Incomplete Tumor Removal Research Articles

Accurate Analysis of Tumor Margins Using a Fluorescent pH Low Insertion Peptide (pHLIP)

The recurrence of certain cancers remains quite high due to either incomplete surgical removal of the primary tumor or the presence of small metastases that are invisible to the surgeon. Near infrared (NIR) fluorescence imaging might improve surgical outcomes by providing sensitive, specific, and real-time visualization of normal and diseased tissues if agents can be found that discriminate between normal and diseased tissue and define tumor margins. We have developed a new approach for revealing tumor borders by using NIR fluorescently labeled pH Low Insertion Peptide (pHLIP) and have created a computational program for the quantitative assessment of tumor boundaries. The approach is tested in vivo by co-localization of GFP-tumors and NIR emission from the fluorescently labeled pHLIP, and it is found that boundaries are accurately reported and that sub-millimeter masses can be detected.

Raman Spectroscopy: A New Tool for the “Skull Base” Surgeon?

Usually only limited real-time information is available regarding the nature of tissues during diagnostic and therapeutic surgical procedures. As a result, sampling errors occur during diagnostic biopsies due to tumor heterogeneity and incomplete tumor removal during tumor resection procedures. Moreover, damage to healthy tissues tends to occur. Identification of the biochemical characteristics of healthy and diseased tissues and the use of these characteristics to guide surgical procedures might be a way to improve their diagnostic and therapeutic accuracy and their safety.

Surgical Treatment of Mass-Forming Intrahepatic Cholangiocarcinoma: An 11-Year Western Single-Center Experience in 107 Patients

Hepatic resection is the only cure for intrahepatic cholangiocellular carcinoma (ICC). The purpose of this study was to clarify the clinicopathologic characteristics and surgical outcome of patients with ICC. We retrospectively studied the records of 67 patients who underwent laparotomy for ICC from January 1995 through December 2005. Univariate and multivariate analyses were conducted for several variables to evaluate their influence on the outcome. Forty-five patients underwent hepatic resection. In 19 patients, the tumors were found to be unresectable at the time of laparotomy. Median 2- and 5-year survival rates in the 45 resected patients were 62% and 35%, respectively. For 36 patients who underwent curative resection, the 2- and 5-year survival were 67% and 41%, respectively; with a median survival of 43 months. The overall 5-year recurrence-free survival was 30%. The 90-day postoperative mortality rate was 4% and morbidity 28%. Multivariate analyses confirmed resection margin, lymph node involvement, blood loss, and blood transfusion to be independent significant variables for overall survival. Predictors of longer recurrence-free survival were lymph node involvement, vascular infiltration, blood loss, and transfusion. Surgical treatment of ICC by curative hepatic resection in patients without nodal invasion provides good long-term results. In contrast, incomplete tumor removal does not provide a survival benefit. An improved quality of preoperative staging was able to increase the resectability rate to acceptable 70%.

Current Status and Future Directions: Management of Colon Cancer with Peritoneal Dissemination

Colorectal cancer is one of the most common cancers worldwide, and although it carries a favorable prognosis when detected at early stages, it is associated with limited survival when metastatic disease is present. Modern systemic therapy has improved median survival in those patients with hematogenous dissemination, but the role of these newer combinations of cytotoxic chemotherapy and biological agents remains undefined in patients with peritoneal carcinomatosis. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy have resulted in long-term good outcomes for patients whose carcinomatosis can be completely removed, but offers no advantage over supportive care for those patients with incomplete tumor removal. At the present time, we lack proven therapeutic strategies on how to treat a patient newly diagnosed with peritoneal carcinomatosis of colorectal origin. A large Phase III multi-institutional trial is being developed to address these issues, and will need full collaboration between medical and surgical oncologists.

PURE ENDOSCOPIC ENDONASAL APPROACH FOR PITUITARY ADENOMAS

The aim of this study was to report the results of a consecutive series of patients undergoing pituitary surgery using a pure endoscopic endonasal approach and to evaluate the efficacy and safety of this procedure. We reviewed 200 consecutive patients with pituitary adenoma who underwent purely endoscopic transsphenoidal resection of their lesions. The patients' clinical outcomes, including remission rates, degrees of tumor removal, and complications, were evaluated and compared with a previous microscopic series. There were 111 nonfunctioning adenomas and 34 growth hormone-secreting, 27 adrenocorticotropin hormone-secreting, 25 prolactin-secreting, and 3 thyroid-stimulating hormone-secreting adenomas. The degree of gross total removal for tumors with suprasellar or parasellar extension and without cavernous sinus involvement was 96% and for intrasellar lesions was 98%. After a median follow-up period of 19 months, the remission results for patients with functioning adenomas were 71% for growth hormone-secreting, 81% for adrenocorticotropin hormone-secreting, and 88% for prolactin-secreting adenomas, with no recurrence at the time of the last follow-up. This compares with similar results reported from series using a standard microsurgical approach (growth hormone-secreting adenomas, 67%; adrenocorticotropin hormone-secreting adenomas, 78%; and prolactin-secreting adenomas, 62%). Endoscopic surgery for recurrent or residual nonfunctioning adenomas that had been previously treated using a microscopic approach revealed in the majority of cases a more limited exposure during the initial surgery, frequently with incomplete tumor removal. Complication rates have been low, and the average length of hospital stay was reduced. A purely endoscopic approach for pituitary adenoma treatment is a safe and effective alternative to the traditional microscopic procedure. Although our results reveal excellent tumor-removal rates, comparable remission rates in functioning tumors, and a very low rate of complications, additional studies with longer follow-up periods are required to confirm whether this approach should be considered the preferred procedure for pituitary surgery.

Histopathologic findings and diagnostic difficulties posed with use of escharotic agents for treatment of skin lesions: a case report and review of the literature

Escharotic agents have been used as alternative therapy for treatment of skin cancer and skin problems for centuries. Internet web sites such as online health product stores and eBay have made them widely available to the general public. The use of these agents carries risk of incomplete removal of tumor, damage of surrounding healthy tissues and marked scarring with poor cosmetic outcome. We report the case of a 27-year-old man who presented with history of moles and self-treatment with an escharotic agent containing bloodroot in order to document the histopathologic findings of topical bloodroot treatment and to show the clinical consequences that may occur in the unsuspecting public. To the best of our knowledge, the histological features following use of bloodroot (Sanguinaria canadensis) have not yet been documented.

Early results of surgery in patients with nonfunctioning pituitary adenoma and analysis of the risk of tumor recurrence

Nonfunctioning pituitary adenomas (NFPAs) are benign tumors of the pituitary gland that typically cause visual and/or hormonal dysfunction. Surgery is the treatment of choice, but patients remain at risk for tumor recurrence for several years afterwards. The authors evaluate the early results of surgery and the long-term risk of tumor recurrence in patients with NFPAs. Between 1990 and 2005, 491 previously untreated patients with NFPA underwent surgery at the Università Vita-Salute. Determinations of recurrence or growth of the residual tumor tissue during the follow-up period were based on neuroradiological criteria. Residual tumor after surgery was detected in 173 patients (36.4%). Multivariate analysis showed that invasion of the cavernous sinus, maximum tumor diameter, and absence of tumor apoplexy were associated with an unfavorable surgical outcome. At least 2 sets of follow-up neuroimaging studies were obtained in 436 patients (median follow-up 53 months). Tumors recurred in 83 patients (19.0%). When tumor removal appeared complete, younger age at surgery was associated with a risk of tumor recurrence. In patients with incomplete tumor removal, adjunctive postoperative radiotherapy had a marked protective effect against growth of residual tumor. Complete surgical removal of NFPAs can be safely achieved in > 50% of cases. Visual symptoms and, less frequently, pituitary function may improve after surgery. However, tumor can recur in patients after apparently complete surgical removal. In patients with incomplete tumor removal, radiation therapy is the most effective adjuvant therapy for preventing residual tumor growth.

Orbital Heterotopic Glial Tissue Presenting as Exotropia

A 5-month-old female infant was noted to have difficulty in fixating with the left eye with accompanying progressive exo-deviation and axial proptosis. She also had optic disc hypoplasia with the double ring sign. Computed tomography showed left superomedial orbital mass without any orbital bony defect. Incisional biopsy through a medial orbitotomy allowed significant reduction in tumor burden except for the most apical portion. The affected eye resumed normal alignment and full motility. Histopathologically, the tumor was composed of glial tissue intermixed with muscle fibers. Immunohistochemically, desmin and glial fibrillary acidic protein were strongly expressed. Minimal proptosis of the left eye heralded the recurrence of the tumor 4 years later, also confirmed by magnetic resonance imaging studies. This patient embodies the rare occurrence of isolated heterotopic glial tissue in the orbit with skeletal muscle as one of its components and optic disc hypoplasia as the associated ocular anomaly. Late recurrence may occur following incomplete tumor removal.

Surgical treatment of dumbbell-shaped neurinomas: report of an experience with 57 cases in a single hospital

BackgroundDumbbell-shaped trigeminal neurinomas are rare benign tumors with a controversy regarding their treatment and surgical approaches. We conducted an investigation on elucidating a strategy for the treatment of DSTNs. MethodsOne hundred thirty-seven patients with trigeminal neurinomas, accounting for 0.6% of all intracranial tumors and 3.8% of intracranial neurinomas, were screened out from the data bank on brain tumors in Hua Shan Hospital (Shanghai, China) from 1978 to 2003. Among them, 57 patients with DSTNs were found without Recklinghausen disease and analyzed retrospectively. Patients were divided into 2 groups. In the early group (1978-1984), a series of conventional intradural approaches were used, and in the latter group (1985-2003), an extradurotransdurotranstrigeminal pore approach with orbitozygomatic craniotomy was applied. After the tumor in the middle cranial fossa was resected, the tumor in the posterior fossa was resected via a suboccipital approach in the early group and through enlarged porus trigeminus without resection of the petrous apex in the latter group. ResultsThere were 12 patients in the early group and 45 patients (including 6 patients with recurrent tumors) in the latter group. The mean age was 37 years (range, 14-56 years) and 39 years (range, 12-72 years), respectively, in the early and latter groups. There was no predominance in sex in the 2 groups. The mean duration of clinical manifestations before admission were 2.2 and 2 years, respectively, in the early and latter groups. Tumor size measured on MRI and/or CT were 30 to 40 mm in 4 (33%) cases from the early group and 14 (31%) cases from the latter group, 41 to 50 mm in 8 (67%) cases from the early group and 25 (56%) cases from the latter group, and more than 50 mm in 6 (13%) cases from the latter group. There were 3 patients in the latter group with a tumor extending into the infratemporal fossa and pterygopalatine fossa. Total tumor resection was achieved in 42% (5/12) of the early group and 87% (39/45) of the latter group (χ2 = 10.897, P < .001); incomplete tumor removal was done in 58% (7/12) of the early group and 13% (6/45) of the latter group. One patient in the early group died of brainstem injury postoperatively. There was no surgical mortality in the latter group. Cranial nerve morbidities were seen in 80% of the early group and 41% of the latter group (χ2 = 12.052, P < .01), when patients were discharged. Six months after operation, however, cranial nerve morbidities were seen in 55% of the early group and 18.6% of the latter group (χ2 = 8.585, P < .01). A long-term follow-up study was available in 41 (75%) patients, with a period of 2 to 20 years (mean, 10 years). Karnofsky prognosis scale scores were at least 90 in 60% of the early group and 77% of the latter group and 70 to 80 in 40% of the early group and 23% of the latter group. Recurrent tumors occurred in 3 patients from the early group and were reoperated on. One patient with a recurrent tumor from the latter group underwent radiosurgery 5 years after the operation. ConclusionThe best treatment for large or giant DSTNs is microsurgery with extradurotransdurotranstrigeminal pore approach via single-stage skull-base craniotomy. It is not necessary to resect the petrous apex for removal of the tumor in the posterior fossa. Radiosurgery can be used for the residual or recurrent tumors.

A Novel Resectoscope for Transurethral Resection of Bladder Tumors and the Prostate

Transurethral bladder tumor resection is associated with imperfect clinical staging and incomplete tumor removal. Transurethral prostate resection may be complicated by inadvertent damage to the urinary sphincter, bladder neck and trigone. We performed a multicenter pilot and feasibility study of a novel working element for resectoscopes designed to improve the efficacy and safety of transurethral endoscopic surgery. An innovative working element for resectoscopes was developed to convert the standard in/out linear/axial movement at the handgrip into a side-to-side, bidirectional, lateral rotating motion. The device is compatible with current optical technology and conventional electrocautery generators, and it has been granted marketing approval. It consists of variably sized cutting loops designed for transurethral resection of bladder tumors and the prostate. To date 80 patients with bladder cancer (38) or benign prostatic hyperplasia (42) have undergone surgery with this instrument at our 3 clinical sites. No safety concerns were evident. When used during transurethral bladder tumor resection, lateral resection at the base of the tumor enabled accurate depth of penetration into the bladder wall, which may decrease the risk of bladder perforation and improve pathological assessment of tumor invasion. During transurethral prostate resection this novel tool facilitated dissection of adenoma adjacent to the verumontanum and prostatovesical junction, which may decrease the risk of sphincteric damage and bladder neck injury. A novel resectoscope is currently under prospective clinical investigation to establish its surgical and pathological efficacy, ease of use and side effect profile. Current data suggest that the learning curve is mild, its use is safe and it provides distinct advantages when used for transurethral resection of bladder tumors and the prostate.

Current state of the art in the diagnosis and surgical treatment of Cushing disease: early experience with a purely endoscopic endonasal technique

Object Transsphenoidal pituitary surgery is the primary therapy for Cushing disease because of its potential to produce lasting remission without the need for long-term drug or hormone replacement therapy. The authors evaluated the current role of pure endoscopic endonasal pituitary surgery in the treatment of Cushing disease. Methods Twenty-five patients underwent pure endoscopic surgery for confirmed Cushing disease. Thirteen patients had microadenomas and seven had macroadenomas; magnetic resonance images obtained in five patients were only suspicious or nondiagnostic, and thus they underwent inferior petrosal sinus sampling. Two patients had evidence of cavernous sinus involvement. Final histological results were consistent with adrenocorticotropin hormone (ACTH)–secreting adenoma in 20 patients. Results Twenty patients (80%) had clinical remission and laboratory confirmation of hypocortisolemia (serum cortisol < 100 nmol/L requiring substitution therapy), suppression to low-dose dexamethasone, and normal 24-hour urinary free cortisol. The median follow-up period was 17 months (range 3–32 months). There was no recurrence at the time of the last follow-up. Three patients presented with new anterior pituitary deficiency, but no one had permanent diabetes insipidus. In one patient a cerebrospinal fluid leak developed but later resolved following lumbar drainage. Treatment failure was attributable to involvement of the cavernous sinus in two patients, incomplete tumor removal in one, negative exploration in one, and nodular corticotroph hyperplasia of the pituitary gland in one. Conclusions Early results indicated that endoscopic endonasal surgery is a safe and effective treatment for ACTH-producing adenomas. The rate of remission in this study is comparable to those in previous series, and the rate of major postoperative complications is extremely low. Further studies with a larger number of patients and longer follow-ups are required to determine whether this more minimally invasive pure endoscopic approach should become the standard of care for the surgical treatment of Cushing disease.

Current state of the art in the diagnosis and surgical treatment of Cushing disease: early experience with a purely endoscopic endonasal technique

Transsphenoidal pituitary surgery is the primary therapy for Cushing disease because of its potential to produce lasting remission without the need for long-term drug or hormone replacement therapy. The authors evaluated the current role of pure endoscopic endonasal pituitary surgery in the treatment of Cushing disease. Twenty-five patients underwent pure endoscopic surgery for confirmed Cushing disease. Thirteen patients had microadenomas and seven had macroadenomas; magnetic resonance images obtained in five patients were only suspicious or nondiagnostic, and thus they underwent inferior petrosal sinus sampling. Two patients had evidence of cavernous sinus involvement. Final histological results were consistent with adrenocorticotropin hormone (ACTH)-secreting adenoma in 20 patients. Twenty patients (80%) had clinical remission and laboratory confirmation of hypocortisolemia (serum cortisol < 100 nmol/L requiring substitution therapy), suppression to low-dose dexamethasone, and normal 24-hour urinary free cortisol. The median follow-up period was 17 months (range 3-32 months). There was no recurrence at the time of the last follow-up. Three patients presented with new anterior pituitary deficiency, but no one had permanent diabetes insipidus. In one patient a cerebrospinal fluid leak developed but later resolved following lumbar drainage. Treatment failure was attributable to involvement of the cavernous sinus in two patients, incomplete tumor removal in one, negative exploration in one, and nodular corticotroph hyperplasia of the pituitary gland in one. Early results indicated that endoscopic endonasal surgery is a safe and effective treatment for ACTH-producing adenomas. The rate of remission in this study is comparable to those in previous series, and the rate of major postoperative complications is extremely low. Further studies with a larger number of patients and longer follow-ups are required to determine whether this more minimally invasive pure endoscopic approach should become the standard of care for the surgical treatment of Cushing disease.

Factors Determining the Incomplete Removal of Tumors and Other Orbital Lesions

Purpose: The success of therapy for large orbital tumors depends on the completeness of surgical tumor excision. However, in each individual case, the relation between advantages of total resection and potential morbidity should be considered. The dimension and the precise MRI localization of the orbital tumors determine the surgical strategies in the treatment of these lesions.

Factors Determining the Incomplete Removal of Tumors and Other Orbital Lesions

Purpose: The success of therapy for large orbital tumors depends on the completeness of surgical tumor excision. However, in each individual case, the relation between advantages of total resection and potential morbidity should be considered. The dimension and the precise MRI localization of the orbital tumors determine the surgical strategies in the treatment of these lesions.

Cytoreduction Results in High Perioperative Mortality and Decreased Survival in Patients Undergoing Pancreatectomy for Neuroendocrine Tumors of the Pancreas

We reviewed our experience with pancreatectomy for neuroendocrine tumors (NE) to determine outcomes after R0/R1 or R2 resection and compare them to patients in whom resection was not attempted. Data were reviewed for all patients presenting with NE tumors of the pancreas between 1990 and 2005. Kaplan-Meier survival curves were compared by log-rank analysis. Multivariate analysis was completed using Cox proportional hazards to identify risk factors for poor survival after resection. Of 120 patients, 65 (54%) had functional tumors. Resection was undertaken in 83: distal pancreatectomy in 41, pancreaticoduodenectomy in 27, enucleation in 14, and central pancreatectomy in 1. Survival was significantly longer after resection (91 months versus 24, P<0.001). R0/R1 resection was accomplished in 64 (77%) and resulted in lower perioperative mortality (2% versus 21%, P<0.01) and longer survival (112 months versus 24, P<0.001) compared to R2 resection. Survival after R2 resection was no better than after no resection. Factors predictive of decreased survival were moderate/poor differentiation, R2 resection, and high-risk features. Long-term survival is possible following complete resection for NE tumors of the pancreas. However, cytoreduction resulting in incomplete tumor removal carries significant perioperative mortality without long-term survival benefit and should be discouraged.

Chirurgische Therapie des intrahepatischen cholangiozellulären Karzinoms

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy. Tumor resection is the treatment of choice, but so far the value of hepatic resection has not been well defined. We report results with an aggressive surgical approach for the treatment of this tumor entity. Between April 1998 and June 2004, 54 liver resections were performed in 120 patients with ICC. In 24 patients, 39 additional procedures were performed: resection of hilar bifurcation (n=18), partial resection of diaphragm (n=6), vascular resection and reconstruction (n=15). There were 30 R0, 21 R1, and three R2 resections. After R1/R2 resection and explorative laparotomy, the median survival times are 9 months and 6 months, respectively. Following R0 resection, the calculated median survival is 46 months, and the 1-, 3-, and 5-year survival rates are 83%, 58%, and 48%, respectively. The presented data show that R0 resection leads to a significant prolongation of survival in patients with ICC. In contrast, incomplete tumor removal does not provide a survival benefit. These results justify an aggressive surgical approach to achieve a R0 resection. The low resectability rate of less than 50% underlines the need for improved preoperative staging.

A clinicopathologic study of dysembryoplstic neuroepithelial tumor

OBJECTIVE To study the clinicopathologic features, radiologic findings, treatment modalities and prognosis of dysembryoplastic neuroepithelial tumor (DNT). The clinical features, histopathologic findings, immunohistochemistry and electron microscopy of 18 cases of DNT were analyzed. Results Among the 18 cases studied, 14 were males and 4 females. The age of these patients ranged from 3 to 46 (mean age = 22. 8 years). Partial seizure was the main presenting symptom in all patients. The history of epilepsy could be as long as 17 years. On magnetic resonance imaging (MRI) study, the tumor was hypodense on T1 and hyperdense on T2. There was neither edema nor mass effect. All but 2 cases were supratentorial and intracortical in location. Ten cases were treated by complete surgical excision and the remaining 8 tumors were partially excised. In the 14 patients with follow-up data available, 13 survived for 1.4 to 11 years after the operation (with more than 10 years survival observed in 2 patients). The average survival period was 5.5 years. None of the cases showed tumor recurrence after operation. Histologically, all tumors demonstrated a multinodular architecture and were intracortical in location, sometimes with extension into the white matter. The characteristic "glioneuronal constituent" was an essential feature for making the diagnosis of DNT. The tumor was formed by an admixture of oligodendrocyte-like cells, mature neurons and astrocytes, with obvious microcystic changes. These neurons were often dispersed singly in the mucoid matrix. In most cases, the foci of cortical dysplasia were found in adjacent areas. Immunohistochemical study demonstrated positivity for synaptophysin, neurofilament and S-100 protein in the neurons and some oligodendrocyte-like cells. The staining of glial fibrillary acidic protein in the oligodendrocyte-like cells was negative. Electron microscopy showed early neuronal, astrocytic and oligodendroglial differentiation of the oligodendrocyte-like cells. DNT is a benign tumor (corresponding to WHO grade I) that can be cured by surgical excision, despite sometimes incomplete tumor removal. A correct diagnosis of this entity requires thorough understanding of the clinical, radiologic, histologic and immunohistochemical features.

“Radical but Conservative” Is the Main Goal for Ultrasonography-Guided Liver Resection: Prospective Validation of this Approach

Despite higher blood loss, morbidity, and mortality, rate of major resection is still high in most surgical institutions because of fear of incomplete tumor removal. To verify whether intraoperative ultrasonography (IOUS) minimizes the rate of major hepatectomies while maintaining treatment radicality, we have prospectively validated our policy, based on extensive use of IOUS resection guidance. Ninety-three consecutive patients with liver tumors were prospectively enrolled. There were 61 men and 32 women with a mean age of 65.6 years. Fifty-nine patients had hepatocellular carcinoma and 34 had colorectal cancer liver metastases. Surgical strategy was based on the relationship between the tumor and intrahepatic vascular structures at IOUS. Rates of major and minor resection, mortality, morbidity, and rate of local recurrences were evaluated. There was no hospital mortality; major morbidity occurred in 2.2% of patients and minor complications in 17%. Six (6.5%) patients required blood transfusion. Major resections (two or more segments) were accomplished in 14 patients (15%), and 5 (5.4%) patients had more than three segments removed. Major vascular invasion was present in 16 patients (17%), and contact without infiltration with major vessels was present in another 16; part of the wall of the inferior vena cava was resected in 1 patient. Surgical clearance was achieved in all patients without local recurrence at a mean followup of 18 months (median 13, range 6 to 52 months). This study shows that liver operations performed under IOUS guidance are safe and radical and reduce need for major hepatectomies.

Facial translocation approach to infratemporal fossa and cranial base in extensive angiofibroma: A review of 7 cases

Angiofibroma extending to infratemporal fossa, orbit and middle cranial fossa is a difficult problem for a surgeon to tackle. Traditional extracranial excision with radiotherapy for the intracranial extension was practiced for a long time with variable results. Different approaches to remove such a tumour are described but most of them are not free from resultant morbidity in the form of facial asymmetry and incomplete tumour removal. Facial translocation approach facilitates complete tumour removal without cutting through the tumour thereby reducing per-operative blood loss. It also avoids facial asymmetry as the zygomatico-orbito-maxillary bony complex is replaced after the tumour removal. We present a review of seven cases with the results. The surgical steps, advantages, disadvantages and the complications are discussed.

Diagnosis and surgical treatment of cavernous sinus hemangiomas: an experience of 20 cases

Objective To elucidate the advances of diagnosis and surgical treatment of the cavernous sinus hemangiomas (CSHs). Methods The data from 20 patients with the CSHs surgically treated by authors from 1996 through 2000 was analyzed retrospectively, and a review of relevant literature was conducted. Results These 20 cases accounted for 16.3% of all intracranial cavernous hemangiomas surgically treated in the same period at Huashan Hospital. The patients were aged from 32∼69 years with an average age of 47 years. There were 17 females and 3 males. The common clinical manifestations were visual loss, diplopia, headache, facial numbness and extraocular muscle palsy. Computed tomography (CT) and magnetic resonance imaging (MRI) were major preoperative diagnostic modalities, but demonstrated nonspecific features. The preoperative misdiagnostic rate was 38.9%. Of the 20 patients undergoing craniotomy via modified pterional approach with or without orbitozygomatic osteotomy, tumors were removed through epidural approach (EDA) in 13 cases, intradural approach (IDA) in 7 cases. Hypotension was induced during the operation in 2 cases. Total tumor removal was achieved in 12 cases (92.3%) in the EDA group and nil in the IDA group. Incomplete tumor removal was 1 case (7.7%) in the EDA group and 7 cases (100%) in the IDA group. One patient in the IDA group died of intracranial hemorrhage postoperatively. Compared with preoperative manifestations, cranial neuropathies at discharge were worsened in 76.9% of patients in the EDA group and 83.3% of patients in the IDA group, improved in 15.4% of patients in the EDA group and 16.7% of patients in the IDA group, unchanged in 7.7% of patients in the EDA group. Follow-up study (range, 1∼6 years; mean, 3 years) was available in 17 patients (89%). All patients in the EDA group improved without tumor recurrence. Nonimprovement (2 cases) and continued worsening (3 cases) occurred in the IDA group. In patients with tumor incompletely removed, the tumor enlarged in 2 cases, and unchanged or decreased in size in 3 cases, in which 2 cases underwent postoperative radiosurgery or radiotherapy. According to pathologic and MRI characteristics, the CSHs can be divided into two types, sponge-like type and mulberry-like type. Conclusion Cavernous hemangioma should be included in differential diagnosis for middle aged females with cavernous sinus tumors. Two types of the CSHs, sponge-like type and mulberry-like type, can be identified. The best microsurgical approach for the removal of the CSHs is epidural approach via the skull-base craniotomy. Radiosurgery should be considered for patients with incomplete tumor removal.