Total Resection Rate Research Articles

A phase I/II study of ruxolitinib with frontline neoadjuvant and post-surgical therapy in patients with advanced epithelial ovarian, Fallopian tube, or primary peritoneal cancer.

5501 Background: The Interleukin-6/JAK/STAT3 axis, via an increase in cancer stem-like cell (CSC) survival, is a reported driver of chemotherapy resistance. We hypothesized that addition of the JAK1/2 inhibitor ruxolitinib to standard chemotherapy would be tolerable and, by targeting therapy-resistant cells, improve the progression-free survival (PFS) of ovarian/fallopian tube/primary peritoneal carcinoma (OV/FT/PPC) patients treated in the up-front setting. Methods: Patients with OV/FT/PPC dispositioned to neoadjuvant chemotherapy were eligible for NRG-GY007 (NCT #02713386). In phase I, treatment was with dose-dense paclitaxel (P) 70 or 80 mg/m2 days 1, 8, and 15; carboplatin (C) AUC 5 or 6 day 1; and ruxolitinib (R) 15mg PO BID, every 21 days. In the absence of tumor progression or an inability to tolerate surgery, interval tumor reductive surgery (TRS) was required after cycle 3. After TRS, 3 additional cycles were administered, followed by maintenance ruxolitinib until progression, unacceptable toxicity, or voluntary withdrawal. In phase II, patients were randomized to dose-dense PC (arm 1) or dose-dense PC plus ruxolitinib (arm 2) at the phase I-defined dose of 15mg PO BID. After 3 cycles, TRS was performed, followed by another 3 cycles of the randomized regimen, without maintenance ruxolitinib. The primary phase II endpoint was progression-free survival (PFS). Results: 17 patients were enrolled in phase I. The MTD was P at 70, C at 5, and R at 15, which was chosen as the phase II dose. 130 patients were enrolled in phase II with a median follow-up of 24 months. There were five Grade 5 events in phase II, 2 in arm 1 and 3 in arm 2, with all except one being unrelated to therapy; a G5 febrile neutropenia in arm 2 was considered possibly related. In arm 2 there was potential trend towards higher grade 3-4 anemia (64% v 27% control), grade 3-4 neutropenia (53% v 37%), thromboembolic events (12.6% v 2.4%), and febrile neutropenia (6% v 0%). The HR for PFS was 0.702 (90% 1-sided CI = 0-0.89, log-rank p = 0.059). The median PFS in arm 1 was 11.6 versus 14.6 in arm 2. The overall survival HR = 0.785 (90% CI = 0.44 to 1.39, p = 0.70). There were no differences between rates of total gross resection. Conclusions: Ruxolitinib 15mg PO BID was well-tolerated with acceptable toxicity in combination with dose-dense PC. The primary endpoint of prolongation of PFS was achieved in the experimental arm. Further study of this combination can be considered. This trial also demonstrates the feasibility of early-phase randomized studies with novel agents and biospecimen collection in front line neoadjuvant treatment of ovarian cancer. Clinical trial information: 02713386.

Comparison of the Clinical Efficacy of Transforaminal Endoscopy and Microtubular Technology for the Treatment of Lumbar Dumbbell-Shaped Tumors.

ObjectiveTo analyze differences in feasibility and efficacy between the paravertebral approach and microtubular tumorectomy (PAMT) or percutaneous transforaminal endoscopic tumorectomy (PTET) for the treatment of lumbar dumbbell-shaped tumors. MethodsClinical data of dumbbell-shaped lumbar tumors in patients treated with PAMT or PTET in our hospital between June 2015 and November 2020 were retrospectively analyzed. The gross total resection (GTR) rate, operation time, estimated blood loss, postoperative hospital stay (PHS), postoperative neurological function, and spinal stability were compared between the 2 surgical methods. Neurological improvement was assessed using the pain visual analogue scale (VAS) and the Japanese Orthopaedic Association (JOA) score. ResultsFifteen cases of GTR (93.8%) and 1 case of subtotal resection were included in the PTET group, whilst all 18 patients in the PAMT group achieved GTR. There was no significant difference in the GTR rate, operation time, and PHS between the PAMT and PTET groups. The estimated blood loss was significantly lower in the PTET group than in the PAMT group. At the last follow-up, there was no significant difference in the VAS or JOA scores between PTET and PAMT. No tumor recurrence or spinal instability was observed in either group during the follow-up period. ConclusionBoth PAMT and PTET can achieve Eden type III-IV lumbar 1-stage tumor resection without additional spinal internal fixation due to reduced muscle, ligament, and facet joint damage. No lumbar instability and tumor recurrence occurred, and neurological function was improved.

Surgical approach of transnasal endoscopic resection of benign lesions in the paramedian lateral skull base

Objective:To investigate the surgical approach of transnasal endoscopic resection of benign lesions in the paramedian lateral skull base. Methods:Retrospectively analyze 40 cases of the clinical data of patients with benign lesions of the skull base from August 2018 to February 2021 with transnasal endoscopic surgery, including 9 cases of cholesteatoma, 6 cases of hemangioma, 1 case of hemangiopericytoma, 6 cases of schwannoma, 15 cases of sphenoid sinus lateral crypt meningocele and cerebrospinal fluid leak, 3 cases of nasopharyngeal carcinoma bone inflammation after radiotherapy. All patients underwent transnasal endoscopic surgery, and different surgical approaches were selected according to the lesion location. Results:The total resection rate was 100% in 40 patients. One patient had cerebrospinal fluid rhinorrhea, which was cured after repair. During the follow-up period of 3-30 months, 39 patients had different degrees of numbness in the maxillary or mandibular region, and the numbness disappeared from 2 weeks to 6 months; one patient with schwannoma still had numbness on one side of the upper lip one year after surgery. Conclusion:Transnasal endoscopic resection of benign lesions in the paramedian skull base has a high surgical safety and cure rate. The surgical approach selection mainly focuses on the pterygoid process and extends to the periphery. The shortest and least damaging approach should be selected according to the lesion location, and the endoscopic approach should also be selected according to the surgeon's expertise.

Clinical Grading System, Surgical Outcomes and Prognostic Analysis of Cranial Base Chordomas.

ObjectiveCranial base chordomas are rare, but their treatment is challenging. Tumor recurrence is still common despite improvements in microsurgical techniques and postoperative radiotherapy. We retrospectively analyzed the course of treatment, overall survival, and recurrence/progression of chordomas over the past 10 years. MethodsWe retrospectively reviewed 50 patients who underwent surgery at Tianjin Huanhu Hospital between 2010 and 2020 and were pathologically diagnosed with chordomas. Tumor resection was performed within the maximum safe range in all patients; the extent of resection was evaluated by imaging; and the incidence of complications, recurrence or progression, and overall survival were assessed. ResultsFifty patients were divided into the low-risk group (LRG) and high-risk group (HRG) based on the cranial chordoma grading system (CCGS). The Karnofsky Performance Scale scores and gross total resection rate of the LRG were significantly higher than those of the HRG (p<0.05). The incidence of complications and mortality in the LRG were lower than those of HRG. The analysis of cumulative survival and cumulative recurrence free survival/progression free survival (RFS/PFS) showed no statistical differences in the extent of resection for survival, recurrence, or progression. Univariate and multivariate analyses showed that Ki-67 was significantly associated with tumor recurrence and was an independent hazard factor (p=0.02). ConclusionThe CCGS can help neurosurgeons anticipate surgical outcomes. Pathological results are important in evaluating the possibility of tumor recurrence, and postoperative radiotherapy improves overall survival and RFS/PFS.

Application of Subperineural Resection Technique in Vestibular Schwannomas: Surgical Efficacy and Outcomes in 124 patients.

ObjectiveWe aimed to explore the application and prospects of the subperineural resection technique for tumor separation and removal under the perineurium during surgery for vestibular schwannomas (VSs).MethodsThis study retrospectively analyzed 124 patients with VSs who underwent surgery via a retrosigmoid approach from July 2015 to October 2020 in the Department of Neurosurgery, Tangdu Hospital, Air Force Military Medical University. The data will be discussed with regard to the following aspects: clinical features, surgical strategies, tumor resection extent, facial–acoustic function preservation, and postoperative complications.ResultsGross total resection (GTR) of the tumor was achieved in 104 patients, with a GTR rate of 83.9%, and subtotal resection (STR) of the tumor was achieved in 20 patients. There was no significant difference in facial and acoustic nerve functional preservation between GTR and STR, as well as in tumor resection between solid and cystic tumors. The retention rate reached 97.6% in terms of complete anatomical facial nerve preservation. Facial nerve function was assessed using the House–Brackmann (HB) grading score. Consequently, HB grades of I–II, III–IV, and V–VI were determined for 96 (77.4%), 25 (20.2%), and 3 (2.4%) cases, respectively, 1 week postoperatively and accounted for 110 cases (88.7%), 13 cases (10.5%), and 1 case (0.8%), respectively, at 6 months. Fifteen of 35 (42.9%) patients with serviceable hearing before the operation still had serviceable hearing at 6 months postoperatively. There were 5 cases of cerebellar or brainstem bleeding after the operation, and one patient died. Multivariate logistic regression analysis showed that older age (≥60 years, p = 0.011), large tumor (>3 cm, p = 0.004), and cystic tumor (p = 0.046) were independent risk factors associated with the extent of adhesion between the tumor and the brainstem and facial–acoustic nerve.ConclusionWe successfully applied the subperineural resection technique to a large series of patients with VSs and achieved satisfactory results. Accurate identification of the perineurium and subperineural resection of the tumor can effectively reduce the disturbance of the facial–acoustic nerve during the operation and provide an intuitive basis for judging the tumor boundary. The subperineural resection technique may be conducive to improving the rate of total tumor resection and facial–acoustic nerve functional preservation in the surgical treatment of VSs.

Resection of Insular Glioma Through the Transfrontal Limiting Sulcus Approach.

The current transsylvian or transopercular approaches make access difficult because of the limited exposure of insular tumors. Hence, maximal and safe removal of insular gliomas is challenging. In this article, a new approach to resect insular gliomas is presented. To determine whether the new transfrontal limiting sulcus approach is helpful for maximal and safe removal of insular gliomas. The authors reported surgical techniques for insular gliomas resected through the transfrontal limiting sulcus approach. The authors evaluated the surgical resections of 69 insular gliomas performed through the new approach in their department. The extents of resection and postoperative neurological outcomes were analyzed to determine the value of this new approach. Based on the Berger-Sanai classification, most insular gliomas were giant tumors (59.42%), followed by zone I + IV tumors (24.64%). The median (interquartile range) extent of resection of all patients was 100% (91%, 100%). The total resection rate for all gliomas was (55 of 69, 79.7%), and the total resection rate for low-grade gliomas was (28 of 40, 70%), which was significantly lower than that for high-grade gliomas (27 of 29, 93.1%) (P = .019). All patients had muscle strength greater than grade 4 3 months after surgery. Only 1 patient had a speech disorder 3 months after surgery. The median Karnofsky Performance Status score at the time of the 3-month follow-up was 90. The transfrontal limiting sulcus approach can help to achieve maximal and safe removal of insular gliomas.

Neuroendoscopy-assisted microneurosurgery for cerebellopontine angle cholesteatoma

A total of 49 patients with cerebellopontine angle cholesteatoma from the Department of Neurosurgery, Affiliated Hospital of Xuzhou Medical University between January 2013 and January 2021 were recruited. All patients were evaluated by MRI scan before surgery and tumor resection was performed under microscope via retrosigmoid sinus approach. Then residual tumor was searched with 0°and 30°neuroendoscopy, and tumor resection was performed.Residual tumors were foundand resectedin 38 cases under theneuroendoscopy after routine microsurgery.Total and subtotalresections were performed in 44 cases and 5 cases, respectively. Complications included aseptic meningitis (n=8), cerebrospinal fluid leakage (n=1) and intracranial hematoma (n=2). Follow-up[42±3(6-72)months] was available in all patients. During follow-up, 45 cases (91.8%) had a Kar-nofsky Performance Status (KPS)score ≥80.Neuroendoscopy-assisted microsurgery for cerebellopontine angle cholesteatomas helps enhance the total resection rate and decrease the operative risk.

Extending the multistage surgical strategy for recurrent initially low-grade gliomas: functional and oncological outcomes in 31 consecutive patients who underwent a third resection under awake mapping.

Maximal safe resection is the first treatment in diffuse low-grade glioma (DLGG). Due to frequent tumor recurrence, a second surgery has already been reported, with favorable results. This study assesses the feasibility and functional and oncological outcomes of a third surgery in recurrent DLGG. Patients with DLGG who underwent a third functional-based resection using awake mapping were consecutively selected. They were classified into group 1 in cases of slow tumor regrowth or group 2 if a radiological enhancement occurred during follow-up. All data regarding clinicoradiological features, histomolecular results, oncological treatment, and survival were collected. Thirty-one patients were included, with a median age of 32 years. There were 20 astrocytomas and 11 oligodendrogliomas in these patients. Twenty-one patients had medical oncological treatment before the third surgery, consisting of chemotherapy in 19 cases and radiotherapy in 8 cases. No neurological deficit persisted after the third resection except mild missing words in 1 patient, with 84.6% of the patients returning to work. The median follow-up duration was 13.1 ± 3.4 years since diagnosis, and 3.1 ± 2.9 years since the third surgery. The survival rates at 7 and 10 years were 100% and 89.7%, respectively, with an estimated median overall survival of 17.8 years since diagnosis. A comparison between the groups showed that the Karnofsky Performance Scale score dropped below 80 earlier in group 2 (14.3 vs 17.1 years, p = 0.01). Median residual tumor volume at the third surgery was smaller (2.8 vs 14.4 cm3, p = 0.003) with a greater extent of resection (89% vs 70%, p = 0.003) in group 1. This is the first consecutive series showing evidence that, in select patients with progressive DLGG, a third functional-based surgery can be achieved using awake mapping with low neurological risk and a high rate of total resection, especially when reoperation is performed before malignant transformation.

Comparison of Neuroendoscopic and Microscopic Surgery for Unilateral Hemilaminectomy: Experience of a Single Institution.

ObjectiveThis study was designed to compare the safety and efficacy of unilateral hemilaminectomy conducted under complete neuroendoscopic visualization (UHNV) relative to unilateral hemilaminectomy under total microscopic visualization (UHMV) for the treatment of patients diagnosed with intraspinal tumors.MethodsIn total, 41 patients undergoing intraspinal tumor resection at Northern Jiangsu People's Hospital were included in this study, including 20 and 21 patients in the UHNV and UHMV groups, respectively. Intraoperative parameters including incision length, operative duration, number of vertebral laminae removed and intraoperative blood loss, as well as indicators of curative efficacy such as total tumor resection rates and postoperative symptom improvement rates, and safety indicators including complication rates, recurrence rates, spinal deformity rates, spinal instability incidence, and length of stay (LOS), were compared between the two groups.ResultsIn contrast to the UHMV group, patients in the UHNV group had a significantly shorter incision length and decreased intraoperative blood loss (P < 0.05), while the operative duration (P > 0.05) showed no statistical difference. Although the postoperative improvement and total tumor resection rates were enhanced, the difference was not statistically significant (P > 0.05). In comparison, the bedridden time and length of stay (LOS) were significantly shortened (P < 0.05) in the UHNV group. However, there were no significant differences in recurrence, incidence of complications, spinal deformity, and spinal instability (P > 0.05).ConclusionCollectively, our findings indicate that UHNV is not inferior to the UHMV approach. Moreover, due to its safe and minimally invasive nature, UHNV represents a promising alternative to UHMV as a treatment for patients with intradural extramedullary tumors.

Combined endoscopic and microsurgical resection of pineal region meningiomas by modified Poppen approach

To retrospectively analyze the clinical data of patients with pineal region meningioma. All the patients underwent combined endoscopic and microsurgical procedure by modified Poppen approach (double-scopic technique) between January 2018 and March 2021 in the Department of Neurosurgery of the First Affiliated Hospital of Soochow University. A total tumor resection was achieved in all the patients without deaths. All the pineal region meningiomas were pathologically confirmed. During the follow-up period, none of the 10 patients experienced tumor progression, and 4 of patients were treated by radiotherapy after surgery. The external ventricular drainage was performed in 8 cases intraoperatively, and no case underwent the ventriculoperitoneal shunt during the follow-up period. The clinical symptoms of 9 cases were improved,1 case had no improvement, and no patients presented deteriorated symptoms. Combined endoscopic and microsurgical surgery resection of pineal region meningiomas by modified Poppen approach helped the surgeons directly observe the cerebral deep vein systems in pineal region with endoscope and significantly enhance the total resection rate of pineal region meningiomas, thereby decreasing the damage of cerebral deep vein systems in pineal region and reducing the incidence of surgical complications.

Surgical Strategy for Skull Base Chordomas : Transnasal Midline Approach or Transcranial Lateral Approach.

ObjectiveThe clinical management paradigm of skull base chordomas is still challenging. Surgical resection plays an important role of affecting the prognosis. Endonasal endoscopic approach (EEA) has gradually become the preferred surgical approach in most cases, but traditional transcranial surgery cannot be completely replaced. This study presents a comparison of the results of the two surgical strategies and a summary of the treatment algorithms for skull base chordomas. MethodsWe retrospectively analyzed the surgical outcomes and follow-up data of 48 patients with skull base chordomas diagnosed pathologically who received transnasal midline approaches (TMA) and transcranial lateral approaches (TLA) from 2010 to 2020. ResultsAmong the 48 patients, 36 cases were adopted TMA and 12 cases were performed with TLA. In terms of gross total resection (GTR) rate, 27.8% in TMA and 16.7% in TLA and with EEA alone it was increased to 38.9%, while 29.7% in primary surgery. In TMA, the cerebrospinal fluid (CSF) leak remains the most common complication (13 cases, 36.1%), other main complications included death, cranial nerve palsy, hypopituitarism, all the comparisons were no statistical significance. The Karnofsky Performance Scale scores in TMA were all better than those in TLA at different time, and the overall survival (OS) and recurrence free survival/progression free survival was just the reverse. ConclusionThe EEA for skull base chordomas resection has improved the GTR rate, but transcranial approach is still an alternative approach. It is necessary to select an appropriate surgical approach based on the location and the pattern of tumor growth in order to obtain the best surgical outcomes.

Clinical Outcomes and Complications of Preoperative Embolization for Intracranial Giant Meningioma Tumorectomy: A Retrospective, Observational, Matched Cohort Study.

ObjectiveThe potential benefits of preoperative embolization for intracranial meningiomas are still under debate. We aimed to investigate whether preoperative embolization can improve surgical and functional outcomes, based on controlling patient- and tumor-related confounding factors.MethodsWe reviewed all meningioma cases in our department from January 2016 to May 2021. Cases in the nonembolization cohort were matched to the embolization cohort by 1:1 ratio propensity score matching, through controlling patient- and tumor-related confounds. Surgical outcomes, complications, and functional outcomes were retrospectively compared between these two groups.ResultsSixty-six cases in each group were included in our study after being matched. We did not find any significant differences of estimated blood loss (600.00 (400) vs. 500.00 (500.00) ml, p = 0.31), decrease of HGB level (30.81 ± 15.82 vs. 26.59 ± 12.90 g/L, p = 0.09), gross total resection rate (74.24% vs. 77.27%, p = 0.68), surgical time (302.50 (136) vs. 300.00 (72) min, p = 0.48), blood transfusion rates (53.03% vs. 42.42%, p = 0.35), blood transfusion volume [650.00 (657.50) vs. 535.00 (875.00) ml, p = 0.63] between the embolization group and nonembolization group. The number of patients who experience postsurgery complications were significantly higher in the nonembolization group (39.39% vs. 21.21%, p = 0.02). Patients in the nonembolization group were more likely to have a higher rate of mRS decline postsurgery (31.82% vs. 15.15%, p = 0.04).ConclusionOur study showed significant lower rates of surgical complications and long-term disabilities of meningioma patients treated with preoperative embolization. There were no significant differences in estimated blood loss, surgical time, and blood transfusion volume between embolization and nonembolization groups.

Subpial en bloc resection improves extent of resection in infiltrating gliomas – A propensity matched comparative cohort analysis

BackgroundSurgery remains the mainstay of glioma therapy and extent of resection is an important prognostic factor. Optimization of surgical outcomes is essential and to this end the technique of resection can potentially play an important role. Based on patterns of glioma growth and extrapolating from other solid cancer surgical principles, a subpial dissection combined with an en-bloc resection (SPER) technique appears to have advantages MethodsWe performed a propensity matched analysis comparing gliomas that were resected using SPER versus a standard piecemeal debulking technique at our centre. Potentially confounding factors (including eloquent location, use of intraoperative imaging, surgeon experience) were adjusted for in the matching of the two cohorts. Outcomes included postoperative morbidity and blinded radiological review documented postoperative ischemia (on diffusion weighted MR imaging - DWI) as well as extent of resection. ResultsIn 57 gliomas (23 SPER and 34 standard), the gross total resection (GTR) rates were significantly higher with SPER (91 vs 65%). Postoperative DWI revealed significant ischemia in almost 50% of cases in either group, though many did not have postoperative deficits. Arterial ischemia was higher in the standard surgery group and this was associated with a significantly higher risk (seven times) of resulting in prolonged neurological deficits. ConclusionsSPER is a useful technique which increases the GTR rates in gliomas undergoing resection. It is associated with lower incidence of arterial ischemia in the postoperative period and this can result in improved long term functional outcomes.

Surgical Outcomes of Sphenoid Wing Meningioma with Periorbital Invasion.

ObjectiveThe aim of this study was to evaluate the clinical outcome of sphenoid wing meningioma with periorbital invasion (PI) after operation. MethodsSixty one patients with sphenoid wing meningioma were enrolled in this study. Their clinical conditions were monitored after the operation and followed up more than 5 years at the outpatient clinic of a single institution. Clinical and radiologic information of the patients were all recorded including the following parameters : presence of PI, presence of peri-tumor structure invasion, pathologic grade, extents of resection, presence of hyperostosis, exophthalmos index (EI), and surgical complications. We compared the above clinical parameters of the patients with sphenoid wing meningioma in the presence or absence of PI (non-PI), then linked the analyzed data with the clinical outcome of the patients. ResultsOf 61 cases, there were 14 PI and 47 non-PI patients. PI group showed a significantly higher score of EI (1.37±0.24 vs. 1.00±0.01, p<0.001), more frequent presence of hyperostosis (85.7% vs. 14.3%, p<0.001), and lower rate of gross total resection (GTR) (35.7% vs. 68.1%, p=0.032). The lower score of pre-operative EI, the absence of both PI and hyperostosis, smaller tumor size, and the performance of GTR were associated with lower recurrence rates in the univariate analysis. However, in the multivariate analysis, the performance of GTR was the only significant factor to determine the recurrence rate (p=0.043). The incidences of surgical complications were not statistically different between the subtotal resection (STR) and GTR groups, but it was strongly associated tumor size (p=0.017). ConclusionThe GTR group showed lower recurrence rate than the STR group without differences in the surgical complications. Therefore, the GTR is strongly recommended to treat sphenoid wing meningioma with PI for the better clinical outcome.

Minimally Invasive Tubular Retractor Surgery for Intradural Extramedullary Spinal Tumor Reduces Postoperative Degeneration of Paraspinal Muscle.

Background Minimally invasive surgery (MIS) using a tubular retractor has been increasingly utilized in spinal surgery for degenerative conditions with the benefit of paraspinal muscle preservation. This benefit has not been previously reported for intradural extramedullary tumors using the MIS approach. In this study, we aimed to compare the degree of postoperative fatty degeneration in paraspinal muscle between MIS with tubular retractor (MIS) and open laminectomy (Open) for intradural extramedullary spinal tumors. Methods This was a retrospective review conducted in a tertiary neurosurgical center from 2015 to 2019. The degree of paraspinal muscle fatty degeneration, as measured by Goutallier grade on postoperative magnetic resonance imaging (MRI), was analyzed, and the degree of excision, tumor recurrence rate, and chronic pain were compared between the two surgical approaches. Results Among 9 patients in the MIS group and 33 patients in the Open group, the rate of gross total resection was comparable (MIS: 100.0%, Open: 97.0%, p = 1.000). The degree of paraspinal muscle fatty degeneration was significantly reduced in the MIS group (median Goutallier grade 1 in MIS group vs. median Goutallier grade 2 in Open group, p = 0.023). There was no significant difference in the tumor recurrence rate, complication rate, and chronic pain severity. A consistent trend of reduced analgesic consumption was observed in the MIS group, though not statistically significant. Conclusions Minimally invasive tubular retractor surgery is an effective approach for appropriately selected intradural extramedullary spinal tumors with significantly reduced postoperative fatty degeneration in paraspinal muscle.

Intraoperative application of yellow fluorescence in resection of intramedullary spinal canal ependymoma.

BackgroundSpinal ependymoma is the most common intramedullary tumor in adults. This study was performed to evaluate whether intraoperative yellow fluorescence use enhances our ability to identify the tumor margin and residual tumor tissue in intramedullary spinal cord ependymoma resection. We also evaluated patients’ clinical conditions at a 3-month follow-up.MethodsWe retrospectively evaluated 56 patients with intramedullary ependymoma. Thirty minutes before anesthesia, the patients received intravenous sodium fluorescein injections. Tumor resection was performed under two illumination modes, traditional white light and yellow fluorescence, and the residual tumor tissue was detected. Magnetic resonance imaging was performed 3 months postoperatively to observe the tumor resection outcome and residual tumor tissue. The McCormick spinal cord function grade was evaluated preoperatively and 3 months postoperatively.ResultsThe total resection rate was 100.0% in all patients. Nine patients had no significant fluorescence imaging. After 3 months, patients with a spinal function grade of I to IV showed significant spinal function improvement. Magnetic resonance imaging showed no residual tumor tissue or recurrence.ConclusionSodium fluorescein aids in total excision of intramedullary spinal cord ependymoma and intraoperative residual tumor tissue identification. At the 3-month follow-up, the patients’ functional outcome in the fluorescein group was good.

Anterior Skull Base Meningioma: Surgical Approach and Complication Avoidance.

Introduction Endoscopic endonasal approach (EEA) and keyhole transcranial approaches (TCAs) are being increasingly used in anterior skull base meningioma (ASBM) surgery. Objective We compare tumor resection rates and complication profiles of EEA and supraorbital keyhole approach (SOKHA) with conventional TCAs. Methods Fifty-four patients with ASBM (olfactory groove meningioma [OGM], n = 19 and planum sphenoidale/tuberculum sellae meningioma [PSM/TSM], n = 35) operated at a single center over 7 years were retrospectively analyzed. Results The overall rate of gross total resection (GTR) was higher in OGM (15/19, 78.9%) than PSM-TSM group (23/35, 65.7%, p = 0.37). GTR rate with OGM was 90% and 75% with TCA and EEA. Death ( n = 1) following medical complication (TCA) and cerebrospinal fluid leak requiring re-exploration ( n = 2, one each in TCA and EEA) accounted for the major complications in OGM. For the PSM/TSM group, the GTR rates were 73.3% ( n = 11/15), 53.8% ( n = 7/13), and 71.4% ( n = 5/7) with TCA, EEA, and SOKHA, respectively. Seven patients (20%) of PSM-TSM developed major postoperative complications including four deaths (one each in TCA and SOKHA, and two in EEA groups) and three visual deteriorations. Direct and indirect vascular complications were common in lesser invasive approaches to PSM-TSM especially if the tumor has encased intracranial arteries. Conclusion No single approach is applicable to all ASBMs. TCA is still the best approach to obtain GTR but has tissue trauma-related problems. SOKHA may be a good alternative to TCA in selected PSM-TSMs, while EEA may be an alternate option in some OGMs. A meticulous patient selection is needed to derive reported results of EEA for PSM-TSM.

Clinical Outcomes of Transcranial and Endoscopic Endonasal Surgery for Craniopharyngiomas: A Single-Institution Experience.

ObjectiveCraniopharyngioma has always been a challenge for the neurosurgeon, and there is no consensus on optimal treatment. The objective of this study was to compare surgical outcomes and complications between transcranial surgery (TCS) and endoscopic endonasal surgery (EES) of craniopharyngiomas.MethodsA retrospective review of patients who underwent craniopharyngioma resection at Wuhan Union Hospital between January 2010 and December 2019 was performed. A total of 273 patients were enrolled in this retrospective study. All patients were analyzed with surgical effects, endocrinologic outcomes, complications, and follow-up results.ResultsA total of 185 patients underwent TCS and 88 underwent EES. There were no significant differences in patient demographic data, preoperative symptoms, and tumor characteristics between the two groups. The mean follow-up was 30.5 months (range 8–51 months). The EES group had a greater gross total resection (GTR) rate (89.8% EES vs. 77.3% TCS, p < 0.05) and lower rate of hypopituitarism (53.4% EES vs. 68.1% TCS, p < 0.05) and diabetes insipidus (DI) (51.1% EES vs. 72.4% TCS, p < 0.05). More postoperative cerebrospinal fluid (CSF) leaks occurred in the EES group (4.5% EES vs. 0% TCS, p < 0.05). More patients in the EES group with preoperative visual deficits experienced improvement after surgery (74.5% EES vs. 56.3% TCS, p < 0.05). There were statistical differences in the recurrence rates (12.5% EES vs. 23.8% TCS, p < 0.05) between the 2 groups.ConclusionThese data support the view that EES is a safe and effective minimally invasive surgery compared to TCS. Compared to TCS, EES has fewer surgical complications and a lower recurrence rate.

Long term outcomes following surgery for pineal region tumors.

Pineal region tumors are surgically demanding tumors to resect. Long term neuro-oncologic outcomes following surgical excision of tumors from this region have been underreported. We sought to define the long term outcomes of patients undergoing resection of pineal region tumors. A retrospective analysis of a prospectively maintained database was performed on patients who underwent intended surgical excision of pineal region tumors. Overall survival (OS) and progression free survival (PFS) were the primary endpoints of this study. Factors associated with OS, PFS and the degree of resection were analyzed, along with 30-day complication rates and dependence on CSF diversion. Sixty-eight patients with a mean age of 30.9 ± 15.3 years were analyzed. The median clinical and radiographic follow-up was 95.7 and 48.2 months, respectively. The supracerebellar infratentorial and the occipital transtentorial corridors were utilized in the majority of cases (80.9%). The gross total resection (GTR) rate was 52.9% (n=36). The 5-year OS and PFS rates were 70.2% and 58.5%, respectively. Achieving GTR was associated with improved OS (HR 0.39, p = 0.03) and PFS (HR 0.4, p = 0.006). The 30-day mortality rate was 5.9%. The need for CSF diversion was high with 77.9% of patients requiring a shunt or ETV by last follow-up. This is the first modern surgical series providing long term follow-up for patients undergoing surgical resection of pineal region tumors. Obtaining a GTR of these challenging tumors is beneficial with regards to PFS/OS. Higher grade tumors have diminished PFS/OS and are treated with adjuvant chemotherapy and/or radiotherapy.

The Benefit of Intraoperative Magnetic Resonance Imaging in Endoscopic and Microscopic Transsphenoidal Resection of Recurrent Pituitary Adenomas.

The surgical treatment of recurrent adenomas can be challenging. Intraoperative magnetic resonance imaging (iMRI) can improve the orientation and increase the safe extent of resection. We conducted a quantitative and qualitative retrospective analysis of recurrent adenomas treated by endoscopic or microscopic iMRI-assisted transsphenoidal surgery. A total number of 59 resections were selected. Detailed volumetric measurements, tumor characteristics, and MRI features of intraoperative remnants were evaluated. Intraoperative MRI increased the gross total resection (GTR) rate from 33.9% to 49.2%. Common locations of tumor remnants after iMRI were the clivus, the wall of the cavernous sinus or the perforation of the diaphragm. Increasing tumor volume and the microscopic technique were significantly associated with further resection after iMRI in the univariate analysis (p = 0.004, OR 1.6; p = 0.009, OR 4.4). Only the increasing tumor volume was an independent predictor for further resection (p = 0.007, OR 1.5). A significantly higher proportion of GTRs was achieved with the endoscopic technique (p = 0.001). Patients with a large recurrent pituitary adenoma who underwent microscopic transsphenoidal resection were the most likely to benefit from iMRI regarding the extent of resection. Occult invasions of the cavernous sinus and/or the clivus were the most common findings leading to further resection of tumor remnants after iMRI.