Tumor Enucleation Research Articles

Surgery of pancreas tumors in children and adolescents: a single institution experience

Purpose: The aim of this study is the surgical management and the clinical and pathological features of patients who underwent pancreatic resection for benign and malignant pancreatic tumors in childhood and adolescence and described the morbidity and mortality of this group of patients. Methods: This is a retrospective review of medical reports of patients ≤19 years with pancreatic tumors who underwent surgery in National Cancer Center, Lima, Peru from January 2000 to January 2019. Results: Thirty-two patients underwent surgery, the mean age was 13.65 years (3-18), 26 patients were women and 6 men. The tumor location was in the head (n = 18), tail (n = 9) and body (n = 5), the mean tumor size 7.34cm (2-13.5cm). The histological types were: solid pseudopapillary tumor (SSP) (n = 27), pancreatoblastoma (n = 3) and neuroendocrine tumor (n = 2) of which one was neuroendocrine carcinoma and another insulinoma. All tumors had R0 in bloc resection, surgical treatment was: pancreaticoduodenectomy (n = 18), distal pancreatectomy (n = 9), central pancreatectomy (n = 4) and tumor enucleation (n = 1). The survival rate according to 5-year Kaplan Meier analysis was 74%. The median duration of follow-up was 33 months. The postoperative mortality was 0%. Conclusions: Radical surgery is a safe treatment in patients with primary tumors of the pancreas with a low mortality rate and postoperative complications. The SSP is the most frequent pathology with a good prognosis.

Blind resection is forbidden in cases of pancreatic insulinoma

Introduction: Insulinoma is one of the most frequent functional pancreatic neuroendocrine tumors (pNETs). Despite the progress of diagnostic technology and techniques there are cases of mistaken tactics in the detection and localization of tumors. Material and Methods: There were 196 patients with pNETs surgically treated in our department from January 2007 to December 2020. All patients underwent abdominal CT and MRI. In complicated cases we used arterial calcium stimulation with hepatic venous sampling (ASVS). There were 7 cases of tactical intraoperative errors. Most of these patients (4 cases) had undergone surgery in other regional clinics and hospitals. The other three had previously been treated in our center. Most of these cases (6) were female with a median age of 43,6. Results: In all cases during final surgery intraoperative ultrasound and frozen sections were performed. Re-resection of the distal pancreas was performed in three cases. When the tumors' localisation was in the pancreatic head a pancreatic head resection (2 cases) or tumor enucleation (1 case) was performed. Postoperative complications included postpancreatectomy hemorrhage – 1, severe postoperative pancreatitis – 1, postoperative pancreatic fistula grade B/C – 2. There was one lethal outcome. The long-term survival results for the other patients have been uneventful. Conclusion: Blind resection of the pancreatic insulinoma is forbidden even in cases of “hidden” insulinoma. All available preoperative diagnostics, including ASVS, must be performed before the surgery. Intraoperative ultrasound and frozen section with confirmation of the neuroendocrine origin of the lesion must be routinely performed.

Feasibility of transoral endoscopic enucleation for large odontogenic jaw tumors

Objective The aim was to describe a transoral endoscopic approach for large odontogenic jaw tumors and to assess the feasibility of endoscopy in complete enucleation of any tumor remnants. Materials and methods This retrospective cohort study was done on patients presenting with different types of large jaw tumors in the period from 2013 to 2017 at the Department of Otolaryngology – Head and Neck Surgery, Mansoura University, Egypt. All patients were managed endoscopically. with the bony port measured in its largest dimension. Outcome measures were the occurrence of recurrence during the follow up. Follow-up ranged from 6 to 36 months. Results All patients had complete removal of tumor from the cavity with the transoral endoscopic approach through portal opening of the tumor cavity with a mean (SD) of 24.3 (3.12 mm). Various types of odontogenic tumors were included. No recurrence was detected in the follow-up period except for 1 case requiring a second look. Conclusion Management of large jaw tumors varies from incomplete excision as shaving to aggressive excision with greater morbidity requiring reconstruction. Endoscopic transoral route provides a marvelous option that ensures complete excision with functional preservation and less morbidity.

Robotic enucleation of pancreatic head insulinoma in two cases with challenging tumor locations

Presenter: John D Karalis MD | University of Texas Southwestern Medical Center Background: Insulinomas are rare neuroendocrine tumors for which surgical resection is the cornerstone of treatment. Enucleation of insulinomas located in the head of the pancreas can be challenging but is preferable to avoid the morbidity associated with pancreaticoduodenectomy. Our video-presentation aims to describe our technique for robotic enucleation of pancreatic head insulinomas. Methods: Our video describes the clinical presentation, diagnostic imaging and technical aspects of the surgical approach in two patients with pancreatic head insulinomas that underwent robotic enucleation. Results: The first patient is a 76-year-old female who presented with a 2-month history of syncope. Biochemical work-up revealed a blood glucose level of 35 mg/dl, C-peptide of 3.3 ng/mL, and proinsulin of 90 pmol/L. CT imaging revealed a 1.5x1.3 cm medial pancreatic head mass, located posterior to the superior mesenteric artery and superior mesenteric vein, anterior to the left renal vein, and in close proximity to the pancreatic duct. Pre-operatively, to aid with intra-operative visualization of the pancreatic duct, a pancreatic duct stent was placed endoscopically. Robotic enucleation of the mass was performed. Intraoperative ultrasound was used to identify the mass and preserve the integrity of the pancreatic duct. Pathology revealed a 1.2 cm well-differentiated neuroendocrine tumor. The patient’s post-operative course was uneventful; her glucose levels normalized, she received a diet on post-operative day 1, her drain was removed on post-operative day 3, and she was discharged home on post-operative day 5. The second patient is a 61-year-old male with a previous history of renal cell carcinoma treated with a robotic-assisted right nephrectomy who presented with mild symptoms attributed to hypoglycemia, with a blood glucose level ranging from 50-70 mg/dl. Biochemical work-up revealed an elevated C-peptide and proinsulin of 8.9 ng/ml and 98 pmol/L, respectively. CT imaging revealed a 1.2 cm pancreatic head mass in close proximity to the pancreatic duct. Pre-operatively, to aid with intra-operative visualization of the pancreatic duct, a pancreatic duct stent was placed endoscopically. Robotic enucleation of the mass was performed. Intraoperative ultrasound revealed that the mass was abutting the main pancreatic duct requiring careful dissection. Pathology revealed a 1.5 cm well-differentiated neuroendocrine tumor. The patient’s post-operative course was uneventful; he received a diet on post-operative day 1, his drain was removed on post-operative day 4, and she was discharged home on post-operative day 5. Conclusion: Robotic enucleation is a safe and feasible option for treatment of pancreatic head tumors in challenging locations. Preoperative pancreatic duct stenting is useful for identification and preservation of the pancreatic duct during the operation, and the use of intraoperative ultrasound is essential for tumor localization. Surgical proficiency and profound understanding of the anatomy of the pancreas are essential for successful robotic enucleation of pancreatic head tumors.

Laparoscopic enucleation and spleen saving distal pancreatectomy for synchronous insulinoma and nesidioblastosis in an adult patient

Introduction: Insulinoma is the most common functional neoplasm of the endocrine pancreas. Patients typically present with features known as Whipple triad. 90% of insulinomas are found to be benign solitary adenomas amenable to surgical resection. Method: We present a case of a lady who had endogenous hyperinsulinism with two DOTATATE avid nodules in the pancreatic body and tail who subsequently underwent laparoscopic enucleation and spleen saving distal pancreatectomy. Results: The patient presented initially with features suggestive of Whipple triad. Further workup by the endocrinologist showed results consistent with endogenous hyperinsulinism. Computed Tomography (CT) scan and DOTATATE scan showed that she had one intensely DOTATE-avid exophytic nodule arising from the pancreatic body that is suspicious for a neuroendocrine tumour while the second DOTATATE-avid nodule is close to the pancreatic tail. There is no suspicious nodal or distant DOTATATE-avid metastasis detected. Her case was discussed in the multidisciplinary meeting and the decision was to proceed with laparoscopic enucleation of both lesions. She subsequently underwent laparoscopic enucleation of pancreatic body lesion with spleen saving distal pancreatectomy. She was discharged well on post operative day 3 and remained symptom free during subsequent follow-ups. Final histology came back as grade 1, well differentiated insulinoma of the pancreatic body and incidental pancreatic nesidioblastosis in the pancreatic tail. Conclusion: Laparoscopic enucleation of pancreatic neuroendocrine tumour is feasible and safe method to resect pancreatic neuroendocrine tumour with less morbidity.

Use of posterior radial nephrotomy in laparoscopic enucleation of renal hilar tumors.

Centrally located completely endophytic renal hilar tumors pose a technical challenge, especially during a minimally invasive surgery. Relation of the tumor to the renal vasculature decides the approach. Tumors placed anterior to the vasculature can be approached in the anterior trans-hilar manner. However, tumors placed posterior to the vasculature need a posterior approach, which is quite a difficult maneuver during transperitoneal laparoscopy. Adequate exposure to access the resection plane is the key principle. We describe a laparoscopic technique for enucleation of such tumors, applying the surgical principle of radial nephrotomy in the intersegmental plane which is usually performed to remove renal stones.

A prospective study comparing side-firing KTP laser enucleation vs bipolar transurethral resection of bladder tumor for small bladder tumors in an outpatient setting.

IntroductionLaser therapy provides an alternative option for treating non-muscle-invasive bladder cancer. The clinical evidence for potassium-titanyl-phosphate (KTP) laser en bloc resection is still limited. Here, we evaluated the efficacy, safety profile, and outcomes of side-firing KTP laser enucleation with bipolar transurethral resection of bladder tumor (TURBT) in carefully selected patients with small bladder tumors in an office setting.Material and methodsA total of 83 patients with small bladder tumors were treated with either side-firing KTP laser enucleation (Group A; n = 40) or bipolar TURBT (Group B; n = 43). Intraoperative and postoperative parameters of interest were recorded and analyzed as per the study so as to evaluate the efficacy, safety profile, and outcome of KTP laser enucleation.ResultsThe mean enucleation time was 23 ±5.24 min in Group A and the mean operative time was 21.98 ±4.77 min in Group B (p = 0.207). Group A had a lower risk of obturator reflex (0 vs 8; p = 0.005) and lesser amount of irrigation used intraoperatively as compared to Group B (6.2 ±0.61 L vs 7.65 ±0.75 L; p <0.0001). There were no perioperative complications. The recurrence rate at 6 months was none in Group A and 2.3% in Group B.ConclusionsThe present study shows that, in patients with small bladder tumors (<3 cm), KTP laser enucleation is an effective and feasible alternative to bipolar TURBT in an office setting and can be carried out safely with comparable treatment outcomes, lesser use of irrigation fluid and lower risk of obturator reflex. However, further studies in larger cohorts are warranted.

Pneumothorax as a Rare Presentation of Bronchial Schwannoma

Tracheobronchial schwannomas are rare diseases. Common signs and symptoms of this tumor include cough, wheezing, and dyspnea. In contrast, pneumothorax is an exceptional presentation. This study reports the first case of bronchial schwannoma presenting with pneumothorax. A 79-year-old woman was diagnosed with pneumothorax by chest radiography. Chest computed tomography unexpectedly revealed a tumor occluding the right main bronchus. Following the pathological diagnosis of bronchial schwannoma, the patient underwent thoracoscopic tumor enucleation. The airway lumens are consequently secured postoperatively. Pneumothorax should be aware of a rare presentation of non-malignant tracheobronchial tumors.

Parenchymal-Sparing Hepatectomies for Colorectal Liver Metastases

Introduction: Parenchymal-sparing hepatectomies (PSH) have been performed widely for the patients of colorectal liver metastases (CLM) to preserve much liver parenchyma and allow for future re-resection. Herein, we divide PSH into 3 types of hepatectomies,ⅰ)limited anatomical resection,ⅱ)tumor-vessel detachment resection, andⅲ)tumor enucleation locating at the deep part of liver parenchyma from the parenchymal slit. In this presentation, we show each case, and evaluate the feasibility. Case1: In this case, the tumor was located at the boundary of S1 and S4. The tumor was 2cm in size, and involving the main trunk of middle hepatic vein (MHV). To preserve lateral section and left hepatic vein, we selected anatomical S1/S4 resection concomitant with MHV resection. Case2: The second patient had a tumor in S7, which was adjacent to the right hepatic vein (RHV). To preserve the venous return from the posterior section, we performed partial resection by detaching the tumor from the RHV. Case3: The last patient had multiple CLMs in bilateral lobe. Most tumors were located in the shallow part of liver parenchyma and dissected by partial resections. However, one tumor in S8 was located at the deep part of liver. Hence, we made parenchymal slit and enucleated the tumor. Results: We archived R0 resection in all cases. Postoperative mortality and morbidity were nil. Conclusions: PSH can be classified into 3 types. All types of PSH are feasible and can be performed safely.

Bladder Condyloma Acuminatum, A Case Report

Background: Human Papilloma virus (HPV) infection is a high incidence entity in the world population. It is highly related to cervical carcinoma, as well as anogenital carcinoma, among others. The presences of bladder HPV lesions are infrequent and there is an association between it and the development of bladder cancer. Case presentation: We present a case of bladder HPV in a woman with a cervical carcinoma history that was presented clinically as a single episode of gross hematuria. We performed a cystoscopy and Holmium laser enucleation of the bladder tumors. Conclusion: We highlight the importance of consider HPV as a differential diagnosis of a bladder tumor, mainly in patients with history of pathologies related with the virus.

Small pancreatic neuroendocrine tumors: Resect or enucleate?

BackgroundThe aim of this analysis is to compare the postoperative outcomes of resection and enucleation of small pancreatic neuroendocrine tumors (PNETs). MethodsThe 2014-17 American College of Surgeons-NSQIP dataset was queried. Patients undergoing pancreatoduodenectomy (N = 297) or distal pancreatectomy (N = 712) for nonfunctional, small PNETs (T1/T2) were compared to 127 patients (11%) who were enucleated. ResultsOperative time (170 vs 261, p < 0.01) and transfusions were less in the enucleation cohort (1.6% vs 6.7% p < 0.01). There was no difference in postoperative pancreatic fistulas, but morbidity was lower in enucleated patients (36.2% vs 48.7% p < 0.01). Fifteen resected patients died postoperatively (1.5%) while all enucleated patients survived (p = 0.058). Mean postoperative length of stay was shorter after enucleation (5.7 vs 7.2 days p < 0.01). ConclusionsEnucleation of PNETs is performed in only 11% of patients, but takes less time, requires fewer transfusions, and is associated with reduced morbidity and shorter length of stay than resection.

Pancreatic neuroendocrine tumours: spectrum of imaging findings.

Pancreatic neuroendocrine tumours (pNETs) are rare and heterogeneous group of neoplasms presenting with a wide variety of symptoms and biological behaviour, from indolent to aggressive ones. pNETs are stratified into functional or non-functional, because of their ability to produce metabolically active hormones. pNETs can be an isolate phenomenon or a part of a hereditary syndrome like von Hippel-Lindau syndrome or neurofibromatosis-1. The incidence has increased in the last years, also because of the improvement of cross-sectional imaging. Computed tomography (CT), magnetic resonance imaging (MRI) and functional imaging are the mainstay imaging modalities used for tumour detection and disease extension assessment, due to easy availability and better contrast/spatial resolution. Radiological imaging plays a fundamental role in detection, characterization and surveillance of pNETs and is involved in almost every stage of patients' management. Moreover, with specific indications and techniques, interventional radiology can also play a role in therapeutic management. Surgery is the treatment of choice, consisting of either partial pancreatectomy or enucleation of the primary tumour. This article reviews the radiologic features of different pNETs as well as imaging mimics, in order to help radiologists to avoid potential pitfalls, to reach the correct diagnosis and to support the multidisciplinary team in establishing the right treatment.

Renal function after partial nephrectomy following intra-arterial embolization of renal tumors

Laparoscopic Partial Nephrectomy (LPN) after intra-arterial Embolization of renal tumors (LPNE) in a hybrid operating room allows renal tumor enucleation without dissection and clamping of the renal pedicle. The purpose was to assess the potential negative impact of embolization on the renal function. This prospective monocentric study included all patients treated with LPNE between May 2015 and June 2019. Clinical data was collected and incorporated into the UroCCR database (NCT03293563). Glomerular Filtration Rate (GFR) and Computed Tomography Renal Volume (CTRV) were compared before and after 6 months following LPNE. The mean post-operative GFR was 86.6 mL/min (SD 22.9). The mean GFR loss was 9.4% (SD 15.1) and the median renal parenchyma loss was 21 mL (SD 20.6). Using a threshold of 25% GFR loss, age was the only significant predictive factor of renal function impairment according to bivariate (59.5 vs 69.3 years, p = 0.017) and multivariable analysis (OR 1.075, CI 1–1.2], p = 0.05). Significant renal function impairment was not correlated with the renal parenchymal volume loss (OR 0.987, CI [0.95–1.02], p = 0.435). Renal function impairment after LPNE seems to be comparable to other techniques of partial nephrectomy.

Laparoscopic enucleation of pancreatic tumours: a single-institution experience of 66 cases.

Laparoscopic enucleation of pancreatic tumours is seemingly a simple procedure, but challenging as the tumour is deeply embedded in the pancreatic parenchyma. Our study reports a single-centre experience for these cases. Cases with a tumour underwent laparoscopic enucleation from January 2014 to March 2020 in our hospital were collected and analysed. Sixty-six cases were enrolled, including 21 men and 45 women with an average age of 43.6 ± 16.7 years old. The mean size of tumours was 2.7 ± 1.8 cm. The tumours were mainly located at the pancreatic head and neck (63.6%). The most common pathological diagnoses were insulinomas, followed by solid pseudopapillary tumours. Incidences of overall complications and pancreatic fistula (PF, Grade B) were 24.2% and 19.7%, respectively. No patient developed PF (Grade C) or died. Cases were divided into two groups according to whether the tumour was deeply embedded in the pancreas. Compared to the group with a superficial tumour (n = 36), the group with an embedded tumour (n = 30) had a longer operation time and drainage duration and a smaller tumour size (P < 0.05), but did not increase the incidence of complications and PF (Grade B/C). Laparoscopic enucleation of tumours that were deeply embedded in the pancreas was technically feasible and safe.

Testis-Preserving Tumor Enucleation Is Applicable in Children with Immature Testicular Teratoma

Introduction: This study investigated the biological characteristics of immature testicular teratoma in children and explored the feasibility of testis-preserving tumor enucleation. Methods: We retrospectively reviewed the cases of 23 children who received a pathologic diagnosis of immature testicular teratoma between January 2005 and December 2018. Ages ranged from 16 days to 13 months (mean: 6 months and 5 days). Painless testicular enlargement was the main clinical manifestation, and the course of disease ranged from 20 days to 4 months (mean: 1.4 months). The tumor volume ranged from 1.5 × 1.2 × 0.5 to 6 × 5 × 4.5 cm. Elevated levels of alpha-fetoprotein were measured in 21 patients. Preoperative ultrasound examination showed a cystic/solid mass with calcification. Results: Excision of the affected testis was done in 10 patients and testis-preserving tumor excision in 13 patients. Postoperative chemotherapy was not employed. Nineteen patients were followed up for 1–10 years, and all showed disease-free survival without recurrence or metastasis. Conclusion: Immature testicular teratoma is found predominantly in children aged <1 year, and its biological characteristics are different from those in adults. Immature testicular teratoma is largely benign in children and can be managed by testis-preserving tumor enucleation, as for other benign tumors (such as mature teratoma). Postoperative monitoring and follow-up are necessary.

Enucleation for benign or borderline tumors of the pancreas: comparing open and minimally invasive surgery

BackgroundThe feasibility and safety of minimally invasive enucleation (ME) for benign or borderline pancreatic tumors is still unclear. The aim of this study was to compare outcomes between ME and open enucleation (OE). MethodsAll patients undergoing pancreatic enucleation between October 2001 and January 2020 were analyzed from a prospective database. Consecutive patients undergoing ME were compared with patients undergoing OE in a matched-pair analysis (1:2). ResultsOf 358 patients, undergoing enucleation, 120 matched patients (ME n = 40, OE n = 80) were included. Patients undergoing ME had less blood loss (median 50 vs. 100 ml, P = 0.025) and had a higher proportion of patients discharged by 7 days, than patients undergoing OE (38% vs. 18%, P = 0.016). The rates of clinically relevant postoperative pancreatic fistula (POPF) and major complications (Clavien grade ≥ 3) were similar between both groups. Risk factor analysis for POPF B/C showed no significant parameters associated with POPF, including tumor size and proximity to the main pancreatic duct. ConclusionCompared with conventional OE, ME reduces the amount of bleeding and allows earlier postoperative discharge, without increasing the incidence of major complications. Thus, minimally invasive enucleation should be considered for benign tumors of the pancreas when technically and oncologically feasible.

Clinical analysis of minimal invasive surgical treatment for pancreatic neuroendocrine tumors

Objective: To analyze the safety and effectiveness of minimal invasive surgery treating pancreatic neuroendocrine tumors (pNETs), and to summarize surgical characteristics and share experience. Methods: The clinical data of 80 pNETs treated by a single hospital from January 2015 to December 2019 were retrospectively analyzed. The patients were divided into laparoscopic group and robot group. And surgical procedures included pancreaticoduodenectomy (PD), distal pancreatectomy (DP), central pancreatectomy (CP), and tumor enucleation. Results: Of 80 patients, 76 cases (95%) underwent minimal invasive surgery and 4 cases (5%) changed to open surgery. There were 38 females, with median age of 54.4 (20-80) years and median BMI (17.0-38.0) kg/m(2). Among them, 24 patients (31.6%) underwent PD, 36 patients (47.4%) underwent DP, 8 patients (10.5%) underwent CP and 8 patients (10.5%) received tumor enucleation. The postoperative incidence of grade B/C pancreatic fistula was 35.5%, the incidence of abdominal infection was 10.5%, the postoperative bleeding was 7.9%, and the reoperation rate was 6.6%, without perioperative deaths. There was no significant difference in postoperative complications among different surgical methods, including postoperative pancreatic fistula (P=0.396), postoperative bleeding (P=0.297), postoperative abdominal infection (P=0.339) and reoperation (P=0.396). Conclusions: Surgical resection is an effective treatment for pNETs. pNETs are suitable for minimally invasive surgery with earlier stage and smaller tumor diameter. Minimally invasive surgery for pNETs is safe and feasible, and functional preserving surgery could take into consideration.

Organ-Sparing Surgery in Testicular Tumor: Is This the Right Approach for Lesions ≤ 20 mm?

Background: This study was conducted in order to analyze factors predicting malignancy in patients undergoing organ-sparing surgery (OSS) for small testicular lesions. Methods: Patients with small (≤20 mm) marker-negative clinical stage I testicular tumors were managed by OSS with tumor enucleation and frozen section examination (FSE) for the past 15 years at our institution. Benign and malignant cases were compared, focusing on preoperative and postoperative lesion sizes. Results: Eighty-nine patients were enrolled in this retrospective study. Ten (11.2%) of them were treated for synchronous bilateral tumors. Sixty-seven (67.7%) of ninety-nine lesions were benign, confirming a high concordance rate (98%) between FSE and final histology. Patients with benign tumors were significantly older than patients with malignant tumors (p = 0.026), and benign tumors were detected more frequently during urologic work-up of hormone disorders (p = 0.001). Preoperative tumor size was a strong predictor of malignancy (area under the curve (AUC) = 0.726; p < 0.001). According to the Youden index, the best cutoff to predict tumor dignity was 13.5 mm, resulting in a sensitivity and specificity of 53% and 85%, respectively. No cases of local recurrence or distant metastasis were confirmed after a median follow-up of 42 months. Conclusion: Our findings are consistent with previous reports, supporting an OSS approach in small testicular tumors whenever possible. Most tumors ≤ 20 mm were benign, and in the case of malignancy, OSS with FSE and consecutive orchiectomy is oncologically safe due to the high concordance rate of FSE and final histology, thus preventing a two-stage procedure.

Decision Making in Retroperitoneal Nerve Sheath and Nerve-Associated Tumors: A Modular Approach.

Surgical treatment of retroperitoneal nerve and nerve-associated tumors is challenging, especially in cases with large extent. A single surgical access may have limitations and jeopardize patients. To present a series of patients to illustrate our individually tailored treatment concept and decision pathway. Retrospectively, clinical findings and imaging were related to surgical features and outcome. An algorithm for choice of approach was established. From 2012 to 2017, we operated on n=13 patients with retroperitoneal tumors, of these n=9 were included (n=6 female, n=3 male). Histological findings included n=2 schwannomas, n=2 malignant peripheral nerve sheath tumors, n=1 non-origin sarcoma, n=1 perineurioma, n=1 intraneural ganglion cyst, n=1 lymphoma, and n=1 paraganglioma. In n=6 patients, we used a monoportal (retroperitoneal/transperitoneal) approach; in n=2 patients, a biportal retroperitoneal to inguinal/transperitoneal to dorsal approach; and in n=1 patient, a triportal transperitoneal to dorsal to gluteal approach. In n=2 patients, we performed an open biopsy only; in n=2 patients, a tumor enucleation; in n=3 patients, a subtotal function-sparing resection; in n=1 patient, a complete resection; and in n=1 patient, intraneural decompression. In n=1 patient, a new motor deficit appeared. n=4 patients required further radio-oncological treatment. n=8/9 patients are alive without tumor progress or recurrence. Retroperitoneal nerve or nerve-associated tumors encompass multiple entities. Depending on suspected histology and tumor extension, extensile or combined surgical approaches may be necessary. We present our algorithm for assessment and decision-making regarding surgical access ports and pathways.

Clinical outcomes and secondary glaucoma after gamma-knife radiosurgery and Ruthenium-106 brachytherapy for uveal melanoma: a single institution experience.

We retrospectively analyzed data from records of 48 patients (48 eyes) treated with gamma-knife (n = 18) or Ruthenium-106 brachytherapy (n = 30) for uveal melanoma, in our Ocular Oncology Unit between December 2013 and September 2019, with the aim to evaluate treatment outcomes, and incidence and risk factors for secondary glaucoma. Patients demographics and tumor characteristics at diagnosis were recorded. Follow-up data were collected regarding local tumor control, treatment complications, enucleation need, metastases occurrence and survival status. The median follow-up period was 33.7 months in the gamma-knife group and 26.2 months in the brachytherapy group. The mean tumor thickness, the largest basal diameter and the tumor volume were significantly higher in the gamma-knife group than in the brachytherapy group. The local tumor control rate was 100% in the brachytherapy group and 77.8% in the gamma-knife group. In the gamma-knife group, six patients were enucleated, no patient treated with brachytherapy underwent enucleation. The overall survival rate was 96.7% in the brachytherapy group and 94.44% in the gamma-knife group. Secondary glaucoma occurred in 10 patients after gamma-knife and in one patient after brachytherapy: it should be emphasized that larger lesions were treated with gamma-knife, whereas smaller tumors were selected for brachytherapy. We found a significative correlation of tumor thickness (P value = 0.043) and volume (P value = 0.040) with secondary glaucoma occurrence after gamma-knife treatment. Moreover, secondary glaucoma significantly correlated with radiation retinopathy in the gamma-knife group (P value = 0.009). This study shows preliminary clinical results that could be useful for further studies with more patients and longer follow-up.