Minimally Invasive Resection of Brain Metastases.

BACKGROUND: Minimally invasive resection of brain metastases aims to maximize resection while minimizing brain trauma. METHODS: Patients with 1 or more metastases that underwent resection following neuro-oncology multidisciplinary meeting discussion from September 2014 to October 2018, with pre- and postoperative magnetic resonance imaging, were included. All patients including posterior fossa metastases or multiple metastases were positioned supine. Hair was not shaved. Volumetric postcontrast T1 magnetic resonance imaging was used for incision planning and neuronavigation. The craniotomy site was tailored to tumor depth according to keyhole principles and ranged between 2 and 5 cm. Intraoperative monitoring and awake mapping were carried out in selected cases. RESULTS: Out of 320 consecutive patients with brain metastases, 44 patients were identified as suitable for minimally invasive resection. Nine patients had no postoperative imaging and were excluded. There were 38 metastases in 35 patients. There were 18 cerebellar metastases, 10 frontal, 3 parietal, 3 occipital, 2 temporal, 1 intraventricular, and 1 basal ganglia. Median length of stay was 3 days (range, 1-24). Average tumor volume was 54.7 cm3 (range, 10-240 cm3). Endoscopic assistance was used in 4 patients. Median performance status improved from 2 to 1 (range, preoperative: 0-4; postoperative: 0-2). Median survival was 14.7 months. CONCLUSIONS: Minimally invasive resection of brain metastasis is safe and effective, and in selected cases confers advantages compared with standard techniques.

Intracranial desmoplastic small round cell tumor presenting as a suprasellar mass.

Desmoplastic small round cell tumors (DSRCTs) are rare, aggressive neoplasms that typically arise from abdominal and pelvic peritoneum in young adults. Other primary sites are uncommon, and an intracranial origin is exceptionally rare. Here the authors report the first case of a DSRCT presenting as a primary suprasellar tumor causing panhypopituitarism and severe bitemporal hemianopia in a young man. Macroscopic debulking of the tumor was undertaken, and histology revealed features of DSRCT. Reverse transcription polymerase chain reaction confirmed the presence of Ewing's sarcoma-Wilms tumor 1 (EWS-WT1) gene rearrangement specific to DSRCT. Postoperative whole-body imaging showed no primary malignancy elsewhere. The tumor recurred 4 months after surgery, and this was followed by cervical and mediastinal lymph node metastases. The patient died 20 months after initial presentation of rapidly progressive disease. DSRCTs should be included in the differential diagnosis of an unusual suprasellar mass in young adults. Early diagnosis is essential, and once the tumor is identified histologically, gross-total resection and radical postoperative treatment involving radiotherapy, chemotherapy, and close surveillance are required because of the lesion's potential for rapidly progressive malignancy.

Treatment by specialist surgical neurooncologists improves survival times for patients with malignant glioma.

OBJECT: Surgeries for CNS tumors are frequently performed by general neurosurgeons and by those who specialize in surgical neurooncology. Subspecialization in neurosurgical practice has become common and may improve patient morbidity and mortality rates. However, the potential benefits for patients of having their surgeries performed by surgical neurooncologists remain unclear. Recently, a shift in patient care to those who practice predominantly surgical neurooncology has been promoted. Evidence for this practice is lacking and therefore requires fundamental investigation. METHODS: The authors conducted a case-control study of neurooncology patients who underwent surgery for glioblastoma and anaplastic astrocytoma during 2006-2009. Outcomes were compared for patients whose surgery was performed by general neurosurgeons (generalists) or by specialist neurooncology neurosurgeons (specialists). An electronic record database and a picture archiving and communication system were used to collect data and assess the extent of tumor resection. Mortality rates and survival times were compared. Patient comorbidity and postoperative morbidity were assessed by using the Waterlow, patient handling, and falls risk assessment scores. Effects of case mix were adjusted for by using Cox regression and a hazards model. RESULTS: Outcomes for 135 patients (65 treated by generalists and 70 by specialists) were analyzed. Survival times were longer for patients whose surgery was performed by specialists (p=0.026) and after correction for case mix (p=0.019). Extent of tumor resection was greater when performed by specialists (p=0.005) and correlated with increased survival times (p=0.004). There was a trend toward reduced surgical deaths when surgery was performed by specialists (2.8%) versus generalists (7%) (p=0.102), and inpatient stays were significantly shorter when surgery was performed by specialists (p=0.008). CONCLUSIONS: The prognosis for glioblastoma multiforme remains dire, and improved treatments are urgently needed. This study provides evidence for a survival benefit when surgery is performed by specialist neurooncology neurosurgeons. The benefit might be attributable to increased tumor resection. Furthermore, specialist neurooncology surgical care may reduce the number of surgical patient deaths and length of inpatient stay. These findings support the recommendations for subspecialization within surgical neurooncology and advocate for care of these patients by specialists.

Trigeminal neuralgia as initial symptom of paramedian tentorial meningioma.

Posterior cranial fossa tumours, not involving the cerebellopontine angle cistern, are a rare cause of trigeminal neuralgia (TN). We describe a patient with a large paramedian tentorial meningioma associated with acquired Chiari malformation who presented with TN. Trigeminal pain resolved after gross total tumour resection and postoperative magnetic resonance images disclosed a minimal residual tumour in the torcular region as well as ascent of cerebellar tonsils. In this article, we investigate the physiopathological hypotheses for this unusual association with emphasis on the role of tonsillar prolapse as neuropathological basis of neuropathic pain in this patient.