Contralateral transcallosal transfalcine approach for bilateral intra-extraventricular anaplastic ganglioglioma via 'the trans-tumoral route': a technical case instruction.

BACKGROUND: Bilateral, biventricular lesions present a challenging scenario in neurosurgery, often requiring complex surgical techniques for management. Gangliogliomas (GG), while typically indolent, can manifest as anaplastic variants (AGG), necessitating comprehensive treatment strategies. This case study explores a unique surgical approach for a patient with bilateral, intra-extraventricular lesions infiltrating the corpus callosum, highlighting the complexities of managing such cases. METHODS: A 63-year-old female presented with a progressive intraventricular lesion infiltrating the left frontal lobe, diagnosed initially as a ganglioglioma. Following resection and histological examination, the lesion was confirmed as a WHO Grade 1 ganglioglioma. Subsequently, a contralateral lesion emerged, necessitating a novel surgical approach to achieve maximal safe resection while minimising neurological deficits. The technique involved extending the surgical corridor contralaterally along the tumour route, guided by neuronavigation and fluorescence imaging. RESULTS: The surgical approach enabled maximal safe resection of the lesion, with postoperative imaging confirming complete resection in most sites except for a known infiltration in the right posterior lateral ventricle. Histological examination revealed AGG, prompting subsequent adjuvant radiotherapy due to its aggressive nature. CONCLUSION: The management of bilateral, biventricular lesions such as AGG requires innovative surgical approaches tailored to individual patient characteristics. The case highlights the efficacy of a transtumoral approach in achieving maximal safe resection while minimising neurological sequelae. Moreover, it underscores the importance of comprehensive treatment strategies, including adjuvant therapies, in addressing aggressive histological variants of gangliogliomas.

Detection of "Incidentalomas" on Brain and Body 68Ga-DOTATOC-PET Scans: A Retrospective Study and Case Illustration.

BACKGROUND/AIM: One of the main limitations of standard imaging modalities is microscopic tumor extension, which is often difficult to detect on magnetic resonance imaging (MRI) and computer tomography (CT) in the early stages of the tumor. (68)Ga-DOTA(0)-Phe(1)-Tyr(3)-octreotide positron-emission tomography/computed tomography (68Ga-DOTATOC PET/CT) has shown efficacy in detecting lesions previously undiagnosed by neuroimaging modalities, such as MRI or CT, and has enabled the detection of multiple benign tumors (like multiple meningiomas in a patient presenting with a single lesion on MRI) or additional secondary metastatic locations. PATIENTS AND METHODS: We retrospectively reviewed data from the Cannizzaro Hospital on brain and body 68Ga-DOTATOC PET/CT "incidentalomas", defined as tumors missed on CT or MRI scans, but detected on 68Ga-DOTATOC PET/CT scans. "Incidentalomas" were classified into "brain" and "body" groups based on their location. The standardized uptake values (SUVs) were compared between the two groups. RESULTS: A total of 61 patients with "incidentalomas" documented on the 68Ga-DOTATOC PET/CT were identified: 18 patients with 25 brain lesions and 43 patients with 85 body lesions. The mean SUV at baseline was 9.01±7.66 in the brain group and 14.8±14.63 in the body group. CONCLUSION: We present the first series on brain and body "incidentalomas" detected on 68Ga-DOTATOC PET/CT. Whole-body 68Ga-DOTATOC PET/CT may be considered in selected patients with brain tumors with high expression of somatostatin receptors to assist radiosurgical or surgical planning and, simultaneously, provide accurate follow-up with early detection of potential metastases.

Hypofractionated Gamma Knife Radiosurgery: Institutional Experience on Benign and Malignant Intracranial Tumors.

BACKGROUND/AIM: We investigated the treatment outcomes and complications associated with hypofractionated GKRS for the treatment of benign and malignant intracranial tumors. PATIENTS AND METHODS: Patients with intracranial tumors not candidate or refusing surgery were evaluated to assess eligibility to undergo hypofractionated Gamma Knife radiosurgery (GKRS). Targeted volumes were calculated using the GammaPlan® workstation, and GKRS protocols were delivered with 3 or 5 daily fractions and a maximal total dose of 25 Gy. The thermoplastic mask was used to immobilize the patient's head without pin-based fixation frames. RESULTS: A total of 41 patients, affected with 6 different histologies, were treated and followed-up for a median of 12 months (range=4-24 months). Meningiomas were the most common tumors (33, 80.5%), followed by brain metastases (4, 9.7%). At last follow-up, 33 patients (80.5%) had stable disease, 8 tumor regression (19.5%), and 0 tumor progression. No acute radiation toxicity was observed. Death was reported in 3 patients (7.3%) due to malignant tumor progression. CONCLUSION: Our hypofractionated GKRS protocol proved to be effective and safe in the treatment of patients with benign and malignant intracranial tumors. Local tumor control was achieved in all patients, with 8 patients showing tumor regression and no cases of acute radiation toxicity.

68Ga-DOTATOC PET/CT Follow Up after Single or Hypofractionated Gamma Knife ICON Radiosurgery for Meningioma Patients.

68Ga-DOTATOC represents a useful tool in tumor contouring for radiosurgery planning. We present a case series of patients affected by meningiomas on who we performed 68Ga-DOTATOC positron emission tomography (PET)/CT pre-operatively, a subgroup of which also underwent a post-operative 68Ga-DOTATOC PET/CT to evaluate the standardized uptake value (SUV) modification after Gamma Knife ICON treatment in single or hypofractionated fractions. Twenty patients were enrolled/included in this study: ten females and ten males. The median age was 52 years (range 33-80). The median tumor diameter was 3.68 cm (range 0.12-22.26 cm), and the median pre-radiotherapy maximum SUV value was 11 (range 2.3-92). The average of the relative percentage changes between SUVs at baseline and follow up was -6%, ranging from -41% to 56%. The SUV was reduced in seven out of 12 patients (58%), stable in two out of 12 (17%), and increased in three out of 12 (25%), suggesting a biological response of the tumor to the Gamma Knife treatment in most of the cases. 68Ga-DOTATOC-PET represents a valuable tool in assessing the meningioma diagnosis for primary radiosurgery; it is also promising for follow-up assessment.

Slit-like hypertensive hydrocephalus: Report of a late, complex, and multifactorial complication in an oncologic patient.

BACKGROUND: Several sophisticated techniques and many chemotherapy drugs have improved life expectancy of oncologic patients allowing us to observe late complications which present many years after the initial treatment. CASE DESCRIPTION: We present a unique case of a patient affected by acute lymphoblastic leukemia at the age of 6 years, treated with whole brain radiotherapy and intrathecal chemotherapy, developing meningiomatosis and leptomeningeal alterations as late complications and the interaction of these two entities caused a peculiar form of hydrocephalus without ventricular dilation. The diagnosis of pseudotumor cerebri was excluded due the postradio/chemotherapy development of meningiomatosis, not present in a previously head magnetic resonance imaging, that exerted compression to the Sylvian aqueduct causing intracranial hypertension with papillary stasis without ventricles enlargement due to brain stiffness. Moreover, a peculiar intraoperative rubbery consistency of brain parenchyma was detected strengthening this complex diagnosis. CONCLUSION: At the best of our knowledge, this is the first report of obstructive hydrocephalus without ventricles dilation caused by brain stiffness related to late alterations of oncologic treatments. This report could be a guide for further complex patients diagnoses and for improving treatments efficacy.