Overall survival has continuously improved in Germany, since an increasing number of patients have been treated according to standardised, multicentre, multimodal treatment recommendations, trials of the German Paediatric Brain Tumour Consortium (HIT-Network) or the International Society of Paediatric Oncology-Europe (SIOP-E) during the last decades. Today, two out of three patients survive. At least 8000 long-term childhood brain tumour survivors (CBTS) are currently living in Germany. They face lifelong disease- and treatment-related late effects (LE) and associated socioeconomic problems more than many other childhood cancer survivors (CCS). METHOD We review the LE and resulting special needs of this particular group of CCS. RESULTS Despite their increasing relevance for future treatment optimisation, neither the diversity of chronic and cumulative LE nor their pertinent risk factors and subsequent impact on quality of survival have yet been comprehensively addressed for CBTS treated according to HIT- or SIOP-E-protocols. Evidence-based information to empower survivors and stakeholders, as well as medical expertise to manage their individual health care, psychosocial and educational/vocational needs must still be generated and established. CONCLUSION The establishment of a long-term research- and care network in Germany shall contribute to a European platform, that aims at optimising CBTSs' transition into adulthood as resilient individuals with high quality of survival including optimal levels of activity, participation and acceptance by society.
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Affiliation(s)
- Gesche Tallen
- Department of Paediatric Oncology/Haematology, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany; Department of Paediatrics, Faculty of Medicine, University of Calgary, 2888 Shaganappi Trail N.W., Calgary, Alberta T3B 6A8, Canada.
| | - Anika Resch
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Gabriele Calaminus
- Department of Paediatric Haematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Andreas Wiener
- Department of Paediatric Haematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Ulrike Leiss
- Medical University Vienna, Department of Paediatric and Adolescent Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Thomas Pletschko
- Medical University Vienna, Department of Paediatric and Adolescent Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Carsten Friedrich
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany; Division of Paediatric Oncology, Haematology and Haemostaseology, Department of Woman's and Children's Health, University Hospital Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany.
| | - Thorsten Langer
- Department of Paediatric Oncology/Haematology, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
| | - Desiree Grabow
- German Childhood Cancer Registry (GCCR), Institute of Medical Biostatistics, Epidemiology, and Informatics (IMBEI), University Medical Center, University of Mainz, Gebäude 902, Obere Zahlbacher Straße 69, 55131 Mainz, Germany.
| | - Pablo Hernáiz Driever
- Department of Paediatric Oncology/Haematology, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Rolf-Dieter Kortmann
- Department of Radiation Oncology, University of Leipzig, Stephanstr. 9a, 04103 Leipzig, Germany.
| | - Beate Timmermann
- Particle Therapy Clinic at West German Proton Therapy Centre Essen, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Torsten Pietsch
- Institute of Neuropathology, University of Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, Germany.
| | - Monika Warmuth-Metz
- Dept. of Neuroradiology, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Brigitte Bison
- Dept. of Neuroradiology, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Ulrich-Wilhelm Thomale
- Department of Paediatric Neurosurgery, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jürgen Krauss
- Department of Neurosurgery, Head Clinic, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Martin Mynarek
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Katja von Hoff
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Holger Ottensmeier
- University Children's Hospital Würzburg, Dept. of Paed. Haematology, Oncology, Josef-Schneider-Str. 2, 97080 Würzburg, Germany.
| | - Michael Frühwald
- Department of Paediatric Oncology/Haematology, Klinikum Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany.
| | - Christof M Kramm
- Division of Paediatric Haematology and Oncology, University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany.
| | - Petra Temming
- Paediatric Haematology/Oncology, Paediatrics III, University of Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Hermann L Müller
- Paediatric Oncology/Haematology, Klinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Str. 10, 26133 Oldenburg, Germany.
| | - Olaf Witt
- German Cancer Research Centre (DKFZ) and Department of Paediatric Oncology/Haematology, University of Heidelberg, Heidelberg, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany.
| | - Uwe Kordes
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Gudrun Fleischhack
- Paediatric Haematology/Oncology, Paediatrics III, University of Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Astrid Gnekow
- Department of Paediatric Oncology/Haematology, Klinikum Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany.
| | - Stefan Rutkowski
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
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McAbee JH, Modica J, Thompson CJ, Broniscer A, Orr B, Choudhri AF, Boop FA, Klimo P. Cervicomedullary tumors in children. J Neurosurg Pediatr 2015; 16:357-66. [PMID: 26114990 DOI: 10.3171/2015.5.peds14638] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cervicomedullary tumors (CMTs) represent a heterogeneous group of intrinsic neoplasms that are typically low grade and generally carry a good prognosis. This single-institution study was undertaken to document the outcomes and current treatment philosophy for these challenging neoplasms. METHODS The charts of all pediatric patients with CMTs who received treatment at St. Jude Children's Research Hospital between January 1988 and May 2013 were retrospectively reviewed. Demographic, surgical, clinical, radiological, pathological, and survival data were collected. Treatment-free survival and overall survival were estimated, and predictors of recurrence were analyzed. RESULTS Thirty-one children (16 boys, 15 girls) with at least 12 months of follow-up data were identified. The median age at diagnosis was 6 years (range 7 months-17 years) and the median follow-up was 4.3 years. Low-grade tumors (Grade I or II) were present in 26 (84%) patients. Thirty patients underwent either a biopsy alone or resection, with the majority of patients undergoing biopsy only (n = 12, 39%) or subtotal resection (n = 14, 45%). Only 4 patients were treated solely with resection; 21 patients received radiotherapy alone or in combination with other treatments. Recurrent tumor developed in 14 children (45%) and 4 died as a result of their malignancy. A high-grade pathological type was the only independent variable that predicted recurrence. The 5- and 10-year treatment-free survival estimates are 64.7% and 45.3%, respectively. The 5- and 10-year overall survival estimate is 86.7%. CONCLUSIONS Children with CMTs typically have low-grade neoplasms and consequently long-term survival, but high risk of recurrence. Therapy should be directed at achieving local tumor control while preserving and even restoring neurological function.
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Affiliation(s)
- Joseph H McAbee
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Joseph Modica
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Clinton J Thompson
- George Washington University Milken Institute School of Public Health, Washington, DC; and
| | - Alberto Broniscer
- Department of Oncology, St. Jude Children's Research Hospital;,Department of Pediatrics, University of Tennessee Health Science Center
| | - Brent Orr
- Department of Pathology, St. Jude Children's Research Hospital
| | - Asim F Choudhri
- Department of Neurosurgery, University of Tennessee Health Science Center;,Department of Radiology, University of Tennessee Health Science Center;,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital
| | - Frederick A Boop
- Department of Neurosurgery, University of Tennessee Health Science Center;,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital;,Department of Surgery, St. Jude Children's Research Hospital; and.,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center;,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital;,Department of Surgery, St. Jude Children's Research Hospital; and.,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
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Abstract
Intraoperative magnetic resonance imaging (iMRI) has emerged as an important tool in guiding the surgical management of children with brain tumors. Recent advances have allowed utilization of high field strength systems, including 3-tesla MRI, resulting in diagnostic-quality scans that can be performed while the child is on the operating table. By providing information about the possible presence of residual tumor, it allows the neurosurgeon to both identify and resect any remaining tumor that is thought to be safely accessible. By fusing the newly obtained images with the surgical guidance software, the images have the added value of aiding in navigation to any residual tumor. This is important because parenchyma often shifts during surgery. It also gives the neurosurgeon insight into whether any immediate postoperative complications have occurred. If any complications have occurred, the child is already in the operating room and precious minutes lost in transport and communications are saved. In this article we review the three main approaches to an iMRI system design. We discuss the possible roles for iMRI during intraoperative planning and provide guidance to help radiologists and neurosurgeons alike in the collaborative management of these children.
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Bisdas S, Roder C, Ernemann U, Tatagiba MS. Intraoperative MR Imaging in Neurosurgery. Clin Neuroradiol 2015; 25 Suppl 2:237-44. [PMID: 26259854 DOI: 10.1007/s00062-015-0443-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/17/2015] [Indexed: 12/01/2022]
Abstract
Intraoperative magnetic resonance imaging (iMRI) has dramatically expanded and nowadays presents state-of-the-art technique for image-guided neurosurgery, facilitating critical precision and effective surgical treatment of various brain pathologies. Imaging hardware providing basic imaging sequences as well as advanced MRI can be seamlessly integrated into routine surgical environments, which continuously leads to emerging indications for iMRI-assisted surgery. Besides the obvious intraoperative diagnostic yield, the initial clinical benefits have to be confirmed by future-controlled long-term studies.
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Affiliation(s)
- S Bisdas
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University Hospital, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.
| | - C Roder
- Department of Neurosurgery, Eberhard Karls University Hospital, Tübingen, Germany
| | - U Ernemann
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University Hospital, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - M S Tatagiba
- Department of Neurosurgery, Eberhard Karls University Hospital, Tübingen, Germany
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Coutinho de Souza P, Mallory S, Smith N, Saunders D, Li XN, McNall-Knapp RY, Fung KM, Towner RA. Inhibition of Pediatric Glioblastoma Tumor Growth by the Anti-Cancer Agent OKN-007 in Orthotopic Mouse Xenografts. PLoS One 2015; 10:e0134276. [PMID: 26248280 PMCID: PMC4527837 DOI: 10.1371/journal.pone.0134276] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 07/08/2015] [Indexed: 12/31/2022] Open
Abstract
Pediatric glioblastomas (pGBM), although rare, are one of the leading causes of cancer-related deaths in children, with tumors essentially refractory to existing treatments. Here, we describe the use of conventional and advanced in vivo magnetic resonance imaging (MRI) techniques to assess a novel orthotopic xenograft pGBM mouse (IC-3752GBM patient-derived culture) model, and to monitor the effects of the anti-cancer agent OKN-007 as an inhibitor of pGBM tumor growth. Immunohistochemistry support data is also presented for cell proliferation and tumor growth signaling. OKN-007 was found to significantly decrease tumor volumes (p<0.05) and increase animal survival (p<0.05) in all OKN-007-treated mice compared to untreated animals. In a responsive cohort of treated animals, OKN-007 was able to significantly decrease tumor volumes (p<0.0001), increase survival (p<0.001), and increase diffusion (p<0.01) and perfusion rates (p<0.05). OKN-007 also significantly reduced lipid tumor metabolism in responsive animals [(Lip1.3 and Lip0.9)-to-creatine ratio (p<0.05)], as well as significantly decrease tumor cell proliferation (p<0.05) and microvessel density (p<0.05). Furthermore, in relationship to the PDGFRα pathway, OKN-007 was able to significantly decrease SULF2 (p<0.05) and PDGFR-α (platelet-derived growth factor receptor-α) (p<0.05) immunoexpression, and significantly increase decorin expression (p<0.05) in responsive mice. This study indicates that OKN-007 may be an effective anti-cancer agent for some patients with pGBMs by inhibiting cell proliferation and angiogenesis, possibly via the PDGFRα pathway, and could be considered as an additional therapy for pediatric brain tumor patients.
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Affiliation(s)
- Patricia Coutinho de Souza
- Advanced Magnetic Resonance Center, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States of America
- Department of Veterinary Pathobiology, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK, United States of America
| | - Samantha Mallory
- University of Oklahoma Children's Hospital, Oklahoma City, OK, United States of America
| | - Nataliya Smith
- Advanced Magnetic Resonance Center, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States of America
| | - Debra Saunders
- Advanced Magnetic Resonance Center, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States of America
| | - Xiao-Nan Li
- Laboratory of Molecular Neuro-Oncology, Texas Children's Cancer Center, Texas Children's Hospital, Houston, TX, United States of America
| | - Rene Y. McNall-Knapp
- University of Oklahoma Children's Hospital, Oklahoma City, OK, United States of America
| | - Kar-Ming Fung
- Peggy and Charles Stephenson Cancer Center, Oklahoma City, OK, United States of America
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
- Department of Pathology, Oklahoma City Veterans Affairs Medical Center, Oklahoma City, OK, United States of America
| | - Rheal A. Towner
- Advanced Magnetic Resonance Center, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States of America
- Department of Veterinary Pathobiology, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK, United States of America
- Peggy and Charles Stephenson Cancer Center, Oklahoma City, OK, United States of America
- * E-mail:
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Akutsu H, Yamamoto T, Masuda Y, Ishikawa E, Masumoto T, Matsuda M, Matsumura A. Movable intraoperative magnetic resonance imaging incorporating a seismic system. Clin Neurol Neurosurg 2015; 135:57-61. [PMID: 26038277 DOI: 10.1016/j.clineuro.2015.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 04/20/2015] [Accepted: 05/07/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION A high-field ceiling-mounted and movable intraoperative MR imaging (iMRI) can minimize additional risks for MRI and enhance safety by not moving the patient. In this system, hanging the heavy magnet from the ceiling requires structural stability; this stability was confirmed in earlier studies, but not proved during a seismic event. OBJECTIVE We have installed a 1.5 T movable iMRI system with an incorporated seismic system in our hospital in Japan, a seismic event-prone region. This arrangement is the first in the world, to our knowledge. The objective of this study was to describe the mechanism of this seismic system and the first clinical experience using this system. METHODS The seismic system consists of a stabilizer pad that is mounted directly under the magnet, in addition to the structural stability. The seismic system was tested with using a shaker table testing at a test laboratory. RESULTS Ninety-one patients underwent neurosurgical intervention using this iMRI and seismic system at our hospital. In all patients, intra-, pre, and/or postoperative MR images were successfully obtained, and image quality was excellent. The workflow of moving the magnet and scanning were smooth and unproblematic. We had 169 seismic events in our city during this time period, but had no incidental or accidental events related to the seismic events. CONCLUSION With the use of the seismic system, a ceiling-mounted, movable iMRI system can be more safely used. This seismic system may contribute to the spread of movable iMRI systems in countries where seismic events occur.
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Affiliation(s)
- Hiroyoshi Akutsu
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yosuke Masuda
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tomohiko Masumoto
- Department of Radiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masahide Matsuda
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Akira Matsumura
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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Boop FA, Bate B, Choudhri AF, Burkholder B, Klimo P. Preliminary experience with an intraoperative MRI-compatible infant headholder: technical note. J Neurosurg Pediatr 2015; 15:539-43. [PMID: 25679382 DOI: 10.3171/2014.10.peds14447] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The development of high-quality intraoperative MRI (iMRI) capability has offered a major advance in the care of patients with complex intracranial disease. To date, this technology has been limited by the need for pin fixation of the calvaria. The authors report their preliminary experience with an MRI-compatible horseshoe headrest that allows for the following: 1) iMRI in patients too young for pin fixation; 2) iMRI in patients with large calvarial defects; 3) the ability to move the head during iMRI surgery; and 4) the use of neuronavigation in such cases. The authors report 2 cases of infants in whom the Visius Surgical Theatre horseshoe headrest (IMRIS Inc.) was used. Image quality was equivalent to that of pin fixation. The infants suffered no skin issues. The use of neuronavigation with the system remained accurate and could be updated with the new iMRI information. The Visius horseshoe headrest offers a technical advance in iMRI technology for infants, for patients with cranial defects or prior craniotomies in whom pin fixation may not be safe, or for patients in whom the need to move the head during surgery is required. The image quality of the system remains excellent, and the ability to merge new images to the neuronavigation system is helpful.
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Klimo P, Venable GT, Boop FA, Merchant TE. Recurrent craniopharyngioma after conformal radiation in children and the burden of treatment. J Neurosurg Pediatr 2015; 15:499-505. [PMID: 25700121 DOI: 10.3171/2014.10.peds14384] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this paper the authors present their experience treating children with recurrent craniopharyngioma who were initially managed with surgery followed by conformal radiation therapy (CRT). METHODS A departmental oncology information system was queried to identify all children (< 18 years old) who received CRT for a craniopharyngioma between 1998 and 2010 (inclusive) and specifically those who experienced tumor progression. For each patient, the authors recorded the type of recurrence (solid, cystic, or both), the time interval to first progression and each subsequent progression, the associated treatment complications, and disease status at last follow-up evaluation. RESULTS Among the 97 patients that met criteria for entry into this study, 18 (18.6%) experienced tumor progression (9 cystic, 3 solid, 6 cystic and solid). The median time to first recurrence was 4.62 years (range 1.81-9.11 years). The subgroup included 6 female and 12 male patients with a median age of 7.54 years (range 3.61-13.83 years). Ten patients experienced first progression within 5 years of CRT. The 5- and 10-year treatment-free survival rates for the entire cohort were 89.0% (95% confidence interval [CI] 80.5%-93.9%) and 76.2% (95% CI 64%-85%), respectively. Seven patients had a single episode of progression and 11 had more than 1. The time interval between each subsequent progression was progressively shorter. The 18 patients underwent 38 procedures. The median follow-up duration for this group was 9.32 years (range 4.04-19.0 years). Three patients died, including 1 from perioperative complications. CONCLUSIONS Craniopharyngioma progression after prior irradiation is exceedingly difficult to treat and local control is challenging despite repeated surgical procedures. Given our results, gross-total resection may need to be the surgical goal at the time of first recurrence, if possible. Decompressing new cyst formation alone has a low rate of long-term success.
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Affiliation(s)
- Paul Klimo
- Semmes-Murphey Neurologic & Spine Institute
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Alexiou GA, Vartholomatos G, Stefanaki K, Lykoudis EG, Patereli A, Tseka G, Tzoufi M, Sfakianos G, Prodromou N. The Role of Fast Cell Cycle Analysis in Pediatric Brain Tumors. Pediatr Neurosurg 2015; 50:257-63. [PMID: 26287721 DOI: 10.1159/000439029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 07/24/2015] [Indexed: 11/19/2022]
Abstract
Cell cycle analysis by flow cytometry has not been adequately studied in pediatric brain tumors. We investigated the value of a modified rapid (within 6 min) cell cycle analysis protocol for the characterization of malignancy of pediatric brain tumors and for the differentiation of neoplastic from nonneoplastic tissue for possible intraoperative application. We retrospectively studied brain tumor specimens from patients treated at our institute over a 5-year period. All tumor samples were histopathologically verified before flow-cytometric analysis. The histopathological examination of permanent tissue sections was the gold standard. There were 68 brain tumor cases. All tumors had significantly lower G0/G1 and significantly higher S phase and mitosis fractions than normal brain tissue. Furthermore low-grade tumors could be differentiated from high-grade tumors. DNA aneuploidy was detected in 35 tumors. A correlation between S phase fraction and Ki-67 index was found in medulloblastomas and anaplastic ependymomas. Rapid cell cycle analysis by flow cytometry is a promising method for the identification of neoplastic tissue intraoperatively. Low-grade tumors could be differentiated from high-grade tumors. Thus, cell cycle analysis can be a valuable adjunct to the histopathological evaluation of pediatric brain tumors, whereas its intraoperative application warrants further investigation.
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Choudhri AF, Chin EM, Klimo P, Boop FA. Spatial distortion due to field inhomogeneity in 3.0 tesla intraoperative MRI. Neuroradiol J 2014; 27:387-92. [PMID: 25196608 DOI: 10.15274/nrj-2014-10081] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 07/14/2014] [Indexed: 11/12/2022] Open
Abstract
We describe a 14-year-old boy with a pilocytic astrocytoma of the left caudate head. Preoperative localization MR imaging (MRI) was performed in the operating room, and spatial distortion was noted felt to be related to head positioning relative to the isocenter of the magnetic field. The distortion artifact was subtle enough to be difficult to detect, but large enough to change the location of the lesion potentially leading to a non-diagnostic stereotactic biopsy. Repeat imaging after changing the head position to allow scanning closer to the isocenter of the magnetic field showed decreased distortion, an improvement greater than that using the manufacturer's distortion correction algorithm on the initial images. Intraoperative MRI, and its requisite limitations in positioning, requires vigilance to detect possible distortion that could alter surgical outcomes if not identified and corrected prospectively.
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Affiliation(s)
- Asim F Choudhri
- Department of Radiology, University of Tennessee Health Science Center; Memphis, TN, USA - Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital; Memphis, TN, USA -
| | - Eric M Chin
- College of Medicine, University of Tennessee Health Science Center; Memphis, TN, USA
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center; Memphis, TN, USA - Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital; Memphis, TN, USA
| | - Frederick A Boop
- Department of Neurosurgery, University of Tennessee Health Science Center; Memphis, TN, USA - Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital; Memphis, TN, USA
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