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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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Schmidt A, Roder C, Eckert F, Baumann D, Niyazi M, Fideler F, Ernemann U, Tatagiba M, Schäfer J, Urla C, Scherer S, Fuchs J, Paulsen F, Bender B. Increasing Patient Safety and Treatment Quality by Using Intraoperative MRI for Organ-Preserving Tumor Resection and High-Dose Rate Brachytherapy in Children with Bladder/Prostate and Perianal Rhabdomyosarcoma. Cancers (Basel) 2023; 15:3505. [PMID: 37444615 DOI: 10.3390/cancers15133505] [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: 06/16/2023] [Revised: 07/01/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023] Open
Abstract
In children with bladder/prostate (BP) and perianal rhabdomyosarcoma (RMS), we use a hybrid treatment concept for those suitable, combining organ-preserving tumor resection and high-dose rate brachytherapy (HDR-BT). This treatment concept has been shown to improve outcomes. However, it is associated with specific challenges for the clinicians. The exact position of the tubes for BT is a prerequisite for precise radiotherapy. It can finally be determined only with an MRI or CT scan. We evaluated the use of an intraoperative MRI (iMRI) to control the position of the BT tubes and for radiotherapy planning in all patients with BP and perianal RMS who received the above-mentioned combination therapy in our department since January 2021. iMRI was used in 12 children. All tubes were clearly localized. No adverse events occurred. In all 12 children, radiotherapy could be started on time. In a historical cohort without iMRI, this was not possible in 3 out of 20 children. The use of iMRI in children with BP and perianal RMS improved patient safety and treatment quality. This technology has proven to be successful for the patient population we have defined and has become a standard procedure in our institution.
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Affiliation(s)
- Andreas Schmidt
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Constantin Roder
- Department of Neurosurgery, University Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital, Eberhard Karls University Tuebingen, 72070 Tuebingen, Germany
| | - Franziska Eckert
- Department of Radiation Oncology, University Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
- Department of Radiation Oncology, AKH, Comprehensive Cancer Center Vienna, Medical University Vienna, 1090 Vienna, Austria
| | - David Baumann
- Department of Radiation Oncology, University Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Frank Fideler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Ulrike Ernemann
- Center for Neuro-Oncology, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital, Eberhard Karls University Tuebingen, 72070 Tuebingen, Germany
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital, Eberhard Karls University Tuebingen, 72070 Tuebingen, Germany
| | - Jürgen Schäfer
- Department of Pediatric Radiology, University Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Cristian Urla
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Simon Scherer
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
- Center for Pediatric Oncology, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital, Eberhard Karls University Tuebingen, 72070 Tuebingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Benjamin Bender
- Center for Neuro-Oncology, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital, Eberhard Karls University Tuebingen, 72070 Tuebingen, Germany
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
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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: 2] [Impact Index Per Article: 2.0] [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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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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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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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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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: 20] [Impact Index Per Article: 3.3] [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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Lam S, Lin Y, Zinn P, Su J, Pan IW. Patient and treatment factors associated with survival among pediatric glioblastoma patients: A Surveillance, Epidemiology, and End Results study. J Clin Neurosci 2017; 47:285-293. [PMID: 29102237 DOI: 10.1016/j.jocn.2017.10.041] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/10/2017] [Indexed: 10/18/2022]
Abstract
Glioblastoma (GBM) is a rare malignancy in children. The United States Surveillance, Epidemiology, and End Results (SEER) database allows large-scale analyses of clinical characteristics and prognostic features. We used it to study patients aged <20 years with histologically confirmed GBM (2000-2010) and examined the relationship between patient demographics, tumor characteristics, patterns of treatment, and outcomes. The primary outcome was disease-specific survival. 302 subjects were identified, with median age 11 years. Median follow-up was 32 months (95% CI 27-39). 34.4% had gross total resection (GTR). 61% underwent radiation after surgery (17% of subjects <3 years, 67% of those aged 4-19 years). Median survival and 2-year survival rates were 20 months and 46.9%, respectively. In multivariate analyses, age, tumor location, extent of resection, and year of diagnosis were significantly associated with the primary outcome. Compared to those aged 0-4 years, subjects aged 5-9 years and 10-14 years had higher risk of mortality. Infratentorial tumor location (HR 2.0, 95% CI 1.2-3.3, p = 0.007) and subtotal resection (HR 2.04, 95% CI 1.4-3.0, p < 0.001) were associated with increased mortality. Later year of diagnosis was significantly associated with decreased risk of death (HR 0.93, 95% CI 0.9-0.99, p = 0.031). There was no association between sex, race, region, or tumor size and the primary outcome. Repeat analyses examining all-cause mortality identified the same risk factors as for CNS cancer-specific mortality. Younger age, supratentorial location, GTR, and later year of diagnosis were associated with improved survival.
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Affiliation(s)
- Sandi Lam
- Baylor College of Medicine, Department of Neurosurgery, Houston, TX, USA; Texas Children's Hospital, Division of Pediatric Neurosurgery, Houston, TX, USA.
| | - Yimo Lin
- Baylor College of Medicine, Department of Neurosurgery, Houston, TX, USA; Texas Children's Hospital, Division of Pediatric Neurosurgery, Houston, TX, USA
| | - Pascal Zinn
- Baylor College of Medicine, Department of Neurosurgery, Houston, TX, USA; Texas Children's Hospital, Division of Pediatric Neurosurgery, Houston, TX, USA
| | - Jack Su
- Baylor College of Medicine, Department of Pediatrics, Houston, TX, USA; Texas Children's Hospital, Division of Pediatric Hematology/Oncology, Houston, TX, USA
| | - I-Wen Pan
- Baylor College of Medicine, Department of Neurosurgery, Houston, TX, USA; Texas Children's Hospital, Division of Pediatric Neurosurgery, Houston, TX, USA
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Zebian B, Vergani F, Lavrador JP, Mukherjee S, Kitchen WJ, Stagno V, Chamilos C, Pettorini B, Mallucci C. Recent technological advances in pediatric brain tumor surgery. CNS Oncol 2016; 6:71-82. [PMID: 28001090 DOI: 10.2217/cns-2016-0022] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
X-rays and ventriculograms were the first imaging modalities used to localize intracranial lesions including brain tumors as far back as the 1880s. Subsequent advances in preoperative radiological localization included computed tomography (CT; 1971) and MRI (1977). Since then, other imaging modalities have been developed for clinical application although none as pivotal as CT and MRI. Intraoperative technological advances include the microscope, which has allowed precise surgery under magnification and improved lighting, and the endoscope, which has improved the treatment of hydrocephalus and allowed biopsy and complete resection of intraventricular, pituitary and pineal region tumors through a minimally invasive approach. Neuronavigation, intraoperative MRI, CT and ultrasound have increased the ability of the neurosurgeon to perform safe and maximal tumor resection. This may be facilitated by the use of fluorescing agents, which help define the tumor margin, and intraoperative neurophysiological monitoring, which helps identify and protect eloquent brain.
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Affiliation(s)
- Bassel Zebian
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK.,Department of Pediatric & Adult Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Francesco Vergani
- Department of Pediatric & Adult Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - José Pedro Lavrador
- Department of Pediatric & Adult Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Soumya Mukherjee
- Department of Neurosurgery, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - William John Kitchen
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Vita Stagno
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Christos Chamilos
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Benedetta Pettorini
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Conor Mallucci
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
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11
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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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12
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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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Swinney C, Li A, Bhatti I, Veeravagu A. Optimization of tumor resection with intra-operative magnetic resonance imaging. J Clin Neurosci 2016; 34:11-14. [PMID: 27469412 DOI: 10.1016/j.jocn.2016.05.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 04/22/2016] [Accepted: 05/09/2016] [Indexed: 11/30/2022]
Abstract
Intra-operative MRI (ioMRI) may be used to optimize tumor resection. Utilization of this technology allows for the removal of residual tumor mass following initial tumor removal, maximizing the extent of resection. This, in turn, has been shown to lead to improved outcomes. Individual studies have examined the impact of ioMRI on the rate of extended resection, but a comprehensive review of this topic is needed. A literature review of the MEDLINE, EMBASE, CENTRAL, and Google Scholar databases revealed 12 eligible studies. This included 804 primary operations and 238 extended resections based on ioMRI findings. Use of ioMRI led to extended tumor resection in 13.3-54.8% of patients (mean 37.3%). Stratification by tumor type showed additional resection occurred, on average, in 39.1% of glioma resections (range 13.3-70.0%), 23.5% of pituitary tumor resections (range 13.3-33.7%), and 35.0% of nonspecific tumor resections (range 17.5-40%). Tumor type (glioma vs. pituitary) did not significantly influence the rate of further excision following ioMRI (p=0.309). There was no difference in secondary resection rate between studies limited to pediatric patients and those including adults (p=0.646). Thus, the use of intra-operative MRI frequently results in further resection of tumors. It is primarily used for the resection of gliomas and pituitary tumors. Tumor type does not appear to be a significant contributing factor to the rate of secondary tumor removal. Limited evidence suggests that extended resection may translate into improved clinical outcomes and mortality rates. However, results have not been unanimous, while clinical effect sizes have often been modest.
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Affiliation(s)
- Christian Swinney
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Amy Li
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Inderpreet Bhatti
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
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14
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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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15
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Abstract
Improved neuronavigation guidance as well as intraoperative imaging and neurophysiologic monitoring technologies have enhanced the ability of neurosurgeons to resect focal brainstem gliomas. In contrast, diffuse brainstem gliomas are considered to be inoperable lesions. This article is a continuation of an article that discussed brainstem glioma diagnostics, imaging, and classification. Here, we address open surgical treatment of and approaches to focal, dorsally exophytic, and cervicomedullary brainstem gliomas. Intraoperative neuronavigation, intraoperative neurophysiologic monitoring, as well as intraoperative imaging are discussed as adjunctive measures to help render these procedures safer, more acute, and closer to achieving surgical goals.
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Affiliation(s)
- Abdulrahman J Sabbagh
- Department of Pediatric Neurosurgery, National Neurosciences Institute, King Fahd Medical City, Riyadh, Kingdom of Saudi Arabia. Tel. +966 (11) 2889999 Ext. 8211, 2305. Fax. +966 (11) 2889999 Ext 1391. E-mail:
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16
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Avula S, Kumar R, Pizer B, Pettorini B, Abernethy L, Garlick D, Mallucci C. Diffusion abnormalities on intraoperative magnetic resonance imaging as an early predictor for the risk of posterior fossa syndrome. Neuro Oncol 2014; 17:614-22. [PMID: 25319997 DOI: 10.1093/neuonc/nou299] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Posterior fossa syndrome (PFS) is an important complication of posterior fossa surgery in children. The pathophysiology of this condition remains unclear, but there is evidence implicating surgical injury of the proximal efferent cerebellar pathway (pECP) and the cerebellar vermis to PFS. We aimed to evaluate if diffusion abnormalities involving these structures on the final intraoperative MRI can predict the development of PFS. METHODS Diffusion-weighted imaging from 31 posterior fossa resections were anonymized and evaluated for abnormalities involving the dentate nucleus, superior cerebellar peduncle, and the mesencephalic tegmentum forming the pECP, vermis, and middle cerebellar peduncle. The case notes were independently evaluated for evidence of PFS. RESULTS The diffusion imaging in 28 cases was of optimal quality for evaluation. Diffusion abnormalities were identified in 10 cases, 7 of which involved the pECP. Retrospective evaluation revealed evidence of PFS in 6 cases. There was a significant association between abnormalities involving pECP structures (P = .001) and development of PFS. Bilateral involvement of pECP (P = .006) was a highly specific risk factor for predicting the development of PFS. Diffusion abnormality of the inferior vermis was significantly associated with PFS (P = .001) but may not represent a risk factor in isolation. CONCLUSION This study demonstrates the feasibility of identifying children at risk for developing PFS at the earliest stage post tumor resection and thus adds to the growing evidence base on its pathophysiology.
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Affiliation(s)
- Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Ram Kumar
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Barry Pizer
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Benedetta Pettorini
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Laurence Abernethy
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Deborah Garlick
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
| | - Conor Mallucci
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (S.A., L.A., D.G.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (R.K.); Department of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK (Barry Pizer); Department of Neurosurgery, Alder Hey Children's N.H.S Foundation Trust, Liverpool, UK (Benedetta Pettorini, C.M.)
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Goodden J, Pizer B, Pettorini B, Williams D, Blair J, Didi M, Thorp N, Mallucci C. The role of surgery in optic pathway/hypothalamic gliomas in children. J Neurosurg Pediatr 2014; 13:1-12. [PMID: 24138145 DOI: 10.3171/2013.8.peds12546] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECT Optic pathway/hypothalamic gliomas (OPHGs) are generally benign tumors situated in an exquisitely sensitive brain region. The location and natural history of OPHGs has led to much debate about optimal treatment. This paper revisits the role of and optimal timing of debulking surgery in OPHG. METHODS This paper presents a series of cases managed by the neuro-oncology team at Alder Hey Children's Hospital and a single surgeon. Data were collected retrospectively for periods prior to 2009 and prospectively thereafter. Tailored treatment strategies were used, including observation and combinations of surgery, chemotherapy, and radiotherapy. Tumor control rates and outcomes are reviewed. RESULTS Forty-two patients were treated between 1998 and 2011. Their median age at diagnosis was 5 years 7 months. Nineteen patients were positive for neurofibromatosis Type 1 (NF1) and 23 patients were negative for NF1. The median duration of follow-up was 77 months (range 21.8-142.3 months). Presenting symptoms included visual impairment (in 50% of cases), headache (in 24%), and hypothalamic/pituitary dysfunction (in 29%). Twenty-two debulking procedures were performed in 21 patients. Four biopsies (3 open, 1 endoscopic) were also performed. The histological diagnosis was pilocytic astrocytoma in 21 patients and pilomyxoid astrocytoma in 2 patients. Ten patients (Group 1) had primary surgical debulking alone and were then observed. Four patients (Group 2) had surgical debulking, plus planned chemotherapy within 3 months. Seven patients (Group 3) required surgical debulking for progressive disease following a variety of treatments. Patient age had the greatest impact on subsequent tumor progression. In total, 13 patients received chemotherapy, 4 on initial presentation, 4 in combination with surgery, and 5 for further tumor progression. Five patients were treated with radiotherapy, 3 prior to referral to Alder Hey. Eleven patients required shunt insertion for hydrocephalus. Vision was stabilized for 74% of patients. The number of patients with hypothalamic/pituitary dysfunction increased from 12 at presentation to 16 by the end of treatment. The overall survival rate was 93%. Three patients died-1 from tumor progression, 1 from infective complications from tumor biopsy, and 1 from a spontaneous posterior fossa hemorrhage. NF1 was associated with improved outcome-fewer patients required active intervention and rates of visual impairment and/or or hypothalamic/pituitary dysfunction were lower. CONCLUSIONS Good long-term survival and functional outcomes can be achieved in children with OPHG. Tumor control was achieved through an individualized approach using surgery, chemotherapy, or radiotherapy in varied combinations. The authors aim to limit radiotherapy to cases involving older children in whom other therapies have failed, due to the well-described and often devastating late effects associated with midline cranial irradiation. Surgery has a clear role for diagnosis, tumor control, and relief of mass effect. In particular, primary surgical debulking of tumor (without adjuvant therapy) is safe and effective. Recent advances in intraoperative MRI may add value and need further assessment.
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