Management strategies for tumors of the axis vertebra

1996 ◽  
Vol 84 (4) ◽  
pp. 543-551 ◽  
Author(s):  
John G. Piper ◽  
Arnold H. Menezes
Keyword(s):  
Management Strategies ◽  
Extent Of Resection ◽  
Gross Total Resection ◽  
Surgical Approaches ◽  
Spinal Stability ◽  
Total Resection ◽  
Content Type ◽  
Presenting Symptoms ◽  
Axis Vertebra ◽  
Fine Print

✓ Primary and metastatic tumors of the axis vertebra pose difficult surgical problems. The authors report 14 cases of patients with axis tumors who underwent surgery between 1970 and 1993. The eight male and six female patients ranged in age from 9 to 70 years (mean 46 years). Presenting symptoms and signs included pain in 12, myelopathy in nine, radiculopathy in four, and cranial nerve deficits in two patients. Preoperative instability of the cervical spine was present in eight patients. The goal of surgery was to achieve diagnosis, decompression, and stabilization; the choice of operative intervention was based on tumor location and patient prognosis. Six transoral—transpalatal resections, two lateral extrapharyngeal approaches, four posterolateral decompressions, and 11 dorsal decompressions were performed. Eleven fusion procedures were required to achieve spinal stability. Patients with aggressive tumors requiring concomitant radiotherapy underwent fusion using contoured loop instrumentation or methyl methacrylate, whereas those with benign lesions underwent fusion using traditional techniques. With maximum medical and surgical intervention, 10 patients are alive and their tumors are in remission. In eight of these 10 patients, gross-total resection was achieved. Four patients died from tumor progression, and in three of these cases gross-total resection was not possible. There were no operative deaths and morbidity was minimal. Development of new surgical approaches to the axis has allowed resection of previously inoperable tumors. The extent of resection correlated with the duration of survival. A classification system for axis tumors is proposed to facilitate selection of appropriate surgical approaches that will maximize the extent of resection while achieving or maintaining spinal stability.

Individualized surgical strategies for Rathke cleft cyst based on cyst location

2013 ◽  
Vol 119 (6) ◽  
pp. 1437-1446 ◽  
Author(s):  
Jun Fan ◽  
Yuping Peng ◽  
Songtao Qi ◽  
Xi-an Zhang ◽  
Binghui Qiu ◽  
...  
Keyword(s):  
Extent Of Resection ◽  
Gross Total Resection ◽  
Surgical Approaches ◽  
Subtotal Resection ◽  
Total Resection ◽  
Surgical Strategies ◽  
Minimal Invasiveness ◽  
Rathke Cleft Cyst ◽  
Csf Leakage ◽  
Keyhole Craniotomy

Object An assessment regarding both surgical approaches and the extent of resection for Rathke cleft cysts (RCCs) based on their locations has not been reported. The aim of this study was to report the results of a large series of surgically treated patients with RCCs and to evaluate the feasibility of individualized surgical strategies for different RCCs. Methods We retrospectively reviewed 87 cases involving patients with RCCs (16 intrasellar, 50 intra- and suprasellar, and 21 purely suprasellar lesions). Forty-nine patients were treated via a transsphenoidal (TS) approach, and 38 were treated via a transcranial (TC) approach (traditional craniotomy in 21 cases and supraorbital keyhole craniotomy in 17). The extent of resection was classified as gross-total resection (GTR) or subtotal resection (STR) of the cyst wall. Patients were thus divided into 3 groups according to the approach selected and the extent of resection: TS/STR (n = 49), TC/STR (n = 23), and TC/GTR (n = 15). Results Preoperative headaches, visual dysfunction, hypopituitarism, and diabetes insipidus (DI) resolved in 85%, 95%, 55%, and 65% of patients, respectively. These rates did not differ significantly among the 3 groups. Overall, complications occurred in 8% of patients in TS/STR group, 9% in TC/STR group, and 47% in TC/GTR group, respectively (p = 0.002). Cerebrospinal fluid (CSF) leakage (3%), new hypopituitarism (9%), and DI (6%) were observed after surgery. All CSF leaks occurred in the endonasal group, while the TC/GTR group showed a higher rate of postoperative hypopituitarism (p = 0.7 and p < 0.001, respectively). It should be particularly noted that preoperative hypopituitarism and DI returned to normal, respectively, in 100% and 83% of patients who underwent supraorbital surgery, and with the exception of 1 patient who had transient postoperative DI, there were no complications in patients treated with supraorbital surgery. Kaplan-Meier 3-year recurrence-free rates were 84%, 87%, and 86% in the TS/STR, TC/STR, and TC/GTR groups, respectively (p = 0.9). Conclusions It is reasonable to adopt individualized surgical strategies for RCCs based on cyst location. Gross-total resection does not appear to reduce the recurrence rate but increase the risk of postoperative complications. The endonasal approach seems more appropriate for primarily intrasellar RCCs, while the craniotomy is recommended for purely or mainly suprasellar cysts. The supraorbital route appears to be preferred over traditional craniotomy for its minimal invasiveness and favorable outcomes. The endoscopic technique is helpful for either endonasal or supraorbital surgery.

Is gross-total resection sufficient treatment for posterior fossa ependymomas?

2005 ◽  
Vol 102 (4) ◽  
pp. 629-636 ◽  
Author(s):  
Leland Rogers ◽  
Jeanette Pueschel ◽  
Robert Spetzler ◽  
William Shapiro ◽  
Stephen Coons ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Posterior Fossa ◽  
Local Control ◽  
Median Duration ◽  
Local Control Rate ◽  
Gross Total Resection ◽  
Total Resection ◽  
Content Type ◽  
Significant Difference ◽  
Fine Print

Object. The goals of this study were to analyze outcomes in patients with posterior fossa ependymomas, determine whether gross-total resection (GTR) alone is appropriate treatment, and evaluate the role of radiation therapy. Methods. All patients with newly diagnosed intracranial ependymomas treated at Barrow Neurological Institute between 1983 and 2002 were identified. Those with supratentorial primary lesions, subependymomas, or neuraxis dissemination were excluded. Forty-five patients met the criteria for the study. Gross-total resection was accomplished in 32 patients (71%) and subtotal resection (STR) in 13 (29%). Radiation therapy was given to 25 patients: 13 following GTR and 12 after STR. The radiation fields were craniospinal followed by a posterior fossa boost in six patients and posterior fossa or local only in the remaining patients. With a median follow-up period of 66 months, the median duration of local control was 73.5 months with GTR alone, but has not yet been reached for patients with both GTR and radiotherapy (p = 0.020). The median duration of local control following STR and radiotherapy was 79.6 months. The 10-year actuarial local control rate was 100% for patients who underwent GTR and radiotherapy, 50% for those who underwent GTR alone, and 36% for those who underwent both STR and radiotherapy, representing significant differences between the GTR-plus-radiotherapy and GTR-alone cohorts (p = 0.018), and between the GTR-plus-radiotherapy and the STR-plus-radiotherapy group (p = 0.003). There was no significant difference in the 10-year actuarial local control rate between the GTR-alone and STR-plus-radiotherapy cohorts (p = 0.370). The 10-year overall survival was numerically superior in patients who underwent both GTR and radiotherapy: 83% compared with 67% in those who underwent GTR alone and 43% in those who underwent both STR and radiotherapy. These differences did not achieve statistical significance. Univariate analyses revealed that radiotherapy, tumor grade, and extent of resection were significant predictors of local control. Conclusions. Gross-total resection should be the intent of surgery when it can be accomplished with an acceptable degree of morbidity. Even after GTR has been confirmed with postoperative imaging, however, adjuvant radiotherapy significantly improves local control. The authors currently recommend the use of postoperative radiotherapy, regardless of whether the resection is gross total or subtotal.

Current neurosurgical management and the impact of the extent of resection in the treatment of malignant gliomas of childhood: a report of the Children's Cancer Group Trial No. CCG-945

1998 ◽  
Vol 89 (1) ◽  
pp. 52-59 ◽  
Author(s):  
Jeffrey H. Wisoff ◽  
James M. Boyett ◽  
Mitchel S. Berger ◽  
Catherine Brant ◽  
Hao Li ◽  
...  
Keyword(s):  
Glioblastoma Multiforme ◽  
Posterior Fossa ◽  
Anaplastic Astrocytoma ◽  
Tumor Resection ◽  
Radical Resection ◽  
Extent Of Resection ◽  
Total Resection ◽  
Content Type ◽  
Cancer Group ◽  
Fine Print

Object. One hundred seventy-two children with high-grade astrocytomas were treated by members of the Children's Cancer Group in a prospective randomized trial designed to evaluate the role of two chemotherapy regimens. Seventy-six percent of the patients (131 children) in whom a diagnosis of either anaplastic astrocytoma or glioblastoma multiforme was confirmed by central pathological review are the subject of this report. Methods. Patients were stratified according to the extent of tumor resection (biopsy [< 10%], partial resection [10–50%], subtotal resection [51–90%], near-total resection [> 90%], and total resection) as determined by surgical observation and postoperative computerized tomography scanning. Information on contemporary neurosurgical management was obtained from the patient's operative records and standardized neurosurgical report forms. The vast majority of tumors were supratentorial: 63% (83 tumors) in the superficial cerebral hemisphere, 28% (37 tumors) in the deep or midline cerebrum, and only 8% (11 tumors) in the posterior fossa. A significant association was detected between the primary tumor site and the extent of resection (p < 0.0001). A radical resection (> 90%) was performed in 37% of the children: 49% of the tumors in the superficial hemisphere and 45% of tumors in the posterior fossa compared with 8% of midline tumors. Tumor location could also be used to predict the need for both temporary and permanent cerebrospinal fluid (CSF) diversion. Half of the deep tumors and 8% of the hemispheric astrocytomas ultimately required a permanent CSF shunt. Improvement in preoperative neurological deficits and level of consciousness was seen in 36% and 34% of the children, respectively. New or increased deficits were present in 14% of the children, with 6% experiencing a diminished sensorium after surgery. Postoperative nonneurological complications were rare: infection, hematoma, and CSF fistula each occurred in 1.7% of the children. Univariate and multivariate analyses demonstrated that radical tumor resection (> 90%) was the only therapeutic variable that significantly improved progression-free survival (PFS) rates. For all patients with malignant astrocytomas, the distributions of PFS rates were significantly different (p = 0.006) following radical resection compared with less extensive (< 90%) resection. The 5-year PFS rates were 35 ± 7% and 17 ± 4%, respectively. The differences in the distribution of PFS rate were significant for the subsets of patients with anaplastic astrocytoma (p = 0.055) and glioblastoma multiforme (p = 0.046). The 5-year PFS rates for anaplastic astrocytoma were 44 ± 11% and 22 ± 6% for cases in which the tumor was radically resected and less than radically resected, respectively; whereas the 5-year PFS rates for glioblastoma multiforme were 26 ± 9% and 4 ± 3% for cases in which the tumor was radically resected and less than radically resected, respectively. Conclusions. The demonstration of a survival advantage provided by radical resection should prompt neurosurgeons to treat malignant pediatric astrocytomas with aggressive surgical resection prior to initiation of radiotherapy or adjuvant chemotherapy.

Vestibular schwannoma management

1998 ◽  
Vol 89 (6) ◽  
pp. 949-955 ◽  
Author(s):  
Bruce E. Pollock ◽  
L. Dade Lunsford ◽  
Douglas Kondziolka ◽  
Raymond Sekula ◽  
Brian R. Subach ◽  
...  
Keyword(s):  
Tumor Growth ◽  
Surgical Resection ◽  
Vestibular Schwannoma ◽  
Tumor Resection ◽  
Gamma Knife Radiosurgery ◽  
Gross Total Resection ◽  
Total Resection ◽  
Content Type ◽  
Tumor Enlargement ◽  
Fine Print

Object. The indications, operative findings, and outcomes of vestibular schwannoma microsurgery are controversial when it is performed after stereotactic radiosurgery. To address these issues, the authors reviewed the experience at two academic medical centers. Methods. During a 10-year interval, 452 patients with unilateral vestibular schwannomas underwent gamma knife radiosurgery. Thirteen patients (2.9%) underwent delayed microsurgery at a median of 27 months (range 7–72 months) after they had undergone radiosurgery. Six of the 13 patients had undergone one or more microsurgical procedures before they underwent radiosurgery. The indications for surgery were tumor enlargement with stable symptoms in five patients, tumor enlargement with new or increased symptoms in five patients, and increased symptoms without evidence of tumor growth in three patients. Gross-total resection was achieved in seven patients and near-gross-total resection in four patients. The surgery was described as more difficult than that typically performed for schwannoma in eight patients, no different in four patients, and easier in one patient. At the last follow-up evaluation, three patients had normal or near-normal facial function, three patients had moderate facial dysfunction, and seven had facial palsies. Three patients were incapable of caring for themselves, and one patient died of progression of a malignant triton tumor. Conclusions. Failed radiosurgery in cases of vestibular schwannoma was rare. No clear relationship was demonstrated between the use of radiosurgery and the subsequent ease or difficulty of delayed microsurgery. Because some patients have temporary enlargement of their tumor after radiosurgery, the need for surgical resection after radiosurgery should be reviewed with the neurosurgeon who performed the radiosurgery and should be delayed until sustained tumor growth is confirmed. A subtotal tumor resection should be considered for patients who require surgical resection of their tumor after vestibular schwannoma radiosurgery.

Repeated operations for infiltrative low-grade gliomas without intervening therapy

2003 ◽  
Vol 98 (6) ◽  
pp. 1165-1169 ◽  
Author(s):  
Meic H. Schmidt ◽  
Mitchel S. Berger ◽  
Kathleen R. Lamborn ◽  
Ken Aldape ◽  
Michael W. McDermott ◽  
...  
Keyword(s):  
Tumor Progression ◽  
Median Time ◽  
Initial Diagnosis ◽  
Gross Total Resection ◽  
Low Grade ◽  
Total Resection ◽  
Content Type ◽  
Low Grade Gliomas ◽  
Second Surgery ◽  
Fine Print

Object. Progression of infiltrative low-grade gliomas (LGGs) has been reported previously. The limitations of such studies include diverse histological grading systems, intervening therapy, and the lack of histological confirmation of malignant tumor progression. The aim of this study was to determine tumor progression in adult patients with an initial diagnosis of infiltrative LGG who subsequently underwent a repeated operation, but no other intervening therapy. The authors examined factors that may be associated with tumor progression. Methods. The authors retrospectively reviewed a database of 300 patients with the initial diagnosis of LGG and who had been treated at their institution between 1990 and 2000. One hundred four of these patients had undergone a second surgery. Patients with infiltrative LGGs who had undergone two surgical procedures at least 3 months apart without intervening therapy were selected; the authors identified 40 patients who fit these criteria. Clinical, neuroimaging, and pathological data were centrally reviewed. There were 29 men and 11 women in the study, whose median age was 35.5 years (range 23–48 years). At the time of the second surgery, 50% of patients had experienced tumor progression. Patients whose tumors had progressed had a longer median time to repeated operation (49 compared with 22.5 months). Patients who had undergone gross-total resection, as demonstrated on postoperative magnetic resonance images, had a median time to repeated operation of 49 compared with 25 and 24 months in patients who underwent subtotal resection and biopsy, respectively (p = 0.02). The extent of resection did not influence the likelihood of tumor progression (p > 0.3). Conclusions. Fifty percent of patients with initially diagnosed infiltrative LGGs had tumor progression at the time of a repeated operation. A gross-total resection was associated with an increased time to repeated surgery. There was no statistically significant effect of gross-total resection as a predictor of tumor progression.

Chondrosarcoma of the spine: 1954 to 1997

1999 ◽  
Vol 90 (1) ◽  
pp. 73-78 ◽  
Author(s):  
Julie E. York ◽  
Rasim H. Berk ◽  
Gregory N. Fuller ◽  
Jasti S. Rao ◽  
Dima Abi-Said ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Surgical Procedures ◽  
Gross Total Resection ◽  
Total Resection ◽  
Disease Free Interval ◽  
Content Type ◽  
Free Interval ◽  
Kaplan Meier ◽  
Disease Free ◽  
Fine Print

Object. Primary chondrosarcoma of the spine is extremely rare. During the last 43 years only 21 patients with this disease were registered at The University of Texas M. D. Anderson Cancer Center. The purpose of this study was to examine the demographic characteristics, treatments, and outcomes of this set of patients. Methods. Medical records for 21 patients were reviewed. Age, sex, race, clinical presentation, tumor histology, tumor location in the spinal column, treatments, surgical details, and response to treatment were recorded. Surgical procedures were categorized as either gross-total resection or subtotal excision of tumor. Neurological function was assessed using Frankel's functional classification. Time to recurrence and survival analyses were performed using the Kaplan—Meier method. The median age of patients was 51 years, with fairly equal gender representation. Eighteen patients underwent at least one surgical procedure for a total of 28 surgical procedures: seven radical resections and 21 subtotal excisions. Radiation therapy was used in conjunction with 10 of the 28 surgical procedures. The median Kaplan—Meier estimate of overall survival for the entire group was 6 years (range 6 months–17 years). Tumors recurred after 18 of the 28 procedures. Kaplan—Meier analysis revealed a statistically significant difference in the per-procedure disease-free interval after gross-total resection relative to subtotal excision (exact log rank 3.39; p = 0.04). The addition of radiation therapy prolonged the median disease-free interval from 16 to 44 months, although this was not statistically significant (exact log rank 2.63; p = 0.16). Conclusions. Our results suggest that gross-total resection of the chondrosarcoma provides the best chance for prolonging the disease-free interval in patients. Subtotal excision should be avoided whenever possible. Addition of radiation therapy does not appear to lengthen significantly the disease-free interval in this patient population.

Thoracoscopic resection of thoracic neurogenic tumors

2002 ◽  
Vol 96 (3) ◽  
pp. 304-308 ◽  
Author(s):  
Patrick P. Han ◽  
Curtis A. Dickman
Keyword(s):  
Gross Total Resection ◽  
Total Resection ◽  
Thoracoscopic Resection ◽  
Content Type ◽  
Neurogenic Tumors ◽  
Normal Tissues ◽  
Intercostal Neuralgia ◽  
Intraspinal Extension ◽  
Fine Print

Object. The authors describe the treatment and results of thoracoscopic resection performed in patients with neurogenic tumors. Methods. Seven patients with large intrathoracic paraspinal neurogenic tumors underwent a thoracoscopic procedure to achieve gross-total resection. All tumors were entirely intrathoracic and treated thoracoscopically except in one patient whose tumor had an intraspinal extension. Gross-total resection was achieved in all cases. Postoperatively, one patient developed Horner syndrome. The only other complication, transient intercostal neuralgia, resolved in all patients. Clinical examination and magnetic resonance imaging follow-up examination in all patients demonstrated no evidence of recurrent disease (mean follow up 12.5 months). Conclusions. Endoscopic transthoracic approaches can reduce approach-related soft-tissue morbidity and facilitate a patient's recovery by preserving the normal tissues of the chest wall, by avoiding rib retraction and muscle transection, and by reducing postoperative pain.

Hemangiopericytoma of the confluence of sinuses and the transverse sinuses

2003 ◽  
Vol 99 (6) ◽  
pp. 1085-1088 ◽  
Author(s):  
Frederic P. Collignon ◽  
Aaron A. Cohen-Gadol ◽  
David G. Piepgras
Keyword(s):  
Differential Diagnosis ◽  
Gross Total Resection ◽  
Total Resection ◽  
Blurred Vision ◽  
Content Type ◽  
First Report ◽  
Dural Sinuses ◽  
Transverse Sinuses ◽  
Fine Print

✓✓ The authors describe the case of a 38-year-old man with progressive headache and blurred vision related to a hemangiopericytoma located exclusively in the confluence of sinuses (CoS) and in the transverse sinuses bilaterally. They believe this is the first report in which a hemangiopericytoma of the dural sinuses has been described without any intradural component. Although the diagnosis was not suspected preoperatively, a gross-total resection of the tumor with restoration of sinus patency was achieved to relieve the symptoms. This diagnosis should be included in the preoperative differential diagnosis of a tumor of the CoS. Successful resection can be achieved in these cases.

Delayed occurrence of cerebellar pleomorphic xanthoastrocytoma after supratentorial pleomorphic xanthoastrocytoma removal

1995 ◽  
Vol 82 (1) ◽  
pp. 116-118 ◽  
Author(s):  
Ryan S. Glasser ◽  
Amyn M. Rojiani ◽  
J. Parker Mickle ◽  
Thomas A. Eskin
Keyword(s):  
Glioblastoma Multiforme ◽  
Posterior Fossa ◽  
Clinical Characteristics ◽  
Clinical Course ◽  
Pleomorphic Xanthoastrocytoma ◽  
Gross Total Resection ◽  
Total Resection ◽  
Content Type ◽  
Atypical Features ◽  
Fine Print

✓ The authors report the case of a 36-year-old woman who underwent gross total resection of a right cerebellar pleomorphic xanthoastrocytoma with atypical features. She had undergone surgery 16 years previously for what was thought to be a right frontal glioblastoma multiforme. In retrospect, based on the histopathology and the clinical course, both lesions were considered to represent atypical variants of pleomorphic xanthoastrocytoma. This report examines the histological and clinical characteristics of this posterior fossa lesion, which exhibited histologically malignant features but has run a relatively indolent course.

Meningiomas of the clivus and apical petrous bone

1986 ◽  
Vol 65 (2) ◽  
pp. 160-167 ◽  
Author(s):  
Marc R. Mayberg ◽  
Lindsay Symon
Keyword(s):  
Cranial Nerve ◽  
Clinical Status ◽  
Surgical Techniques ◽  
Petrous Bone ◽  
External Carotid ◽  
Total Resection ◽  
Content Type ◽  
Presenting Symptoms ◽  
Cranial Nerve Palsies ◽  
Fine Print

✓ Between March, 1966, and June, 1985, 23 women and 12 men underwent partial or total resection of apical petrous or clivus meningiomas at The National Hospital for Nervous Diseases. Presenting symptoms were typically of long duration (mean 29 months) and consisted primarily of gait disturbance, headache, hearing loss, and facial pain. Cranial nerve deficits, especially affecting the fifth, seventh, and eighth nerves, were observed in nearly every patient. Tumor size, but not location, was generally associated with degree of preoperative disability. Plain skull films were usually unremarkable, but computerized tomography (CT) proved highly accurate in determining tumor location and size. A characteristic pattern of vascular displacement was seen on vertebral angiograms, although blood supply to the tumors was derived primarily from branches of the internal and external carotid arteries. Subtotal or total resection was undertaken in all cases; nine patients required adjunctive cerebrospinal fluid shunting procedures. Although surgical techniques evolved during the course of the 20-year study, a combined supra- and infratentorial approach proved a relatively safe and effective means of surgical treatment. New or worsened postoperative deficits, especially cranial nerve palsies, and complications in the immediate postoperative period frequently resulted in temporary deterioration of the clinical status during this period; the total operative mortality rate was 9%. Follow-up periods ranged up to 9 years; 70% of patients resumed an independent existence, and none is known to have required subsequent tumor surgery. The size of the lesion was the only significant factor in determining outcome. These data suggest that meningiomas of the clivus and apical petrous bone can be accurately diagnosed by CT and three-vessel angiography, and effectively treated by microsurgical resection.

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