Rate Of Gross Total Resection Research Articles

P62. Changing the clinical course of glioma patients by preoperative motor mapping with navigated transcranial magnetic brain stimulation

Objective Mapping of the motor cortex by navigated transcranial magnetic stimulation (nTMS) can be used for preoperative planning in brain tumor patients. Just recently, it has been proven to actually change outcomes by increasing the rate of gross total resection and by reducing the surgery-related rate of paresis. Yet, we also need data that shows if these changes also lead to a changed clinical course. Methods We prospectively enrolled 70 patients with supratentorial motor eloquently located high-grade gliomas (HGG) undergoing preoperative nTMS (2010–2014) and matched these patients with 70 HGG patients who did not undergo preoperative nTMS (2007–2010). Results The overall size of the craniotomy was 25.3 ± 9.7 cm 2 (median 22.5 cm 2 , range 12.0–61.6 cm 2 ) for nTMS and 30.8 ± 13.2 cm 2 (median 28.0 cm 2 , range 4.6–65.7 cm 2 ) for non-nTMS patients ( p = 0.0058). Median inpatient stay was 12 days for the nTMS and 14 days for the non-nTMS group (nTMS: CI 10.5–13.5 days; non-nTMS: CI 11.6–16.4 days; p = 0.0446). 60.0% of patients of the nTMS group and 54.3% of patients of the non-nTMS group were eligible for postoperative chemotherapy (OR 1.2630, CI 0.6458–2.4710, p = 0.4945), while 67.1% of nTMS patients and 48.6% of non-nTMS patients received radiotherapy (OR 2.1640, CI 1.0910–4.2910, p = 0.0261). There was a trend toward higher survival in the nTMS group (nTMS: 15.7 ± 10.9 months; non-nTMS: 11.9 ± 10.3 months; p = 0.1310). Moreover, 3, 6, and 9 month survival was significantly better in the nTMS group ( p = 0.0298, p = 0.0015, and p = 0.0167), while there was a trend in 12 month survival ( p = 0.0544). Conclusion The data illustrate that HGG patients benefit from preoperative nTMS motor mapping with regard to craniotomy size, duration of inpatient stay, and eligibility for adjuvant therapy. Even more important, a trend towards higher survival rates for the nTMS group compared to the non-nTMS group was revealed.

Intraoperative Magnetic Resonance Imaging in Intracranial Glioma Resection: A Single-Center, Retrospective Blinded Volumetric Study

Intraoperative magnetic resonance imaging (IoMRI) was devised to overcome brain shifts during craniotomies. Yet, the acceptance of IoMRI is limited. To evaluate impact of IoMRI on intracranial glioma resection outcome including overall patient survival. A retrospective review of records was performed on a cohort of 164 consecutive patients who underwent resection surgery for newly diagnosed intracranial gliomas either with or without IoMRI technology performed by 2 neurosurgeons in our center. Patient follow-up was at least 5 years. Extent of resection (EOR) was calculated using pre- and postoperative contrast-enhanced and T2-weighted MR-images. Adjusted analysis was performed to compare gross total resection (GTR), EOR, permanent surgery-associated neurologic deficit, and overall survival between the 2 groups. Overall median EOR was 92.1%, and 97.45% with IoMRI use and 89.9% without IoMRI, with crude (unadjusted) P < 0.005. GTR was achieved in 49.3% of IoMRI cases, versus in only 21.4% of no-IoMRI cases, P < 0.001. GTR achieved was more with the use of IoMRI among gliomas located in both eloquent and noneloquent brain areas, P = 0.017 and <0.001, respectively. Permanent surgery-associated neurologic deficit was not (statistically) more significant with no-IoMRI, P = 0.284 (13.8% vs. 6.7%). In addition, the IoMRI group had better 5-year overall survival, P < 0.001. This study shows that the use of IoMRI was associated with greater rates of EOR and GTR, and better overall 5-year survival in both eloquent brain areas located and non-eloquent brain areas located gliomas, with no increased risk of neurologic complication.

Long-term quality of life after endonasal endoscopic resection of adult craniopharyngiomas.

Craniopharyngiomas are benign parasellar tumors for which surgical removal, although potentially curative, often leads to morbidity with resulting decreases in quality of life (QOL). The endonasal endoscopic approach is a minimal-access technique for removing these tumors and may reduce postoperative morbidity. The QOL following this method for resection of craniopharyngiomas has not been documented. The authors reviewed a database of consecutive endonasal endoscopic surgeries done at Weill Cornell Medical College. Adult patients with histologically proven craniopharyngiomas were included who had completed either only postoperative (> 9 months) or both pre- and postoperative QOL forms, the Anterior Skull Base Quality of Life (ASBQ) questionnaire, and the 22-Item Sinonasal Outcome Test (SNOT-22). Rates of gross-total resection (GTR), complications, and visual and endocrine function were collected. Retrospective independence (Wen score) was also assigned. A contemporaneous group of patients undergoing endonasal endoscopic pituitary macroadenoma resection was used as a control. This study included 33 procedures performed in 31 patients. The average postoperative ASBQ score was 3.35 and the SNOT-22 score was 19.6. Better QOL was associated with GTR and postoperative radiation. Worse QOL was associated with persistent visual defects, hypopituitarism, tumor recurrence, increase in body mass index, and worsening Wen score. In a subset of 10 patients, both pre- and postoperative (> 9 months) QOL scores were obtained. Both ASBQ and SNOT-22 scores showed stability and a trend toward improvement, from 2.93 ± 0.51 to 2.96 ± 0.47 (ASBQ) and 23.7 ± 10.8 to 18.4 ± 11.6 (SNOT-22). Compared with 62 patients undergoing endoscopic pituitary macroadenoma resection, patients with craniopharyngiomas had worse postoperative QOL on the ASBQ (3.35 vs 3.80; p = 0.023) and SNOT-22 (19.6 vs 13.4; p = 0.12). This report of validated site-specific QOL following endoscopic surgery for craniopharyngiomas shows an overall maintenance of postoperative compared with preoperative QOL. Better QOL could be seen in patients with GTR and radiation therapy, and worse QOL was found in patients with visual or endocrine deficits. Nevertheless, patients with craniopharyngiomas still had worse QOL than those undergoing similar surgery for pituitary macroadenomas, confirming the worse prognosis of craniopharyngiomas even when removed via a minimally invasive approach. These measures should serve as benchmarks for comparison with open transcranial approaches to similar tumors.

Changing the clinical course of glioma patients by preoperative motor mapping with navigated transcranial magnetic brain stimulation.

BackgroundMapping of the motor cortex by navigated transcranial magnetic stimulation (nTMS) can be used for preoperative planning in brain tumor patients. Just recently, it has been proven to actually change outcomes by increasing the rate of gross total resection (GTR) and by reducing the surgery-related rate of paresis significantly in cohorts of patients suffering from different entities of intracranial lesions. Yet, we also need data that shows whether these changes also lead to a changed clinical course, and can also be achieved specifically in high-grade glioma (HGG) patients.MethodsWe prospectively enrolled 70 patients with supratentorial motor eloquently located HGG undergoing preoperative nTMS (2010–2014) and matched these patients with 70 HGG patients who did not undergo preoperative nTMS (2007–2010).ResultsOn average, the overall size of the craniotomy was significantly smaller for nTMS patients when compared to the non-nTMS group (nTMS: 25.3 ± 9.7 cm2; non-nTMS: 30.8 ± 13.2 cm2; p = 0.0058). Furthermore, residual tumor tissue (nTMS: 34.3%; non-nTMS: 54.3%; p = 0.0172) and unexpected tumor residuals (nTMS: 15.7%; non-nTMS: 32.9%; p = 0.0180) were less frequent in nTMS patients. Regarding the further clinical course, median inpatient stay was 12 days for the nTMS and 14 days for the non-nTMS group (nTMS: CI 10.5 – 13.5 days; non-nTMS: CI 11.6 – 16.4 days; p = 0.0446). 60.0% of patients of the nTMS group and 54.3% of patients of the non-nTMS group were eligible for postoperative chemotherapy (OR 1.2630, CI 0.6458 – 2.4710, p = 0.4945), while 67.1% of nTMS patients and 48.6% of non-nTMS patients received radiotherapy (OR 2.1640, CI 1.0910 – 4.2910, p = 0.0261). Moreover, 3, 6, and 9 months survival was significantly better in the nTMS group (p = 0.0298, p = 0.0015, and p = 0.0167).ConclusionsWith the limitations of this study in mind, our data show that HGG patients might benefit from preoperative nTMS mapping.

Study of the biodistribution of fluorescein in glioma-infiltrated mouse brain and histopathological correlation of intraoperative findings in high-grade gliomas resected under fluorescein fluorescence guidance.

Intravenous fluorescein sodium has been used during resection of high-grade gliomas to help the surgeon visualize tumor margins. Several studies have reported improved rates of gross-total resection (GTR) using high doses of fluorescein sodium under white light. The recent introduction of a fluorescein-specific camera that allows for high-quality intraoperative imaging and use of very low dose fluorescein has drawn new attention to this fluorophore. However, the ability of fluorescein to specifically stain glioma cells is not yet well understood. The authors designed an in vitro model to assess fluorescein uptake in normal human astrocytes and U251 malignant glioma cells. An in vivo experiment was also subsequently designed to study fluorescein uptake by intracranial U87 malignant glioma xenografts in male nonobese diabetic/severe combined immunodeficient mice. A genetically induced mouse glioma model was used to adjust for the possible confounding effect of an inflammatory response in the xenograft model. To assess the intraoperative application of this technology, the authors prospectively enrolled 12 patients who underwent fluorescein-guided resection of their high-grade gliomas using low-dose intravenous fluorescein and a microscope-integrated fluorescence module. Intraoperative fluorescent and nonfluorescent specimens at the tumor margins were randomly analyzed for histopathological correlation. The in vitro and in vivo models suggest that fluorescein demarcation of glioma-invaded brain is the result of distribution of fluorescein into the extracellular space, most likely as a result of an abnormal blood-brain barrier. Glioblastoma tumor cell-specific uptake of fluorescein was not observed, and tumor cells appeared to mostly exclude fluorescein. For the 12 patients who underwent resection of their high-grade gliomas, the histopathological analysis of the resected specimens at the tumor margin confirmed the intraoperative fluorescent findings. Fluorescein fluorescence was highly specific (up to 90.9%) while its sensitivity was 82.2%. False negatives occurred due to lack of fluorescence in areas of diffuse, low-density cellular infiltration. Margins of contrast enhancement based on intraoperative MRI-guided StealthStation neuronavigation correlated well with fluorescent tumor margins. GTR of the contrast-enhancing area as guided by the fluorescent signal was achieved in 100% of cases based on postoperative MRI. Fluorescein sodium does not appear to selectively accumulate in astrocytoma cells but in extracellular tumor cell-rich locations, suggesting that fluorescein is a marker for areas of compromised blood-brain barrier within high-grade astrocytoma. Fluorescein fluorescence appears to correlate intraoperatively with the areas of MR enhancement, thus representing a practical tool to help the surgeon achieve GTR of the enhancing tumor regions.

Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification.

OBJECT An important prognostic factor for the surgical outcome and recurrence of a pituitary adenoma is its invasiveness into parasellar tissue, particularly into the space of the cavernous sinus (CS). The aims of this study were to reevaluate the existing parasellar classifications using an endoscopic technique and to evaluate the clinical and radiological outcomes associated with each grade. METHODS The authors investigated 137 pituitary macroadenomas classified radiologically at least on one side as Grade 1 or higher (parasellar extension) and correlated the surgical findings using an endoscopic technique, with special reference to the invasiveness of the tumor into the CS. In each case, postoperative MRI was performed to evaluate the gross-total resection (GTR) rate and the rate of endocrinological remission (ER) in functioning adenomas. RESULTS The authors found a 16% rate of CS invasion during surgery for these macroadenomas. Adenomas radiologically classified as Grade 1 were found to be invasive in 1.5%, and the GTR/ER rate was 83%/88%. For Grade 2 adenomas, the rate of invasion was 9.9%, and the GTR/ER rate was 71%/60%. For Grade 3 adenomas, the rate of invasion was 37.9%, and the GTR/ER rate was 75%/33%. When the superior compartment of the CS (Grade 3A) was involved, the authors found a rate of invasion that was lower (p < 0.001) than that when the inferior compartment was involved (Grade 3B). The rate of invasion in Grade 3A adenomas was 26.5% with a GTR/ER rate of 85%/67%, whereas for Grade 3B adenomas, the rate of surgically observed invasion was 70.6% with a GTR/ER rate of 64%/0%. All of the Grade 4 adenomas were invasive, and the GTR/ER rate was 0%. A comparison of microscopic and endoscopic techniques revealed no difference in adenomas with Grade 1 or 4 parasellar extension. In Grade 2 adenomas, however, the CS was found by the endoscopic technique to be invaded in 9.9% and by microscopic evaluation to be invaded in 88% (p < 0.001); in Grade 3 adenomas, the difference was 37.9% versus 86%, respectively (p = 0.002). Grade 4 adenomas had a statistically significant lower rate of GTR than those of all the other grades. In case of ER only, Grade 1 adenomas had a statistically significant higher rate of remission than did Grade 3B and Grade 4 adenomas. CONCLUSIONS The proposed classification proved that with increasing grades, the likelihood of surgically observed invasion rises and the chance of GTR and ER decreases. The direct endoscopic view confirmed the low rate of invasion of Grade 1 adenomas but showed significantly lower rates of invasion in Grade 2 and 3 adenomas than those previously found using the microscopic technique. In cases in which the intracavernous internal carotid artery was encased (Grade 4), all the adenomas were invasive and the GTR/ER rate was 0%/0%. The authors suggest the addition of Grades 3A and 3B to distinguish the strikingly different outcomes of adenomas invading the superior CS compartments and those invading the inferior CS compartments.

Novel classification for surgical approach of petroclival meningiomas: A single-surgeon experience.

Management of petroclival meningiomas (PCMs) is a surgeons' challenge. Planning the surgical approach and extent of excision play a vital role. The current study discusses a novel grading system that may help to choose the surgical approach. We prospectively analyzed 76 patients operated after selecting the surgical approach through a novel grading system based on the extent of dural attachment of PCM in the posterior fossa. The mean age of the study group was 39.74 ± 13.38 years and 51% of the patients were women. Gross total resection (GTR) was achieved in 59 (77.6%) patients. Among patients who underwent subtotal resection (STR), the mean sagittal diameter of the tumor was greater than axial (4.6 ± 0.9 mm vs. 3.4 ± 1.3 mm; P = 0.01) and coronal diameters (4.6 ± 0.9 mm vs. 3.8 ± 1.4 mm; P < 0.01). The complication rate was 34.2%. The most frequent complication was cerebrospinal fluid leak in 10 (13.1%) patients. In patients where STR was done, the sagittal diameter of the tumor was higher in patients without complications (4.5 ± 0.9 mm vs. 3.9 ± 1.1 mm; P = 0.02). At 6 years follow-up, 6 patients where STR was performed, developed tumor progression. The proposed grading is helpful in achieving higher rates of GTR with minimal complications in surgical excision of PCMs. The role of sagittal diameter in planning the extent of excision needs further research.

Impact of intraoperative magnetic resonance imaging and functional neuronavigation on surgical outcome in patients with gliomas involving language areas.

Balancing the benefit of extensive tumor resection with the consequence of potential postoperative language deficits remains a challenge in glioma surgery involving language areas. This study is designed to evaluate the impact of intraoperative magnetic resonance imaging (iMRI) and functional neuronavigation on surgical outcome in patients with gliomas involving language areas. Two hundred seventeen patients were prospectively enrolled, 124 in the study group underwent iMRI and functional neuronavigation-guided microsurgery and 93 in the control group underwent conventional navigation-guided microsurgery. Extent of tumor volume resection (EoR) and rate of gross total resection (rGTR) were calculated perioperatively. Aphasia quotient (AQ) was assessed to evaluate the change of language function perioperatively and at 6-month follow-up. Survival outcome for glioblastoma, including progression-free survival (PFS) and overall survival (OS), were recorded. In 198 glioma patients (112 in the study group and 86 in the control group), EoR (95.50 versus 89.85%, p < 0.001) and rGTR (69.60 versus 47.70%, p = 0.002) were significantly higher in the study group, and language functions were also better at 6-month follow-up in the study group (87.47 versus 78.73, p = 0.001). Furthermore, postoperative new aphasia occurred in 34.8% of the control group, whereas it occurred only in 2.3% of the study group (p < 0.001). In addition, PFS (12.5 versus 6.6 m, p = 0.003) and OS (19.6 versus 13.0 m, p < 0.001) for patients with glioblastomas were dramatically prolonged in the study group than in the control group. These results indicated that iMRI and functional neuronavigation may help maximize tumor resection, minimize language deficits in patients with gliomas involving language areas, and improve survival time for patients with glioblastomas.

Early Gamma Knife stereotactic radiosurgery to the tumor bed of resected brain metastasis for improved local control.

Optimal case management after surgical removal of brain metastasis remains controversial. Although postoperative whole-brain radiation therapy (WBRT) has been shown to prevent local recurrence and decrease deaths, this modality can substantially decrease neurocognitive function and quality of life. Stereotactic radiosurgery (SRS) can theoretically achieve the same level of local control with fewer side effects, although studies conclusively demonstrating such outcomes are lacking. To assess the effectiveness and safety profile of tumor bed SRS after resection of brain metastasis, the authors performed a retrospective analysis of 110 patients who had received such treatment at the Centre Hospitalier Universitaire de Sherbrooke. They designed the study to identify risk factors for local recurrence and placed special emphasis on factors that could potentially be addressed. Patients who had received treatment from 2004 through 2013 were included if they had undergone surgical removal of 1 or more brain metastases and if the tumor bed was treated by SRS regardless of the extent of resection or prior WBRT. All cases were retrospectively analyzed for patient and tumor-specific factors, treatment protocol, adverse outcomes, cavity outcomes, and survival for as long as follow-up was available. Univariate and multivariate Cox regression analyses were performed to identify risk factors for local recurrence and predictors of increased survival times. Median patient age at first SRS treatment was 58 years (range 37-84 years). The most frequently diagnosed primary tumor was non-small cell lung cancer. The rate of gross-total resection was 81%. The median Karnofsky Performance Scale score was 90%. Tumor bed SRS was performed at a median of 3 weeks after surgery. Median follow-up and survival times were 10 and 11 months, respectively. Actuarial local control of the cavity at 12 months was 73%; median time to recurrence was 6 months. According to multivariate analysis, risk factors for recurrence were a longer surgery-to-SRS delay (HR 1.625, p = 0.003) and a lower maximum radiation dose delivered to the cavity (HR 0.817, p = 0.006). Factors not associated with increased recurrence were subtotal or piecemeal resections, prior WBRT, histology of the primary tumor, and larger cavity volume. No factors predictive of survival were identified. Symptomatic radiation-induced enhancement occurred in 6% of patients and leptomeningeal dissemination in 11%. Pathologically confirmed radiation-induced necrosis occurred in 1 (0.9%) patient. Adjuvant tumor bed SRS after the resection of brain metastasis is a valuable alternative to adjuvant WBRT. Risk factors for local recurrence are lower maximum radiation dose and a surgery-to-SRS delay longer than 3 weeks. Outcomes were not worse for patients who had undergone prior WBRT and subtotal or piecemeal resections. Pending the results of prospective randomized controlled trials, the authors' study supports the safety and efficacy of adjuvant SRS after resection of brain metastasis. SRS should be performed as early as possible, ideally within 3 weeks of the surgery.

BI-17 * EARLY COGNITIVE FUNCTION TESTS PREDICT EARLY PROGRESSION IN NEWLY-DIAGNOSED GLIOBLASTOMA

BACKGROUND: Cognitive dysfunction is a characteristic of tumor infiltration and a major morbidity causing functional deterioration in glioblastoma patients. Here we investigated whether pre-operative cognitive function tests can predict early prognosis in glioblastoma. METHODS: Consecutive patients who underwent glioma surgery were evaluated with pre-operative cognitive function tests, including Mini-Mental State Examination, Geriatric Depression Scale, Digit Span Tests (forward and backward), Controlled Oral Ward Association Test, Trail-Making Tests (TMT, type a, b, and c), and Stroop Tests. Pathologically-confirmed glioblastoma were treated with the standard protocol using radiation and temozolomide, and the 6-month progression-free survivals (PFS-6) were analyzed. RESULTS: Among 126 patients who underwent glioma surgery, 55 patients were diagnosed as glioblastoma, and 50 patients were finally eligible for the PFS-6 analysis. Thirty four patients (68%) achieved PFS-6. In the comparison of those without progression (PFS-6) with those with progression (No-PFS-6), there was no difference in the patients' demographics, tumor locations, tumor sizes, performance scores, initial symptoms, and genetic characteristics of tumors. The PFS-6 patients had higher rates of gross total resection, more use of concomitant chemo-radiation, and longer years of total education, than the no-PFS-6 patients. In the cognitive function tests, the PFS-6 patients had better performance in TMT-a, and TMT-b. Other cognitive function tests were not associated with PFS-6. In multivariate logistic regression, TMT-b was the only independent predictor for PFS-6, while age ( 12 yr), gross total resection, concomitant chemo-radiation, and TMT-a were not. Patients with good performance in TMT-b not only showed better early prognosis in the Kaplan-Meier survival analysis, but also had better recursive partitioning analysis classes. CONCLUSION: Our results indicate that the early cognitive function test before surgery can predict the early prognosis in glioblastoma. Poor executive function and slow psychomotor speed as detected in TMT suggest early progression of the tumor.

SO-06 * SURGICAL STRATEGIES AND OUTCOMES OF SPINAL EPENDYMOMAS OF DIFFERENT LENGTHS: ANALYSIS OF 210 PATIENTS

OBJECTIVE: The aim of this study was to investigate the surgical strategies and outcomes for spinal ependymomas of different lengths. METHODS: The authors used data from 210 patients with spinal ependymomas (WHO Grades II and III) in this 10-year retrospective study (January 1999 to December 2008), dividing them into 3 different groups according to length (spinal ependymomas 10 cm). All patients underwent tumor resection. The basic characteristics of the patients were reviewed and the functional status was assessed using the McCormick classification. RESULTS: There were 89, 81, and 40 patients, respectively, in the 3 groups ( 10 cm). Grosstotal resections (GTRs) were performed in 172 patients (81.9% overall, or 86.5%, 79.0%, and 77.5% in the 3 groups, respectively). Subtotal and partial resections were achieved in 38 patients (18.1%). Eight patients with medulla oblongata or upper cervical cord tumors received a tracheotomy postoperatively. The follow-up period ranged from 56 to 176 months. One hundred thirty-five patients (76.7%) experienced improvement, (88.2%, 83.8%, and 34.4% in the 10 cm groups, respectively). Thirty-three patients (18.8%) maintained their pretreatment status, and 8 patients (4.5%) showed deterioration following tumor resection at 6 months. CONCLUSIONS: Radical resection of spinal ependymomas could be performed in most patients, and the rate of GTR was significantly different in the different-length groups Patients with longer tumors had worse surgical results compared with those with small tumors and more postoperative neuropathic pain and proprioceptive deficits could usually be observed in patients harboring larger tumors. Early diagnosis and timely operation are critical to achieving better neurological outcomes. For tumors with dense adhesions, complete removal should be performed cautiously because of the significant incidence of neurological deterioration.

AT-57 * LONG-TERM CLINICAL RESULTS OF EXTENSIVE TUMOR REMOVAL FOLLOWED BY ACNU-BASED CHEMORADIOTHERAPY FOR 147 ANAPLASTIC GLIOMAS

INTRODUCTION: Recent randomized trials showed that highly extent of resection (EOR) and PCV chemoradiotherapy had therapeutic long-term efficacy to anaplastic glioma (AG). From 2000, we have consistently enforced extensive removal and ACNU-based chemoradiotherapy for AG. We report retrospective clinical results of a single institution. METHODS: We reviewed 147 cases of primary AG between 2000 and 2011 (Male : Female = 94:53, average age; 43.9 year-old). 69 were anaplastic astrocytoma (41%), 43 were anaplastic oligoastrocytoma (29%), and 44 were anaplastic oligodendroglioma (30%). The intraoperative MRI was performed in 133 cases (90%), and awake surgery was performed in 58 cases (39%). Gross-total removal was 46 (31%), partial removal was 89 (61%), and biopsy was 12 (8%) (average; 83%, median; 95%). After resection, 60 Gy radiotherapy and ACNU or PAV chemotherapy were performed. The average Mib-1 index was 15%. The mean observation periods were 57 months and 95% follow-up rate. RESULTS: Overall survival (OS) wasn't reached median. The 3y-OS was 82%, 5y-OSs was 72%, and 10y-OS was 66%. There was no statistical significance among AA, AOA, AO (5y-OS; 64%, 79%, 77%). The each 5 years survival rate of gross-total resection, partial resection, and biopsy were 83%, 70%, 39%, and there was statistical significance (P = 0.0024). Extent of resection (EOR) correlated OS in AA (P = 0.02) but not in oligodendroglial subtypes (P = 0.6). Statistical significant factors were EOR (P = 0.0024) and Mib-1 index (P = 0.013). The significant factors in multi variable analysis were EOR (more than 95% or not, HR 2.5) and Mib-1 index (more than 13% or not, HR 2.3). The median PFS was 8.3, and 5y-PFS was 59%,and 10y-PFS was 45%. CONCLUSION: Our long-term clinical results of AG treated with extensive resection and ACNU-based chemoradiotherapy were better than previous reports. The EOR contributed better prognosis especially for AA.

Pediatric choroid plexus tumors: epidemiology, treatments, and outcome analysis on 202 children from the SEER database.

Choroid plexus papillomas (CPPs) and carcinomas (CPCs) are rare neoplasms that affect mostly children. Due to their rarity, their epidemiology and outcomes are incompletely understood. The National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program is a well-established population-based group of registries that collects and publishes cancer incidence and survival data representing approximately 28 % of the US population. SEER-STAT v8.1.2 was used to identify patients with ICD-O-3 codes for choroid plexus tumors in patients aged 0-19. Demographics, initial treatment, and follow-up data were collected. Statistical methods including Kaplan-Meier curves, log rank tests, and Cox proportional hazards regression were used to estimate associations between independent variables and survival. The SEER registries contained 107 CPPs (2004-2010) and 95 CPCs (1978-2010). Median follow-up was 38 and 40 months, respectively. More than 75 % of CPCs were diagnosed before the age of 5 years, versus 48 % for CPPs. Sixty-five percent of CPCs and 57 % of CPPs occurred in males. In both groups at least 90 % of children underwent surgical resection. Gross total resection (GTR) was achieved in 67.0 % of CPCs and 63.6 % of CPPs. Almost 17 % of CPCs were treated with radiation versus only 0.9 % of CPPs. More than 98 % of patients with CPP were alive at the last follow-up, versus 62 % of CPC patients. For CPC, surgery was significantly associated with increased overall survival, but contrary to previous reports, extent of surgical resection was not associated with survival. Age, sex, race, and radiation treatment also had no effect on survival. This report, using the SEER datasets, corroborates many findings of previous smaller studies on CPTs. CPC occurs in younger children, with a male predominance, and a much worse prognosis than CPP. As such, these tumors have been treated aggressively with high rates of GTR and radiation treatment. Despite these treatments, overall survival for CPC remains poor.

Endoscopic endonasal resection of skull base meningiomas: the significance of a "cortical cuff" and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection.

This paper describes a consecutive series of skull base meningiomas resected using an endoscopic endonasal approach through various corridors at a single institution over 7 years. The impact of case selection and experience, the presence of a cortical cuff between the tumor and surrounding vessels, and brain edema on morbidity and rates of gross-total resection (GTR) were examined. A retrospective review of a series of 46 skull base meningiomas from a prospective database was conducted. The series of cases were divided by location: olfactory groove (n = 15), tuberculum and planum (n = 20), sellar/cavernous (n = 9) and petroclival (n = 2). Gross-total resection was never intended in the sellar/cavernous tumors, which generally invaded the cavernous sinus. Clinical charts, volumetric imaging, and pathology were reviewed to assess the extent of resection and complications. Cases were divided based on a time point in which surgical technique and case selection improved into Group 1 (surgery prior to June 2008; n = 21) and Group 2 (surgery after June 2008; n = 25) and into those with and without a cortical cuff and with and without brain edema. Improved case selection had the greatest impact on extent of resection. For the entire cohort, rates of GTR went from 38% to 76% (p = 0.02), and for cases in which GTR was the intent, the rates went from 63% to 84% (not significant), which was mostly driven by the planum and tuberculum meningiomas, which went from 75% to 91.7 % (nonsignificant difference). The presence of a cortical cuff and brain edema had no impact on outcomes. There were 3 CSF leaks (6.5%) but all were in Group 1. Hence, CSF leak improved from 14.2% to 0% with surgical experience. Lessons learned for optimal case selection are discussed. Surgical outcome for endonasal endoscopic resection of skull base meningiomas depends mostly on careful case selection and surgical experience. Imaging criteria such as the presence of a cortical cuff or brain edema are less important.

Intraoperative 3T MRI for pituitary macroadenoma resection: Initial experience in 73 consecutive patients

ObjectiveTo report a single-center experience with a 3T intraoperative magnetic resonance imaging (iMRI) to assess transsphenoidal microsurgery on pituitary macroadenomas. MethodsIn a dual, independent operating room (OR) magnetic resonance imaging (MRI) suite, the operating table with the anesthetized patient was moved on rail tracks once a supposed maximized resection was reached to the MRI room for intraoperative image acquisition and interpretation. After the assessment of the iMRI images, the neurosurgeon evaluated whether additional resection was still possible. The resection rates were assessed on iMRI and postoperative MRI at 3 months. ResultsA total of 73 macroadenomas benefited from an iMRI from March 2006 to October 2011. The gross total resection (GTR) rate at the time of the first iMRI was 58.9% (n=43). Based on the iMRI, eight patients (10.9%) underwent a second surgical resection. In 3 cases, the intraoperative imaging results were suspicious for a minor residue but not convincing enough for further surgery. Fortunately, the 3 months postoperative MRI control did not disclose any residual tumor in these cases. Finally, the GTR rate at the 3-month postoperative MRI increased to 72.6% (n=53). Conclusions3T intraoperative MRI offered excellent quality images. Its use during transsphenoidal microsurgery on pituitary macroadenomas led to an increase not only in the extent of tumor resection (in 8 patients) but also in the rate of radical resections (69% instead of 60%). No complications due to the iMRI procedure were observed.

Minimally Invasive Endoscopic Resection of Intraparenchymal Brain Tumors

The endoscope in neurosurgery has at times been accused of being a tool looking for a purpose. In many applications, it has successfully refuted this accusation: it is hard to imagine a cogent argument against using endoscopy for a third ventriculostomy or intraventricular tumor biopsy in the right setting. Also, although the entire field of endonasal anterior skull base surgery has not yet reached full maturity, few would argue that the subspecialty does not have value. The endoscope works best in open spaces, either air or fluid, such as the ventricle or nose. Therein the illumination, magnification, and wide angles of visualization allow the endoscope to be used to its full advantage. In such spaces, the freedom of movement provided to the endoscopist overcomes much of the potential clumsiness that comes from working with a view that is not coaxial to the working angle. The cerebral parenchyma has no open cavity, and it is largely for this reason that the brain “space” itself has been left as the last great frontier for the endoscope. The bar to be reached for any technique used in the removal of intrinsic and metastatic brain tumors must be that the technique provides less neuroanatomical and neurological impact and equal or better efficacy than the traditional microscope-based approach. It is far from a foregone conclusion that the conditions for such success will be met with new endoscopic techniques. In the article in a recent issue of WORLD NEUROSURGERY by Plaha et al., a nontubular, endoscopic technique for resecting intraparenchymal brain tumors is applied and evaluated prospectively for safety and efficacy. Using this method, the authors demonstrated gross total resection (GTR) in 48% of cases and near-total (greater than 95%) resection in 70% of cases. They show that GTR rates in this study were comparable with those published by other groups that used standard microsurgical resection for highgrade gliomas (where most evidence demonstrates that extent of resection plays a significant prognostic role). The authors conclude that the procedure can be performed safely, with only one major complication recorded secondary to anomalous anatomy (left anterior cerebral artery infarct), and a reported infection rate lower than that for other nonendoscopic craniotomy procedures at their institution. They conclude by suggesting that although their study does not imply superiority, it does support a role for this method of intraparenchymal tumor removal.

Follow-up and long-term outcome of nonfunctioning pituitary adenoma operated by transsphenoidal surgery with intraoperative high-field magnetic resonance imaging.

Intraoperative MRI (iMRI) increases gross total resection (GTR) rates in transsphenoidal surgery; however, long-term follow-up data is lacking. The objective is to assess the outcome of patients with nonfunctioning pituitary adenomas (NFA) at a mean follow-up of > 5 years. Patients with NFA operated in a single institution with resection control by a 1.5 T intraoperative magnetic resonance imaging (iMRI) scanner and no previous pituitary surgery were included. Microscopical transsphenoidal approaches with optional endoscopy were used. The iMRI was chosen for spacious suprasellar or retrosellar and/or invasive tumours. IMRI-scans were made if GTR or if nonresectable remnants were presumed. The patients had a full neuroradiological, endocrinological and ophthalmological follow-up at the institution. Eighty-five patients (67 % male;55 ± 14 years) with a follow-up of 5.6 ± 1.9 years were included. The initial GTR rate on iMRI was 44 %. In 83 %, further resections were possible, resulting in a final GTR rate of 66 %. In invasive tumours, the GTR rate was increased by 29 %. The detection of remnants by iMRI had high sensitivity and specificity (100 %), as opposed to endoscopy (21 %;78 %). During follow-up, four (7 %) tumours recurred and 14 (64 %) remnants grew. The recurrence and regrowth rate were 0.013 and 0.114 patients/years, respectively. Seventy-nine percent of the growing remnants were seen < 5 years postoperatively. The use of iMRI for transsphenoidal resection leads to low recurrence rates. Even in case of invasive tumours, distinctly more patients show long tumour-free follow-ups. Tumour remnants detected by iMRI are at high risk to grow within 5 years after surgery.

Practical surgical indicators to identify candidates for radical resection of insulo-opercular gliomas.

Maximum resection of gliomas with minimum surgical complications usually leads to optimum outcomes for patients. Radical resection of insulo-opercular gliomas is still challenging, and selection of ideal patients can reduce risk and obtain better outcomes. This retrospective study included 83 consecutively treated patients with newly diagnosed gliomas located at the insulo-opercular region and extending to the sylvian fissure around the primary motor and somatosensory cortices. The authors selected 4 characteristics as surgical indicators: clear tumor boundaries, negative enhancement, intact lenticulostriate arteries, and intact superior extremity of the central insular sulcus. Univariate analysis showed that tumors with clear boundaries were associated with higher rates of gross-total resection than were tumors with ambiguous boundaries (75.7% vs 19.6%). Tumors with negative enhancement compared with enhanced tumors were associated with lower frequency of tumor progression (32.0% vs 81.8%, respectively) and lower rates of surgical complications (14.0% vs 45.5%, respectively). Tumors with intact lenticulostriate arteries were associated with higher rates of gross-total resection than were tumors with involved lenticulostriate arteries (67.3% vs 11.8%, respectively). Tumors with intact superior extremity of the central insular sulcus were associated with higher rates of gross-total resection (57.4% vs 20.7%, respectively) and lower rates of surgical complications (18.5% vs 41.4%, respectively) than were tumors with involved anatomical structures. Multivariate analysis showed that clear tumor boundaries were independently associated with gross-total resection (p < 0.001). Negative enhancement was found to be independently associated with surgical complications (p = 0.005), overall survival times (p < 0.001), and progression-free survival times (p = 0.004). Independent associations were also found between intact lenticulostriate arteries and gross-total resection (p < 0.001), between intact lenticulostriate arteries and progression-free survival times (p = 0.026), and between intact superior extremity of the central insular sulcus and gross-total resection (p = 0.043). Among patients in whom all 4 indicators were present, prognosis was good (5-year survival rate 93.3%), resection rate was maximal (gross-total resection 100%), and surgical complication rate was minimal (6.7%). Also among these patients, overall rates of survival (p = 0.003) and progression-free survival (p = 0.005) were significantly higher than among patients in whom fewer indicators were present. The authors propose 4 simple indicators that can be used to identify ideal candidates for radical resection of insulo-opercular gliomas, improve the outcomes, and promote maximum resection without introducing neurological complications. The indicators are clear tumor boundaries, negative enhancement, intact lenticulostriate arteries, and intact superior extremity of the central insular sulcus.

Prognosis by tumor location in adults with intracranial ependymomas

Intracranial ependymomas are rare tumors in adults. Thus, factors affecting prognosis are poorly understood. We performed a study to investigate whether tumor location is an important prognostic factor in adults who undergo surgery for intracranial ependymomas. PubMed was searched to identify studies that reported clinical outcomes in adult patients with intracranial ependymoma. Data were extracted for patient and tumor characteristics, extent of resection, progression-free survival (PFS), and overall survival (OS). Tumors were categorized as supratentorial or infratentorial and extraventricular or intraventricular. Presenting clinical features and tumor characteristics were tabulated. Kaplan–Meier and multivariate Cox regression survival analyses were performed to determine PFS and OS by tumor location. Extent of resection was also analyzed by tumor location. A total of 183 patients were included in the meta-analysis. Patients presented at a mean of 8.2months with a myriad of clinical features. The mean tumor size was 3.38cm, and 19.3% of tumors were cystic. Supratentorial tumors were most commonly located in the frontal and parietal lobes, and infratentorial tumors in the fourth ventricle. Supratentorial tumors demonstrated significantly poorer PFS (p<0.001) and OS (p=0.003) than infratentorial tumors, despite a higher rate of gross total resection (GTR) for the supratentorial tumors (72.6% versus 42.1%). Extraventricular ependymomas displayed significantly poorer PFS than intraventricular ependymomas (p=0.009). In summary, supratentorial ependymomas have significantly poorer PFS and OS than their infratentorial counterparts, despite being more conducive to GTR, suggesting increased clinical aggressiveness. Extraventricular location is also associated with significantly poorer PFS than intraventricular location.

Endoscopic Endonasal Resection of Craniopharyngiomas: A Case Series and Review of the Literature

Objectives: Transcranial approaches were historically the first established routes for craniopharyngiomas resection. There is a limited body of literature on the outcome of endoscopic endonasal approach in resection of craniopharyngiomas. Therefore, the present study aims to assess the outcome of endoscopic endonasal approach in resection of craniopharyngiomas. Study Design: We retrospectively analyze and report our case series result and surgical outcomes and complications. Material and Methods: Total 11 patients underwent surgery at Loghman-Hakim and Day General Hospitals (Tehran, Iran). One patient had recurrent lesion. The gross-total resection (GTR) was attempted in nine surgeries. Results: GTR in nine cases and near-total resection in three cases were achieved. The average follow-up period was 30 months during which one recurrence in near resection cases was observed. Vision was improved by 80%. Seven cases developed diabetes insipidus that three was permanent and three cases developed panhypopituitarism postoperatively. Furthermore, postoperative cerebrospinal fluid (CSF) leaks occurred in two patients, one of them needed reoperation for CSF leak management. In addition, postoperative bacterial meningitis occurred in two cases. Postoperative mortality was one due to bacterial meningitis and hyponatremia. Conclusion: Endoscopic, endonasal surgery for craniopharyngioma can be accompanied by high rates of GTR in selected case with acceptable results.