Nontotal Resection Research Articles

Functional and oncological outcome of petroclival chondrosarcoma operated on through an extradural anterior petrosectomy approach. A single center experience

BackgroundManagement of skull base chondrosarcoma (SBC) remains challenging due to its deep location and complex growth pattern. Non-total resection and postoperative residual mass are common features, with controversy regarding the need to offer systematic postoperative radiation therapy or additional surgery. MethodsA single-center retrospective cohort study was conducted on 10 consecutive patients harboring petroclival chondrosarcomas that were operated on between May 2007 and March 2019. After resection, the patients were allocated to a wait-and-rescan policy. ResultsPatients were operated on through an extradural anterior petrosectomy (EAP). Subtotal tumor resection was achieved in all patients. The mean duration of follow-up was 70 months (range 25–137/median 67 months). Clinical outcomes dramatically improved in three (30%) patients, while five patients retained preoperative cranial nerve (CN) disturbances after surgery (50%). Two patients reported transient postoperative worsening of their symptoms (20%). All of the postoperative CN new deficits improved within one year, except in one patient who showed permanent facial nerve palsy. The preoperative median Karnofsky Performance Scale (KPS) score was 80 (range 70–100), and then it became 90 (range 70–100) postoperatively. Patients harboring a tumor residue were included in a wait-and-rescan policy. With this regimen, tumor control was obtained in seven patients (70% of cases until the last follow-up). Three patients (30%) showed progression of the residual; two of them were treated with adjuvant therapy, while an extra cranial growth residue was observed in the third. ConclusionOptimal and reasonable surgical resection of petroclival chondrosarcomas could be achieved with good to excellent functional outcomes through an EAP. In spite of a significant percentage of regrowth, only one patient required additional salvage surgery.

Malignant transformation in low-grade astrocytoma for long-term monitoring.

Malignant transformation (MT) of low-grade astrocytoma (LGA) produces a poor prognosis in benign tumors. Currently, variables linked with MT of LGA have proven equivocal. The present study aims to evaluate the risk variables, indicating that LGA gradually differentiates to malignant astrocytoma. Retrospective cohort analysis of LGA patients was performed. Both univariate and multivariate studies were used to discover variables connected to MT using the Cox regression method. As a result, the cumulative incidence of MT for each covariate survival curve was built after the final model. In the current study, 115 individuals with LGA were included in the analysis, and MT was found in 16.5% of cases. In the case of MT, 68.4% of patients progressed to glioblastoma, whereas 31.6% progressed to anaplastic astrocytoma. Significant factors included supratentorial tumor (hazard ratio (HR) 3.41, 95% CI 1.18-12.10), midline shift > 5 mm (HR 7.15, 95% CI 2.28-34.33), and non-total resection as follows: subtotal resection (HR 5.09, 95% CI 0.07-24.02), partial resection (HR 1.61, 95% CI 1.09-24.11), and biopsy (HR 2.80, 95% CI 1.18-32.52). In individuals with LGA, MT dramatically altered the disease's natural history to a poor prognosis. The present study's analysis of the clinical features of patients indicated supratentorial LGA, a midline shift greater than 5 mm, and the degree of resection as risk factors for MT. The more extensive the resection, the greater the reduction in tumor load and MT. In addition, more molecular study is necessary to elucidate the pathophysiology of MT.

Risk Factors Associated with Malignant Transformation of Astrocytoma: Competing Risk Regression Analysis.

Background Malignant transformation (MT) of low-grade astrocytoma (LGA) triggers a poor prognosis in benign tumors. Currently, factors associated with MT of LGA have been inconclusive. The present study aims to explore the risk factors predicting LGA progressively differentiated to malignant astrocytoma. Methods The study design was a retrospective cohort study of medical record reviews of patients with LGA. Using the Fire and Gray method, the competing risk regression analysis was performed to identify factors associated with MT, using both univariate and multivariable analyses. Hence, the survival curves of the cumulative incidence of MT of each covariate were constructed following the final model. Results Ninety patients with LGA were included in the analysis, and MT was observed in 14.4% of cases in the present study. For MT, 53.8% of patients with MT transformed to glioblastoma, while 46.2% differentiated to anaplastic astrocytoma. Factors associated with MT included supratentorial tumor (subdistribution hazard ratio [SHR] 4.54, 95% confidence interval [CI] 1.08–19.10), midline shift > 1 cm (SHR 8.25, 95% CI 2.18–31.21), and nontotal resection as follows: subtotal resection (SHR 5.35, 95% CI 1.07–26.82), partial resection (SHR 10.90, 95% CI 3.13–37.90), and biopsy (SHR 11.10, 95% CI 2.88–42.52). Conclusion MT in patients with LGA significantly changed the natural history of the disease to an unfavorable prognosis. Analysis of patients' clinical characteristics from the present study identified supratentorial LGA, a midline shift more than 1 cm, and extent of resection as risk factors associated with MT. The more extent of resection would significantly help to decrease tumor burden and MT. In addition, future molecular research efforts are warranted to explain the pathogenesis of MT.

Functional outcome and long-term relapse rate in KOOS 4 vestibular schwannomas undergoing non-total resection

Functional outcome and long-term relapse rate in KOOS 4 vestibular schwannomas undergoing non-total resection

Risk Factors Associated with Malignant Transformation of Astrocytoma: Competing Risk Regression Analysis.

Background:Malignant transformation (MT) of low-grade astrocytoma (LGA) triggers a poor prognosis in benign tumors. Currently, factors associated with MT of LGA have been inconclusive. The present study aims to explore the risk factors predicting LGA progressively differentiation to malignant astrocytoma.Materials and Methods:The study design was a retrospective cohort study of medical record reviews of patients with LGA. Using the Fire and Grey method, the competing risk regression analysis was performed to identify factors associated with MT, using both univariate and multivariable analyses. Hence, the survival curves of the cumulative incidence of MT of each covariate were constructed following the final model.Results:Ninety patients with LGA were included in the analysis, and MT was observed in 14.4% of cases in the present study. For MT, 53.8% of patients with MT transformed to glioblastoma, while 46.2% differentiated to anaplastic astrocytoma. Factors associated with MT included supratentorial tumor (subdistribution hazard ratio [SHR] 4.54, 95% CI 1.08–19.10), midline shift >1 cm (SHR 8.25, 95% CI 2.18–31.21), nontotal resection as follows: Subtotal resection (SHR 5.35, 95% CI 1.07–26.82), partial resection (SHR 10.90, 95% CI 3.13–37.90), and biopsy (SHR 11.10, 95% CI 2.88–42.52).Conclusion:MT in patients with LGA significantly changed the natural history of the disease to an unfavorable prognosis. Analysis of patients' clinical characteristics from the present study identified supratentorial LGA, a midline shift more than 1 cm, and extent of resection as risk factors associated with MT. The more extent of resection would significantly help to decrease tumor burden and MT. In addition, future molecular research efforts are warranted to explain the pathogenesis of MT.

The role of apparent diffusion coefficient as a predictive factor for tumor recurrence in patients with cerebellopontine angle epidermoid tumor.

Intracranial epidermoid tumors are slowly growing benign tumors, but due to adjacent critical neurovascular structures, surgical resection is challenging, with the risk of recurrence. The apparent diffusion coefficient (ADC) has been used to evaluate the characteristics of brain tumors, but its utility for intracranial epidermoid tumors has not been specifically explored. This study analyzed the utility of preoperative ADC values in predicting tumor recurrence for patients with intracranial epidermoid tumors. Between 2008 and 2019, 21 patients underwent surgery for cerebellopontine angle (CPA) epidermoid tumor, and their preoperative ADC data were analyzed. The patients were divided into two groups: the recurrence group, defined by regrowth of the remnant tumor or newly developed mass after gross total resection on magnetic resonance imaging (MRI); and the stable group, defined by the absence of growth or evidence of tumor on MRI. Receiver operating characteristic (ROC) analysis was used to obtain the ADC cutoff values for predicting tumor recurrence. The prognostic value of the ADC was assessed using Kaplan-Meier curves. The minimum ADC values were significantly lower in the recurrence group than in the stable tumor group (P = 0.020). ROC analysis showed that a minimum ADC value lower than 804.5 × 10-6 mm2/s could be used to predict higher recurrence risk of CPA epidermoid tumors. Non-total resection and mean and minimum ADC values lower than the respective cutoffs were negative predictors of recurrence-free survival. Minimum ADC values could be useful in predicting the recurrence of CPA epidermoid tumors.

Evolving Role of Non-Total Resection in Management of Acoustic Neuroma in the Gamma Knife Era.

To examine patients with residual tumor after vestibular schwannoma (VS) resection with focus on need for further therapy, including stereotactic radiosurgery (SRS) and revision surgery. Retrospective review at two tertiary otology referral centers. Patients undergoing primary surgery for VS from 2007 to 2017. Degree of resection and need for further treatment. Of 289 patients undergoing surgery, 38 (13.1%) underwent subtotal resections (<95% of tumor resected) and 77 (26.6%) underwent near-total resections (≥95% but <100%). Patients with any residual tumor had larger tumors preoperatively (mean estimated volume 6.3 cm versus 2.1 cm, p < 0.0005) but were otherwise clinically and demographically similar to the population as a whole. Further treatment (surgery or SRS) was needed in 4.6, 14.3, and 50.0% of patients after gross total, near-total, and subtotal resections, respectively (p < 0.0005). Patients undergoing additional therapy had larger residual tumors (median post- to preoperative estimated volume ratio 0.09 versus 0.01, p < 0.0005). Patients undergoing subtotal and near-total resections had poorer facial function at ultimate follow up than those undergoing gross total resections (p = 0.001), likely due to larger tumors and more difficult resections. Literature review revealed higher rates of gross total resection as well as facial palsy in the pre-SRS era. Residual tumor following VS resection is more common today than in the pre-SRS era. Availability of SRS may encourage leaving residual tumor intraoperatively to preserve neural structures. Current surgical strategies decrease surgical morbidity but necessitate further treatment in over 10% of cases.

Aberrant Expression of Extracellular Signal-Regulated Kinase and 15-Hydroxyprostaglandin Dehydrogenase Indicates Radiation Resistance and Poor Prognosis for Patients with Clival Chordomas

To explore molecular markers of radiosensitivity and prognostic factors in patients with clival chordomas. Retrospective review was performed of 35 patients. Mean follow-up interval was 66.37 months (range, 29-106 months). Kaplan-Meier method was used for survival analysis. Immunohistochemical staining was used to detect expression levels of extracellular signal-regulated kinase (ERK) and 15-hydroxyprostaglandin dehydrogenase (HPGD). Total resection was achieved in 12 cases, subtotal resection was achieved in 12 cases, and partial resection was achieved in 11 cases. Radiation-sensitive group comprised 17 cases, and radiation-resistant (RR) group comprised 18 cases. Five-year progression-freesurvival (PFS) rates in total resection and nontotal resection groups were 46.3% and 10.1%, respectively (P=0.005). Mean H-scores of ERK in radiation-resistant and radiation-sensitive groups were 110.38 and 82.98, respectively (P= 0.043). Mean H-scores of HPGD in radiation-resistant and radiation-sensitive groups were 178.62 and 203.47, respectively (P= 0.031). Mean PFS in low ERK expression group (58.61 months) was significantly longer than mean PFS in high ERK expression group (24.94 months) (P= 0.022). Mean PFS in high HPGD expression group (39.54 months) was significantly longer than mean PFS in low HPGD expression group (9.5 months) (P= 0.013). Radical resection with protection of important structures is the most effective treatment of clival chordomas. High HPGD expression and low ERK expression were associated with radiation sensitivity and better prognosis. HPGD and ERK can be used as biomarkers to predict prognosis and guide treatment.

Endoscopic endonasal surgery for epidermoid and dermoid cysts: a 10-year experience.

Epidermoid and dermoid cysts may be found along the cranial base and are commonly resected via open transcranial approaches. The use of endoscopic endonasal approaches for resection of these tumors has been rarely reported. The authors retrospectively reviewed the medical records of 21 patients who underwent endoscopic endonasal surgery for epidermoid and dermoid cyst resection at the University of Pittsburgh Medical Center between January 2005 and June 2014. Surgical outcomes and variables that might affect the extent of resection and complications were analyzed. Total resection (total removal of cyst contents and capsule) was achieved in 8 patients (38.1%), near-total resection (total removal of cyst contents, incomplete removal of cyst capsule) in 9 patients (42.9%), and subtotal resection (incomplete removal of cyst contents and capsule) in 4 patients (19%). Larger cyst volume (≥ 3 cm3) and intradural location (15 cysts) were significantly associated with nontotal resection (p = 0.008 and 0.0005, respectively). In the whole series, surgical complications were seen in 6 patients (28.6%). No complications were observed in patients with extradural cysts. Among the 15 patients with intradural cysts, the most common surgical complication was postoperative CSF leak (5 patients, 33.3%), followed by postoperative intracranial infection (4 patients, 26.7%). Larger cysts and postoperative CSF leak were associated with intracranial infection (p = 0.012 and 0.028, respectively). Subtotal resection was marginally associated with intracranial infection when compared with total resection (p = 0.091). All patients with neurological symptoms improved postoperatively with the exception of 1 patient with unchanged abducens nerve palsy. Endoscopic endonasal approaches may be effectively used for resection of epidermoid and dermoid cysts in carefully selected cases. These approaches are recommended for cases in which a total or near-total resection is possible in addition to a multilayer cranial base reconstruction with vascularized tissue to minimize the risk of intracranial infection.

Intradural Extramedullary Bronchogenic Cyst: Clinical and Radiologic Characteristics, Surgical Outcomes, and Literature Review.

An intradural extramedullary bronchogenic cyst (IEBC) is a congenital malformation and an extremely rare type of endodermal cyst. This study aims to report the clinical and radiologic characteristics and surgical outcomes of IEBCs and to review the available literature. The medical records of 6 patients (3 female) with pathologically confirmed bronchogenic cysts involving the spinal cord between 2009 and 2016 were retrospectively reviewed, and follow-up evaluations were performed. Of the 6 symptomatic lesions, 4 were located in the cervical vertebra, 1 at the lumbar vertebra, and the remaining 1 at the craniocervical junction. Radiographs showed signals similar to cerebral spinal fluid on all magnetic resonance imaging sequences without contrast enhancement. Total resection was achieved in 3 patients. Histopathology revealed simple and pseudostratified respiratory epithelium with benign subepithelial mucous glands and fat components neighboring the cyst. After a mean follow-up duration of 49.2 months, 2 asymptomatic residual lesions regrew after nontotal resection. In previous literature including 19 cases, most IEBCs (84.2%) tended to be homogeneous and well demarcated on radiologic images, and 85.7% were not contrast enhancing. Cervical or upper thoracic segments were predilection sites with intradural extramedullary localization. The majority of IEBCs had similar benign histological features. The recurrence rate was 15.4% after nontotal resection but nil after total resection. IEBCs displayed an indolent course, and the most effective management with positive outcomes was total resection. Nontotal resection, cystic fenestration, and biopsy, which were associated with recurrence, should be avoided.

Ventriculoscopic Approach for Intraventricular Neurocysticercosis: A Single Neurosurgical Center's Experience.

To retrospectively analyze patients with intraventricular neurocysticercosis (NCC) who underwent a ventriculoscopic approach at a single neurosurgical center and assess the efficacy of this treatment in patients with intraventricular NCC. Patients with intraventricular NCC patients who underwent surgery via a ventriculoscopic approach between January 2008 and March 2014 at Beijing Tiantan Hospital were analyzed. A total of 21 patients with intraventricular NCC (15 men and 6 women; mean age, 38.0 ± 16.8 years; range, 9-65 years) were enrolled in the study. Ten of the patients underwent complete resection. The median progression-free survival (PFS) was 53.7 months (95% confidence interval, 31.7-75.6 months). On univariate analysis, PFS was better in the patients who underwent total NCC resection compared with those who underwent nontotal resection (P < 0.05). The ventriculoscopic approach to NCC resection is an effective technique with unique advantages for intraventricular NCC. Radical resection is necessary for intraventricular NCC. Combined application of rigid and flexible endoscopes can improve the total removal rate of intraventricular NCC.

Adult IDH wild-type lower-grade gliomas should be further stratified.

Astrocytoma of the isocitrate dehydrogenase (IDH) wild-type gene is described as a provisional entity within the new World Health Organization (WHO) classification. Some groups believe that IDH wild-type lower-grade gliomas, when interrogated for other biomarkers, will mostly turn out to be glioblastoma. We hypothesize that not all IDH wild-type lower-grade gliomas have very poor outcomes and the group could be substratified prognostically. Seven hundred and eighteen adult WHO grades II and III patients with gliomas from our hospitals were re-reviewed and tested for IDH1/2 mutations. One hundred and sixty-six patients with IDH wild-type cases were identified for further studies, and EGFR and MYB amplifications, mutations of histone H3F3A, TERT promoter (TERTp), and BRAF were examined. EGFR amplification, BRAF, and H3F3A mutations were observed in 13.8%, 6.9%, and 9.5% of patients, respectively, in a mutually exclusive pattern in IDH wild-type lower-grade gliomas. TERTp mutations were detected in 26.8% of cases. Favorable outcome was observed in patients with young age, oligodendroglial phenotype, and grade II histology. Independent adverse prognostic values of older age, nontotal resection, grade III histology, EGFR amplification, and H3F3A mutation were confirmed by multivariable analysis. Tumors were further classified into "molecularly" high grade (harboring EGFR, H3F3A, or TERTp) (median overall survival = 1.23 y) and lower grade (lacking all of the 3) (median overall survival = 7.63 y) with independent prognostic relevance. The most favorable survival was noted in molecularly lower-grade gliomas with MYB amplification. Adult IDH wild-type lower-grade gliomas are prognostically heterogeneous and do not have uniformly poor prognosis. Clinical information and additional markers, including MYB, EGFR, TERTp, and H3F3A, should be examined to delineate discrete favorable and unfavorable prognostic groups.

OS11.4 Adult IDH wild-type lower-grade gliomas should be further stratified

IDH wild-type astrocytoma is described as a provisional entity within the new WHO classification. Some groups believe that IDH wild-type lower-grade gliomas, when interrogated for other biomarkers, will mostly turn out to be glioblastoma. We hypothesize that not all IDH wild-type lower-grade gliomas have very poor outcomes and the group could be sub-stratified prognostically. 718 adult WHO Grade II and III gliomas from our hospitals were re-reviewed and tested for IDH1/2 mutations. 166 IDH wild-type cases were identified for further studies and EGFR and MYB amplifications, mutations of histone H3F3A, TERT promoter and BRAF were examined. EGFR amplification, BRAF and H3F3A mutations were observed in 13.3%, 8.6% and 9.1% respectively, in a mutually exclusive pattern in IDH wild-type lower-grade gliomas. TERTp mutations were detected in 26.4% of cases. Favorable outcome was observed in tumors with oligodendroglial phenotype, grade II histology and total resection. Independent adverse prognostic values of older age, non-total resection, grade III histology, EGFR amplification, and H3F3A mutation were confirmed by multivariate analysis. Tumors were further classified into “molecularly” high grade (harboring EGFR, H3F3A or TERTp) (median OS=1.2 years) and lower-grade (lacking all of the three) (median OS=7.6 years) with independent prognostic relevance. The most favorable survival was noted in molecularly lower-grade gliomas with MYB amplification. In summary, adult IDH wild-type lower-grade gliomas are prognostically heterogeneous and do not have uniformly poor prognosis. Clinical information and additional markers including MYB, EGFR, TERTp and H3F3A should be examined to delineate bad and good prognostic groups.

Facial Nerve Function and Quality of Resection in Large and Giant Vestibular Schwannomas Surgery Operated By Retrosigmoid Transmeatal Approach in Semi-sitting Position with Intraoperative Facial Nerve Monitoring.

Large and giant vestibular schwannomas pose a real problem in their management. The preservation of facial nerve function may limit tumor resection despite the use of intraoperative monitoring of the facial nerve. In Algeria, vestibular schwannomas represent 5% of all intracranial tumors operated on, 80.5% of which are large or giant. From January 2010 to December 2015, 151 large and giant vestibular schwannomas were operated in our department. Tumor diameter was between 30 and 60mm. The most common presenting symptom was hearing loss, which was observed in 41.66% of all our patients. All patients were operated in the semi-sitting position with opening of the posterior wall of the internal auditory canal and under continuous intraoperative facial nerve function monitoring. Tumor resection was total in 126 patients. Anatomic preservation of the facial nerve was the reason for nontotal resection in 25 patients. The facial nerve was anatomically preserved in 149 patients. Two years after surgery, the facial nerve function was grade I-II House-Brackmann (H-B) score in 124 cases (82%),grade III-IV H-B score in 21 cases (14%), and grade V-VI H-B score in 06 cases (04%). The status and the improvement of postoperative facial nerve function depend on 4 factors: anatomic preservation of nerve,stimulation threshold, cystic form, and the presence of train activity. The development of anesthesia techniques and microsurgery and the systematic use of intraoperative monitoring of the facial nerve have allowed us to move from a life preservation era to another era of preservation of function.

Outcomes of Endonasal and Lateral Approaches to Petroclival Meningiomas.

Transpetrosal approaches for the treatment of petroclival meningiomas are often associated with substantial morbidity and long recovery. With the goal of early clinical improvement, we have used less invasive surgical approaches for petroclival meningiomas. We retrospectively reviewed 32 patients with petroclival meningiomas. Eleven patients (34.4%) were managed with lateral approaches (retrosigmoid or far lateral approach), 17 (53.1%) with anterior midline approaches (endoscopic endonasal approach [EEA]), and 4 (12.5%) with a combination. The average Karnofsky Performance Score (KPS) at presentation was 73.8. The average postoperative KPS improved to 87.9 (P < 0.001) during short-term follow-up of 14 months (range, 1-42) and was significantly higher in primary tumors (P= 0.013), tumors <4 cm (P= 0.039), and tumors without vascular encasement (P= 0.002) but remained significant regardless of age, tumor size, or vascular encasement. The greatest benefit occurred withprimary tumors, in young patients and in those who underwent nontotal resection (P < 0.001). EEA had a significantly greater potential for improved KPS (P= 0.002). Gross (n= 6) or near total (n= 9) resection was achieved in 15 of 32 cases (47%). Complications included new cranial nerve palsies affecting mainly the abducens nerve (18.7%). New lower cranial nerve palsies occurred in only 1 case (3.1%). Other complications included postoperative hydrocephalus (15.6%) and cerebrospinal fluid leak (28.1%). One patient died in the perioperative period (3.1%). In the short-term, less aggressive cranial base approaches, including retrosigmoid exposures and the recently introduced EEA, are effective alternatives to transpetrosal approaches for debulking petroclival meningiomas with significant early clinical improvement and limited major surgical complications.

Clinical Features and Prognostic Factors of Children and Adolescents with Clival Chordomas

Chordomas in children and adolescents are rare, and minimal published information is available. Our aim was to research clinical features and prognostic factors associated with clival chordomas in younger patients. The study included 25 patients (10 males and 15 females). Average follow-up time was 42.95 months (range, 2-108 months). Kaplan-Meier analysis was used to determine overall survival (OS) and progression-free survival. Pearson correlation was used to perform correlation analysis. Immunohistochemistry was used to detect Ki-67, cytokeratin 8 (CK8), platelet-derived growth factor receptor-β, and brachyury expression levels. Average age (± SD) of patients was 14.44 (3.44) years. Total resection was achieved in 5 cases, and nontotal resection was achieved in 20 cases. Average OS of patients with Karnofsky performance scale score ≥90 and patients in the total resection group was significantly longer compared with OS of patients with Karnofsky performance scale score <90 (P= 0.041) and patients in the nontotal resection group (P= 0.0497). Patients with lower Ki-67 expression levels had longer OS (P= 0.0207). Progression-free survival of patients with lower CK8 expression levels was significantly longer compared with patients with higher CK8 levels (P= 0.008). Expression levels of platelet-derived growth factor receptor-β were significantly correlated with expression levels of brachyury (P= 0.016). In children and adolescents with clival chordomas, higher preoperative Karnofsky performance scale score, total resection, and lower levels of Ki-67 and CK8 expression are favorable prognostic factors. Platelet-derived growth factor receptor-β may play a role in tumorigenesis and epithelial-mesenchymal transition of clival chordomas.

Relative ADC and Location Differ between Posterior Fossa Pilocytic Astrocytomas with and without Gangliocytic Differentiation.

Pilocytic astrocytomas, the most common posterior fossa tumors in children, are characterized by KIAA1549-BRAF fusions and shows excellent 5-year survival rates. Pilocytic astrocytoma with gangliocytic differentiation, a recently defined pilocytic astrocytoma variant that includes glial and neuronal elements similar to a ganglioglioma, may be distinguished from a classic ganglioglioma by molecular, radiologic, and histopathologic features. This study investigated whether imaging could distinguish posterior fossa pilocytic astrocytoma with and without gangliocytic differentiation. Preoperative MRIs (± CTs) of 41 children (age range, 7 months to 15 years; mean age, 7.3 ± 3.7 years; 58.5% male) with pilocytic astrocytoma with gangliocytic differentiation (n = 7) or pilocytic astrocytoma (n = 34) were evaluated; differences in tumor location, morphology, and minimum relative ADC between tumor types were compared (Wilcoxon rank sum test, Fisher exact test). Histopathology and BRAF fusion/mutation status were reviewed. Associations of progression-free survival with diagnosis, imaging features, and BRAF status were examined by Cox proportional hazards models. Pilocytic astrocytoma with gangliocytic differentiation appeared similar to pilocytic astrocytoma but had lower minimum relative ADC (mean, 1.01 ± 0.17 compared with 2.01 ± 0.38 for pilocytic astrocytoma; P = .0005) and was more commonly located within midline structures (P = .0034). BRAF status was similar for both groups. Non-total resection (hazard ratio, 52.64; P = .0002), pilocytic astrocytoma with gangliocytic differentiation diagnosis (hazard ratio, 4.66; P = .0104), and midline involvement (hazard ratio, 3.32; P = .0433) were associated with shorter progression-free survival. Minimum relative ADC and tumor location may be useful adjuncts to histopathology in differentiating pilocytic astrocytoma with gangliocytic differentiation from pilocytic astrocytoma. Shorter progression-free survival in pilocytic astrocytoma with gangliocytic differentiation is likely due to a propensity for involvement of midline structures and poor resectability.

Foramen magnum meningiomas: surgical results and risks predicting poor outcomes based on a modified classification.

OBJECTIVE This study aimed to evaluate neurological function and progression/recurrence (P/R) outcome of foramen magnum meningioma (FMM) based on a modified classification. METHODS This study included 185 consecutive patients harboring FMMs (mean age 49.4 years; 124 females). The authors classified the FMMs into 4 types according to the previous classification of Bruneau and George as follows: Type A (n = 49, 26.5%), the dural attachment of the lesion grows below the vertebral artery (VA); Type B (n = 39, 21.1%), the dural attachment of the lesion grows above the VA; Type C1 (n = 84, 45.4%), the VA courses across the lesion with or without VA encasement or large lesions grow both above and below the bilateral VA; and Type C2 (n = 13, 7.0%), Type C1 plus partial/total encasement of the VA and extradural growth. RESULTS The median preoperative Karnofsky Performance Scale (KPS) score was 80. Gross-total resection (GTR) was achieved in 154 patients (83.2%). Lower cranial nerve morbidity was lowest in Type A lesions (16.3%). Type C2 lesions were inherently larger (p = 0.001), had a greater percentage of ventrolateral location (p = 0.009) and VA encasement (p < 0.001), lower GTR rate (p < 0.001), longer surgical duration (p = 0.015), higher morbidity (38.5%), higher P/R rate (30.8%, p = 0.009), and poorer recent KPS score compared with other types. After a mean follow-up duration of 110.3 months, the most recent follow-up data were obtained in 163 patients (88.1%). P/R was observed in 13 patients (7.2%). The median follow-up KPS score was 90. Compared with preoperative status, recent neurological status was improved in 91 (49.2%), stabilized in 76 (41.1%), and worsened in 18 (9.7%) patients. The multivariate Cox proportional hazard regression model demonstrated Type C2 (HR 3.94, 95% CI 1.04-15.0, p = 0.044), nontotal resection (HR 6.30, 95% CI 1.91-20.8, p = 0.003), and pathological mitosis (HR 7.11, 95% CI 1.96-25.8, p = 0.003) as independent adverse predictors for tumor P/R. Multivariate logistic regression analysis identified nontotal resection (OR 4.06, 95% CI 1.16-14.2, p = 0.029) and pathological mitosis (OR 6.29, 95% CI 1.47-27.0, p = 0.013) as independent risks for poor outcome (KPS score < 80). CONCLUSIONS The modified classification helped to predict surgical outcome and P/R in addition to the position of the lower cranial nerves. Preoperative imaging studies and neurological function should be reviewed carefully to establish an individualized management strategy to improve long-term outcome.

Long-Term Functional and Recurrence Outcomes of Surgically Treated Jugular Foramen Schwannomas: A 20-Year Experience

To investigate the outcomes of jugular foramen schwannomas (JFSs) and to evaluate the risk factors for tumor recurrence and poor final outcomes. Between 1993 and 2013, 133 patients (68 female patients) with JFSs were surgically treated. Clinical charts were reviewed, and scheduled follow-up examinations were performed. The average preoperative Karnofsky Performance Scale (KPS) score was 79.6. The JFSs were classified as follows: 65 cases, type A; 15 cases, type B; 5 cases, type C; and 48 cases, type D. Gross total resection was achieved in 107 (80.5%) patients. Transient and permanent morbidities affecting cranial nerves IX and X were 19.8% and 11.5%, respectively. After a mean follow-up duration of 108.0 months, 13 (9.9%) patients experienced recurrence. The most recent KPS scores averaged 83.7. Compared with the preoperative KPS score, the most recent KPS score was improved in 87 (65.4%) patients and stabilized in 29 (21.8%) patients. The presence of a solid tumor (hazard ratio [HR] = 5.815, P = 0.010), nontotal resection (HR = 4.613, P = 0.007), and pathologic mitoses (HR = 11.018, P < 0.001) were independent risk factors for tumor recurrence. Decreased preoperative KPS score (per 10 points) (odds ratio [OR] = 2.483, P = 0.027), a less soft tumor consistency (OR = 2.257, P = 0.039), and a solid tumor (OR = 3.755, P = 0.041) were risk factors for poor long-term outcomes. Quality of life and preservation of neurologic function are the goals of surgical treatment of JFSs. Favorable long-term surgical outcomes for JFSs can be achieved. Morbidity of cranial nerves IX and X is significant, and patients with nontotal resection or pathologic mitosis should be followed closely.

Surgical management and outcomes of petroclival meningiomas: a single-center case series of 259 patients

Surgical management of petroclival meningiomas is challenging. Various and inconsistent outcome and prognostic factors of the lesions have been evaluated previously. In the present study, the surgical outcome, philosophy, and experience of petroclival meningiomas are detailed based on a large patient series. A series of 259 patients with petroclival meningiomas (70 males and 189 females) were surgically treated. Clinical charts and radiographs were reviewed. Follow-up results were evaluated. The preoperative Karnofsky Performance Scale (KPS) score was 74.2 ± 10.5. The mean tumor size was 4.3 ± 1.0 cm. The gross total resection (GTR) rate was 52.5%. During a mean follow-up period of 55.3 months, recurrence/progression (R/P) occurred in 11 patients. The recent KPS score was 78.4 ± 22.7, it improved in 139 (57.2%) patients and stabilized in 53 (21.8%) patients, and 201 (82.7%) patients lived independently. The risk factors affecting the KPS score included (but were not limited to) age ≥ 60, preoperative KPS ≤ 60, and brainstem edema. The adverse factors contributing to R/P-free survival included (but were not limited to) non-total resection and the absence of the subarachnoid space. The R/P-free survival rate was 94.5% at 5 years and 91.2% at 9 years. The overall survival rate was 94.7% at 5 years and 94.7% at 9 years. Favorable outcomes from petroclival meningiomas could be achieved by microsurgery. Neurological function and quality of life were prioritized, and GTR was attempted. Risk factors should be considered in surgical schemes, and tumor recurrence should be aggressively monitored and treated.