Cavernous sinus exenteration for invasive cranial base tumors.

OBJECTIVE: Invasive tumors involving the cavernous sinus, such as recurrent benign meningiomas or sarcomas, raise therapeutic problems that may be resolved by cavernous sinus exenteration (CSE). METHODS: Our series comprises 18 patients (9 women and 9 men ranging in age from 14 to 64 yr) who underwent CSE during the past 8 years. The tumors in these patients included 12 meningiomas, 3 chondrosarcomas, 1 rhabdomyosarcoma, 1 lipomyosarcoma, and 1 epidermoid carcinoma. Preoperative occlusion of the internal carotid artery was confirmed in 15 cases by a balloon occlusion test. Three patients had a negative balloon occlusion test, and their internal carotid arteries were preserved (n = 1) or revascularized (n = 2) through an external carotid artery-to-middle cerebral artery bypass. RESULTS: CSE was performed as a primary treatment in 5 patients and after one to five recurrences in 13 patients. In all patients, CSE included the internal carotid artery and Cranial Nerves III, IV, and VI and one to three branches of Cranial Nerve V. Orbital exenteration was performed in eight patients, and partial hypophysectomy was performed in five patients. Ten patients had received radiotherapy before CSE, and five patients underwent irradiation after CSE. The operative mortality includes two patients. Cerebrospinal fluid leakage was the main complication in four patients, with three patients having meningitis. Follow-up ranged from 6 months to 5 years, with three deaths from new recurrences at 2, 3, and 4 years after CSE. As compared with their clinical courses before CSE, all patients except the two who died postoperatively benefited from CSE. CONCLUSION: CSE has useful indications in invasive and rapidly growing tumors, including apparently benign meningiomas. A better understanding of the biological behavior of these tumors is necessary for appropriate selection of patients for CSE.

Suboccipital and cervical chordomas: the value of aggressive treatment at first presentation of the disease.

OBJECT: Chordoma is a locally invasive tumor with a high tendency for recurrence for which radical resection is generally recommended. To assess the benefits of aggressive treatment of chordomas, the authors compared results in patients treated aggressively at the first presentation of this disease with results in patients who were similarly treated, but after recurrence. METHODS: Among 36 patients with cervical chordomas who were treated at the authors' institution, 22 underwent primary aggressive treatment (Group A) and 14 were treated secondarily after tumor recurrence (Group B). Two cases were excluded from Group A because of unrelated early deaths and three from Group B because of insufficient pre- or postoperative data. Most tumors were located at the suboccipital level and only eight cases at a level below C-2. Radiotherapy and proton therapy were similarly conducted in both groups of patients. The actuarial survival rates were 80 and 65% at 5 and 10 years, respectively, in Group A patients and 50 and 0% at 5 and 10 years, respectively, in Group B patients (p = 0.049, log-rank test). The actuarial recurrence-free rates were 70 and 35% at 5 and 10 years, respectively, in Group A and 0% at 3 years in Group B (p < 0.0001, log-rank test). The numbers of recurrences per year were 0.15 in Group A and 0.62 in Group B (p > 0.05). All other parameters that were analyzed (patient age, delay before diagnosis, clinical symptoms, chondroid type of lesion, and histological features) did not prove to influence prognosis in a statistically significant manner. CONCLUSIONS: Aggressive therapy, combining as radical a resection as possible with radiotherapy, seems to improve the prognoses of suboccipital and cervical chordomas when applied at the patient's first presentation with the disease.

Transcranial approach for venous embolization of dural arteriovenous fistulas.

OBJECT: Transvenous embolization is effective in the treatment of an intracranial dural arteriovenous fistula (DAVF). Access to the fistula via the internal jugular vein (IJV) may be limited by associated dural sinus thrombosis; a transcranial approach has been developed for venous embolization in such a situation. The authors report their experiences with the use of a transcranial approach for venous embolization of DAVFs. METHODS: Ten patients with DAVFs underwent craniectomy and embolization procedures in which direct sinus puncture was performed. The DAVFs were located inside the dura mater that constituted the walls of the transverse sinus in five cases, the superior sagittal sinus in four cases, and the superior petrosal sinus in one case. All DAVFs drained directly into a sinus with secondary reflux into leptomeningeal veins. In all cases, the fistula could not be accessed from the IJVs. Craniectomy was performed in an operating room and, in seven cases, subsequent enlargement of the craniectomy was required. Sinus catheterization was performed after the patient had been transferred to the angiography room. The DAVFs were embolized using coils only in five patients, glue only in two patients, and both coils and glue in three patients. Angiographic confirmation that embolization of the fistula was successful was obtained in all cases. A transient complication occurred during the first case after sinus catheterization was attempted in the operating room. CONCLUSIONS: The transcranial approach allows straightforward access to DAVFs located on superficial dural sinuses that are inaccessible from the IJVs. The effectiveness of this approach is similar to that of the standard retrograde venous approach. The correct location and adequate extent of the craniectomy are essential for success to be achieved using this technique.

[Pituitary germinoma and lymphocytic hypophysitis: a pitfall. Report of two cases]. / Germinome hypophysaire. A propos de deux cas trompeurs.

We report two cases of pituitary germinomas in two young men aged 13 and 21, revealed by insipidus diabetes associated with visual field defects or hypopituitarism. Neuroimaging of the first case was initially normal, then showed an infiltration of the stalk; the lesion of the second case appeared as a nodular thickening of the stalk and subsequently a pituitary infiltration. Histologically they mimicked lymphocytic infundibulo-neuro-hypophysitis (LINH) or lymphocytic hypophysitis (LH), the large tumoral clear cells being out-numbered by the heavy inflammatory stroma or mistaken for macrophages. Only the immuno-staining by placental alkaline phosphatase led to the diagnosis. In these tumours, immunostaining positive for CD-117 and negative for CD30, confirmed the diagnosis and should allow the distinction of pituitary germinoma from other germ cell tumours as recently described in the testis, and may have a therapeutic interest.