Radiologic and Clinical Outcomes of Stereotactic Radiosurgery for Intraventricular Metastases.

OBJECTIVE: The optimal management of intraventricular metastases remains debatable. The aim of this study is to define the safety and efficacy of Gamma-Knife radiosurgery in the treatment of intraventricular metastases. METHODS: This retrospective, single-center study involved patients that were treated with stereotactic radiosurgery (SRS) for intraventricular metastases. The study end points included SRS-related toxicity, local and distal intracranial tumor control, as well as the incidence of post-treatment hydrocephalus and leptomeningeal dissemination. Factors associated with radiologic and clinical outcomes were also analyzed. RESULTS: The cohort included 17 consecutive patients who underwent stereotactic radiosurgery for treatment of 41 intracranial metastases, of which 23 were primary intraventricular (intraventricular metastasis). Median overall survival from primary tumor diagnosis and from SRS treatment were 28 and 5 months, respectively. With a median radiological follow-up of 3 (interquartile range 3) months, 7 patients (41.18%) experienced overall intracranial disease progression, whereas 7 (27.27%) intraventricular metastases progressed radiologically. Four (23.53%) and 3 (17.65%) patients developed hydrocephalus and leptomeningeal dissemination post-SRS, respectively. Four patients (23.53%) died due to intracranial disease progression. CONCLUSIONS: SRS offers a reasonable chance of local tumor control for patients with intraventricular brain metastasis. However, the risk of hydrocephalus and leptomeningeal spread of disease is not inconsequential and merits close follow-up for patients with brain metastasis involving the ventricular system.

Endoscopic versus stereotactic biopsies of intracranial lesions involving the ventricles.

Stereotactic biopsies of ventricular lesions may be less safe and less accurate than biopsies of superficial lesions. Accordingly, endoscopic biopsies have been increasingly used for these lesions. Except for pineal tumors, the literature lacks clear, reliable comparisons of these two methods. All 1581 adults undergoing brain tumor biopsy from 2007 to 2018 were retrospectively assessed. We selected 119 patients with intraventricular or paraventricular lesions considered suitable for both stereotactic and endoscopic biopsies. A total of 85 stereotactic and 38 endoscopic biopsies were performed. Extra procedures, including endoscopic third ventriculostomy and tumor cyst aspiration, were performed simultaneously in 5 stereotactic and 35 endoscopic cases. In 9 cases (5 stereotactic, 4 endoscopic), the biopsies were nondiagnostic (samples were nondiagnostic or the results differed from those obtained from the resected lesions). Three people died: 2 (1 stereotactic, 1 endoscopic) from delayed intraventricular bleeding and 1 (stereotactic) from brain edema. No permanent morbidity occurred. In 6 cases (all stereotactic), additional surgery was required for hydrocephalus within the first month postbiopsy. Rates of nondiagnostic biopsies, serious complications, and additional operations were not significantly different between groups. Mortality was higher after biopsy of lesions involving the ventricles, compared with intracranial lesions in any location (2.4% vs 0.3%, p = 0.016). Rates of nondiagnostic biopsies and complications were similar after endoscopic or stereotactic biopsies. Ventricular area biopsies were associated with higher mortality than biopsies in any brain area.

Efficacy of gamma knife radiosurgery in the treatment of intraventricular meningiomas.

Intraventricular meningiomas (IVMs) are notably limited tumors and express one of the most challenging tumors in neurosurgery. Gamma Knife radiosurgery (GKRS) as an alternative for IVMs has been reported only in a few case series. We aimed to present six patients with IVMs who were treated with GKRS and do a literature review. The data of patients were retrospectively reviewed. All patients underwent a single session of GKRS with a median marginal dose of 12 Gy (range, 11-13). Target volume ranged from 1.2 to 9.5 cc. Routine imaging with contrast-enhanced MRI scans was performed every six months initially and thereafter yearly. New neurological deficits and symptoms stated or observed during follow-up were recorded and investigated. The mean age was 41.3 years (range, 30-71). GKRS was used as a primary treatment in five patients and as adjunctive treatment in one patient. The most common presenting symptom was a headache. The median duration of symptoms was 30 months (range, 5-240). Four tumors (67%) were located in the left lateral ventricle, and two were in the right lateral ventricle. During a median follow-up of 71.5 months (range, 23-139), tumor volume was noted to have shrunk (median = 59.6%) in all patients (100%). One patient experienced post-GKRS peritumoral edema that resolved after a short course of steroids. The mean progression-free survival was 117.5 months (95% CI, 81-154 months). Neurologic symptoms and signs improved in all patients. GKRS may be a feasible treatment alternative in patients with small IVMs with low morbidity.

Intraventricular choroid plexus tumors: clinical characteristics and impact of current management on survival.

INTRODUCTION: Choroid plexus tumors (CPTs) represent one of the most common intraventricular tumors. Although most are benign, they often reach considerable sizes before clinical manifestation, challenging their surgical management. We aim to describe the clinical characteristics and the impact of current management on the survival of patients harboring intraventricular CPT. METHODS: The National Cancer Database (NCDB) was queried to identify biopsy-proven intraventricular CPT patients (2004-2015). Demographic and patterns of care were described, the log-rank method was used to independently analyze survival according to age, WHO grade and extent of resection (EOR). Multivariate analysis was performed to investigate the impact of prognostic factors on overall survival (OS). RESULTS: A total of 439 CPT patients with known WHO grade were included. WHO grade I tumors were more frequent in adults, while WHO grade III tumors were more common in pediatric population. Most CPTs were benign, with a median tumor size of 3-4 cm. Mean tumor size in pediatric population was greater than in adult population (4.39 cm vs. 2.7 cm; p < 0.01). Frequency was similar between males and females (51.7% vs. 48.3%; p > 0.0.5). Five- and ten-year OS among all patients was 87% and 84%, respectively. EOR was not associated with survival for any WHO grade. On multivariable analysis, only patient age (p = 0.022), WHO grade (p = 0.003) and medical comorbidity scores (p = 0.002) were independently associated with OS after diagnosis. CONCLUSION: Patients with CPTs present at different stages of life, with sizable tumor burden and distinct WHO grade prevalence. Considering their favorable survival, efforts to improve tumor control should be meticulously weighed against the long-term risk associated with surgery, radiation, and chemotherapy.

Survival of Ventricular and Periventricular High-Grade Gliomas: A Surveillance, Epidemiology, and End Results Program-Based Study.

BACKGROUND: Aggressiveness of surgical resection for periventricular/ventricular high-grade gliomas (HGGs) is determined by operative risks and assumed effectiveness of radiation therapy (RT) on residual tumor. We aimed to clarify the impact of surgery and postoperative RT on patient survival in a population-based study. METHODS: This population-based study used the Surveillance, Epidemiology, and End Results (SEER) database. Patients with ventricular malignant tumors were screened for HGGs. In accordance with the World Health Organization (WHO) 2016 classification, we included cases with "diffuse astrocytic and oligodendroglial tumors," "other astrocytic tumors," "ependymal tumors," and "other gliomas". Tumor grading followed definitions established by the WHO with supplementation from SEER classifications. Only grades III and IV were included. Individual factors were assessed by hazard ratio (HR) from multivariable survival analysis using accelerated failure time (AFT) regression. RESULTS: We included 353 patients after application of inclusion and exclusion criteria. The mean patient age was 38.77 ± 24.95 years, and the cohort was 61.5% male. Overall median survival was 12 months, with notable improvement over the last 3 decades. In a multivariate AFT model, older age (per 10-year increase, HR, 1.19; P < 0.001) was the sole nontreatment variable found to predict survival, whereas postoperative RT had a significant survival benefit (HR, 0.50; P < 0.001). No tumor characteristic (e.g., size, extent of invasion) predicted prognosis. Interestingly, neither partial resection nor TR/GTR was associated with improved outcome. CONCLUSIONS: The prognosis of ventricular HGGs is poor, with worse prognosis in older patients. We found no evidence to support aggressive surgical resection. Postoperative chemoradiation should be administered; however, the benefit of modification of the protocol for chemoradiation specifically for ventricular HGGs remains unknown and warrants further investigation.

The Prognostic Impact of Ventricular Opening in Glioblastoma Surgery: A Retrospective Single Center Analysis.

OBJECTIVE: Ventricular opening during glioblastoma (GBM) resection is controversial. Sufficient evidence regarding its prognostic role is missing. We investigated the impact of ventricular opening on overall survival (OS), hydrocephalus development, and postoperative morbidity in patients with GBM. METHODS: Patients who underwent primary GBM resection between 2006 and 2013 were assessed retrospectively. Established predictors for overall survival (age, Karnofsky Performance Status, extent of resection, O-6-methylguanine-DNA methyltransferase promoter methylation status, isocitrate dehydrogenase mutation status) and further clinical data (postoperative status, further treatment, preoperative tumor volume, proximity to the ventricle) were included in univariate and multivariate analyses. RESULTS: Thirteen (5.7%) of 229 patients developed a hydrocephalus. Multivariate logistic regression showed that neither ventricular opening, tumor size, proximity to the ventricle, nor extent of resection were significant risk factors for hydrocephalus. Ventricular opening did not delay postoperative therapy and was not associated with neurological morbidity. Kaplan-Meier analysis demonstrated that patients who underwent ventricular opening (n = 114) exhibited a median OS of 14.3 months (12.9-16.5), whereas patients who did not undergo ventricular opening (n = 115) exhibited a median OS of 18.6 months (16.1-20.8). However, multivariate Cox regression (n = 134) did not confirm ventricular opening as an independent negative predictor of OS (risk ratio 1.09, P = 0.77). Instead, it showed that a greater preoperative tumor volume >22.8 cm3 was a negative predictor of OS (risk ratio 1.76, P = 0.02). CONCLUSIONS: Because extent of resection is a strong independent predictor of OS and ventricular opening is safe, neurosurgeons should consider ventricular opening to achieve maximal tumor resection.

The clinical features and surgical outcomes of intracranial tanycytic ependymomas: a single-institutional experience.

Tanycytic ependymoma is a rare subtybe of ependymoma with a predilection for the spinal cord and intracranial tanycytic ependymoma is thus extremely rare. Most studies on intracranial tanycytic ependymomas included only one or two cases. Here we report nine patients with pathologically confirmed intracranial tanycytic ependymomas. The clinical characteristics, including radiological and histological examination, operative records, and prognoses were reviewed. The case series included six male and three female patients with an average age of 19.3 years. Tumors were located in the lateral ventricle (3/9), the fourth ventricle (2/9), and the supratentorial extraventricle (4/9). Gross total resection (GTR) of the tumor was achieves in seven cases, and subtotal resection (STR) was achieved in the other two cases. One patient died 21 months after discharge. The left eight patients showed improved symptoms after surgery, and no tumor recurrence was found in these cases during the follow-up. It seems that intracranial tanycytic ependymoma has the best long-term prognosis compared to the other two subtypes of ependymoma. According to our experience, we recommend surgery including GTR and STR followed by radiotherapy for patients with intracranial tanycytic ependymomas.

Intracranial intraventricular tumors: long-term surgical outcome of 25 patients.

BACKGROUND/AIM: The aim of this paper is to provide the long-term surgical outcome of patients with intracranial intraventricular tumors. MATERIALS AND METHODS: Twenty-five patients operated on for intraventricular tumors between June 1999 and June 2014 are reviewed. Data from before, during, and after surgery were obtained from the patients' files and patients were followed regularly after surgery. RESULTS: The group of patients comprised 15 females and 10 males with a mean age of 31.6 ± 16 years. The majority were adults and only 3 children were included. Three, 4, and 18 patients had tumors in the 4th, 3rd, and frontal horn of the lateral ventricles, respectively. All patients showed a varying degree of hydrocephalus and headache was the most common presenting symptom. Overall, central neurocytoma was the most common pathological diagnosis. Complications were found in only 4 patients and, in long-term follow-up, 3 patients had died due to the malignant nature or upgrading to a malignant tumor and the rest were alive. CONCLUSION: Total removal of the intraventricular tumor increases survival because the majority of these tumors are benign and slow-growing. The type of surgical intervention should be chosen according to the location of the tumor in the ventricular system.

The Incidence and Risk Factors of Postoperative Entrapped Temporal Horn in Trigone Meningiomas.

OBJECTIVE: To determine risk factors for the occurrence of postoperative entrapped temporal horn (ETH), a specific form of isolated hydrocephalus that is a severe complication after resection of lateral ventricular trigone tumors, following trigone meningioma surgery. METHODS: A retrospective review was performed of 121 cases of trigone meningiomas surgically treated between November 2011 and March 2015 in Beijing Tiantan Hospital. Patient demographics, imaging features, surgical procedures, and postoperative complications were evaluated by statistical analysis. RESULTS: The median follow-up time was 24.1 months. Postoperative ETH developed in 23 patients (19.0%). Primary univariate analysis showed that young age, a longer clinical history, development of postoperative meningitis, and a longer duration of ventricular drainage were significantly associated with an increased risk of postoperative ETH. Subsequent multiple logistic regression analysis indicated that a clinical history of >3 months (odds ratio [OR], 4.8; P = 0.008), postoperative neurologic deficits (OR, 4.2; P = 0.014), duration of ventricular drainage >3 days (OR, 4.8; P = 0.012), and postoperative meningitis (OR, 9.9; P = 0.001) were independently associated with a risk of postoperative ETH. CONCLUSIONS: Postoperative ETH frequently occurs in patients with trigone meningiomas. The severity of surgical injury of the surrounding brain tissue partly accounts for the risk of postoperative ETH. Clinical management of ventricular drainage and postoperative meningitis are of utmost importance. Ventricular drainage should be performed on an individual basis, and drainage tubes should be removed as early as possible.

Diagnostic Yield, Morbidity, and Mortality of Intraventricular Neuroendoscopic Biopsy: Systematic Review and Meta-Analysis.

OBJECTIVE: Neuroendoscopic techniques for biopsy of intraventricular tumors are increasingly used, although published data have demonstrated a wide range of outcomes. We performed a systematic review and meta-analysis to investigate the diagnostic yield, morbidity, and mortality of neuroendoscopic biopsy. METHODS: Medline and Embase were searched for original data on outcomes of neuroendoscopic biopsy. Summary estimates were achieved by applying a random effects model as per DerSimonian-Laird. Measures of heterogeneity and publication bias were also assessed. Meta-regression was used to assess the relative effect of rigid versus flexible endoscopy on the outcomes of interest. Data on study demographics, operative variables, histopathologies of identified lesions, and clinical features of intraventricular tumors were also collected. RESULTS: A total of 30 studies with 2069 total biopsies were included. Neuroendoscopic biopsies were performed concurrently with at least 1 other procedure in 82.7% (n = 1252/1513) of procedures. Germ cell tumors, astrocytomas, and non-neoplastic lesions accounted for most of reported intraventricular lesions at 26.6% (n = 423), 25.5% (n = 406), and 12.4% (n = 198), respectively. The combined diagnostic yield of 28 studies reporting 1995 total biopsies was 87.9% (95% confidence interval [CI] 84.1%-90.9%) with moderate heterogeneity (I(2) = 68.0%). The combined major morbidity of 17 studies reporting 592 total biopsies was 3.1% (95% CI 1.9%-5.1%). The combined mortality of 22 studies reporting 991 total biopsies was 2.2% (95% CI 1.3%-3.6%). There was no significant heterogeneity for major morbidity and mortality (both I(2) = 0). Among included studies, 50% (n = 14) reported using a rigid endoscope exclusively. The results of meta-regression demonstrated no significant differences in diagnostic yield when comparing studies using rigid versus flexible endoscopes exclusively. CONCLUSIONS: These results indicate that neuroendoscopic biopsy has a very good diagnostic yield and reasonably low complication rate. The procedure seems most advantageous for diagnosis of intraventricular lesions where cerebrospinal fluid diversion is an additional therapeutic requirement.

Calidad de vida en pacientes con tumores cerebrales: importancia de las variables psicológicas / Quality of life in patients with gliomas: The role of psychological variables

Los síntomas clínicos de ansiedad y depresión, así como el deterioro cognitivo determinan la calida de vida de los pacientes con tumores cerebrales (Liu, Page, Solheim, Fox y Chang, 2009). El objetivo de este estudio es analizar la calidad de vida y su relación con diferentes variables psicológicas en individuos diagnosticados de glioma hace seis meses. La muestra estuvo formada por 28 pacientes (58.6% hombres) con una edad media de 54.38 años, el 89.2% de los cuales estaba recibiendo tratamiento oncológico adyuvante. A todos ellos se les aplicó un protocolo de valoración con un instrumento de calidad de vida y una batería neuropsicológica (ansiedad y depresión, orientación, atención, memoria, lenguaje, gnosias y funciones ejecutivas). Los pacientes del estudio presentaron una peor calidad de vida en determinadas dimensiones (física, familiar, funcional) y en la percepción global de bienestar. Todas las áreas de la calidad de vida se asocian con variables de estado de ánimo y la presencia de manifestaciones clínicas de depresión explica una deficitaria calidad de vida. Por otra parte, el mejor rendimiento cognitivo de los pacientes con gliomas en procesos de reconocimiento de objetos, memoria y planificación indica una mayor calidad de vida global de dichos pacientes

Clinical symptoms of anxiety and depression as well as cognitive impairment determine the quality of life of patients with brain tumors (Liu, Page, Solheim, Fox, & Chang, 2009). The aim of this paper is to analyze the quality of life and its relationship to psychological variables in individuals diagnosed with glioma six months earlier. The sample consisted of 28 patients (58.6 % male) with a mean age of 54.38 and 89.2 % of them receiving adjuvant therapy (chemotherapy). All subjects were administered a neuropsychological battery assessing quaility of life, anxiety and depression, attention, memory, language, visuoconstructive skills, visual organization, language, and executive functions. These patients have a worse quality of life in certain dimensions (physical, functional, family) and overall perception of well-being. All areas of quality of life are associated with mood and the presence of clinical manifestations of depression accounts for a lower quality of life. On the other hand, improved cognitive performance in object recognition processes, memory, and planning indicates a higher overall quality of life of these patients

Stereotactic radiosurgery for intraventricular brain metastases.

OBJECT: The authors' institution previously reported a 69% rate of crude local control for surgical management of lateral ventricle metastases at the University of Texas MD Anderson Cancer Center. For comparison, the authors here report their institutional experience with use of stereotactic radiosurgery (SRS) to treat intraventricular metastases. METHODS: To identify patients with intraventricular metastases for this retrospective review, the authors queried an institutional SRS database containing the medical records of 1962 patients with 5800 brain metastases who consecutively underwent SRS from June 2009 through October 2013. End points assessed were local control (crude and locoregional), distant failure-free survival, progression-free survival, and overall survival. RESULTS: Of the 1962 records examined, those for 25 (1.3%) patients with 30 (0.52%) intraventricular metastases were identified. Median patient age at SRS was 55.8 years. The most common primary malignancy was renal cell carcinoma (n = 13), followed by melanoma (n = 7) and breast adenocarcinoma (n = 5). Median tumor volume was 0.75 cm(3) (range 0.01-5.6 cm(3)). Most lesions were located in the lateral ventricles (n = 25, 83.3%) and were treated to a median dose of 20 Gy (range 14-20 Gy). A total of 12 (48%) patients received whole-brain radiation therapy, most (n = 10) before SRS. With a median follow-up of 11.4 months (range 1.6-39.2 months), the rate of crude local control was 93.3%, and the rates of 6-month and 1-year actuarial locoregional control were 85.2% and 56.2%, respectively. The median overall survival time after SRS was 11.6 months (range 1.3-38.9 months), and the 6-month and 1-year actuarial rates were 87.1% and 46.7%, respectively. Disease dissemination developed in 7 (28%) patients as a second intraventricular metastatic lesion (n = 3, 12%), leptomeningeal disease (n = 3, 12%), or both (n = 1, 4%). Radiographic changes developed in 5 (20%) patients and included necrosis (n = 2, 8%) and hemorrhage (n = 3, 12%). A primary diagnosis of renal cell carcinoma was associated with an improved rate of distant failure-free survival (p = 0.05) and progression-free survival (p = 0.08). CONCLUSIONS: SRS provides excellent local control for intraventricular metastases, with acceptable treatment-related toxicity, thereby supporting nonsurgical treatment for these lesions. The propensity for intraventricular dissemination among intraventricular metastases seems to be histologically dependent.

Intraventricular craniopharyngiomas: surgical management and outcome analyses in 24 cases.

OBJECTIVE: Pure intraventricular craniopharyngioma is a rare subtype of craniopharyngioma that attaches frequently to the hypothalamus. The main challenge in tumor removal is protection of hypothalamic structure. The aim of our study was to set up a feasible risk-evaluation approach to help the surgeons make an individual treatment plan. METHODS: We reviewed retrospectively 24 patients with pure intraventricular craniopharyngioma who underwent surgical therapy. Third ventricular deformation and thalamic attachment of the tumor were assessed by preoperative magnetic resonance imaging and intraoperative inspection. Correlations between the outcome, extent of removal, and different attachment grades were analyzed. RESULTS: Preoperative magnetic resonance imaging grade had a significant correlation with functional outcome. Attachment grade was significantly correlated with endocrine, functional, and radiologic outcome. In the gross total removal (GTR) group, significantly more newly developed endocrinologic deficits were observed compared with patients who underwent subtotal removal (STR). All 6 GTR cases with the greatest attachment grade (grade 2) acquired newly developed endocrine insufficiency. CONCLUSIONS: Attachment and deformation grade evaluated based on our criteria are significantly correlated with postoperative outcome. GTR of tightly attached tumor is associated with worse endocrinologic, functional, and radiologic outcomes compared with STR. Hence, we suggest that individual surgical plans should be made according to the grade of tumor attachment and hypothalamic deformation. STR should used in tumors with a high grade to achieve a good long-term outcome and avoid severe postoperative sequelae.

A modern minimally invasive transcallosal approach to the third ventricle. A personal experience of 30 patients.

INTRODUCTION: Expansive processes around the third ventricle have always been a major neurosurgical challenge. Despite all the technological and scientific progress recorded over the last few years, third ventricle tumors are still a very difficult pathology to approach due to their formidable complexity.Treating such a tumor demands a good knowledge of local anatomy, pathophysiology, pathology and a good capacity to integrate all the data gathered from the patient prior to and during surgery. Last but not least, the correct means to approach such a tumor involves using modern neuronavigation technology which might be too expensive to access in certain clinics (1,2). OBJECTIVE: This article presents the personal experience of the authors, gathered while using a novel surgical approach,configured to maximize the success rate of interventions for tumors within the third ventricle, without using neuronavigation technology. MATERIALS AND METHODS: The authors have developed a study of neuroanatomy using 30 adult human brains, without any pathological lesions, harvested during routine autopsies and analysed using a a standard protocol (Protocol of the Ludwig-Maximilians University Clinic of Neurosurgery, Laboratory of Microanatomy - Munich, Germany). The authors assessed a series of anatomic elements which were later used as landmarks to build the neurosurgical operative field. After completing the anatomic study the authors moved on to record morphometric data for 30 volunteers. The authors used sagittal T1 weighted images. The volunteers were males and females, all adults, with the mean age of 45.3 years. (The age interval: 21-83 years, sex distribution: 17 males and 13 females). The images were digitally enhanced and the specific targets were outlined using Corel Draw, thus allowing for a systematic identification of contours and landmarks. Each contour was recorded and saved as a sequence of dots. The next stage of the study, after having studied all the data recorded, consisted of establishing the appropriate transcallosal surgical corridor (transforaminal or inter forniceal) for each of the 30 patients (not to be mistaken with the 30 volunteers)who were admitted for third ventricle tumors and who were included in this study. After having performed surgery for there section of the above mentioned third ventricle tumors, the authors observed pre- and postoperative clinical data which were corroborated with the neuropsychological examination which was also performed prior to and after surgery. CONCLUSIONS: The results obtained through observation and anatomical measurements have proven to be highly valuable in determining a standard access corridor through the corpuscallosum. The data gathered and the patient's MRI exam images helped obtain an optimal surgical corridor of the third ventricle. In what regards the surgical act in 23 cases (77%) the authors managed to achieve a complete resection of the tumor.In 6 cases (20%) the authors managed a subtotal resection of the tumors. In a single case the authors performed only a biopsy. A number of 24 patients (80%) achieved an excellent outcome (Glasgow Outcome Scale - GOS V). Minor deficits were recorded in 5 patients (17%) (disabled but independent)(GOS IV) No cases were recorded with serious impairment(GOS III) or vegetative state (GOS II). One patient with anaplastic glioma died 4 months after surgery after an initial favorable evolution. The tumor had spread to the hypothalamus. A single postoperative complication was linked to the surgical approach in a 73-year-old female patient who suffered a venous infarction due to a venous thrombosis in atributary vein of the superior sagittal sinus in the access area.The patient, after a slow recovery managed to improve her condition reaching GOS IV. There were no other complications connected to the surgical act.

Intraventricular neurocytomas: a systematic review of stereotactic radiosurgery and fractionated conventional radiotherapy for residual or recurrent tumors.

To determine optimal treatment for recurrent or residual intraventricular neurocytomas (IVNs), a systematic review of PubMed and EMBASE was conducted comparing fractionated conventional radiotherapy (FCRT) versus stereotactic radiosurgery (SRS). Inclusion criteria included histological IVN documentation, at least 6 months of follow-up observation and described dose of FCRT or SRS administered. Descriptive statistical and Kaplan-Meier analyses were performed. The literature search yielded 451 articles. Sixteen studies met inclusion criteria. The local tumor control proportion was 93% and 88% in the SRS and FCRT subgroups, respectively. The relative risk (RR) of local recurrence was 0.57 less (95% CI: 0.21-1.57; log-rank p=0.85) and the RR of all-cause mortality was 0.23 less (95% CI: 0.05-1.05; log-rank p=0.22) in SRS subgroup compared to the FCRT subgroup but did not reach statistical significance. Recurrence was significantly associated with presence of histological atypia (log-rank p<0.001). Severe complications were lower in SRS subgroup (5.5% versus 7.5%, p=0.74); however, distant tumor recurrence was slightly lower in the FCRT subgroup (1.5% versus 5.5%, p=0.24). The role of SRS or FCRT in the management of residual or recurrent IVNs will continue to depend on the balance between the risks and benefits of SRS and FCRT until better quality data are available.

Primary tumors of the lateral ventricles of the brain.

BACKGROUND: The lateral ventricles are located in the center of the brain. Each ventricle lies in contact with five critical neural structures: the caudate nucleus, the thalamus, the fornix, the corpus callosum, and the genu of internal capsule.The authors report their experience in primary tumors of the lateral ventricles of the brain by analysing the symptomatology,the surgical treatment, the complications and the postoperative results. OBJECTIVE: To determine the importance of the surgical technique on the morbidity and the recurrence of lateral ventricles tumors. Total surgical resection followed by radiotherapy and or chemotherapy had been the main objective in the cases of anaplastic tumors. METHODS: This retrospective study makes reference to 202 primary tumors of the lateral ventricles operated by Leon Danaila between 1982 and 2012. The respective analysis is based on the operative approaches and on the extent of resection. The surgical access routes were the interhemispheric transcallosal approach and the transcortical approach. RESULTS: A number of 177 (87%) of the primary tumors of the lateral ventricles were benign (low grade lesions), while 25(12.37%) of them were anaplastic. The most frequent tumors were ependymomas, astrocytomas, subependymomas, choroid plexus papillomas and meningiomas. Out of the total of 202 tumor cases, 164 (81.18%) were discharged with very good and good results, 35 (17.32%) were left with neurological deficits,and 3 (1.48%) died. A significant proportion of the patients undergoing surgery develop cerebrospinal fluid outflow obstruction, and this fact made the postoperative mounting of a number of ventricular shunts necessary. CONCLUSION: The majority of these tumors were benign, with are latively slow growth rate. Owing to this fact, the preoperative dimensions of the tumors were of several centimeters. The average age of the patients was lower than that of those with similar lesions located intraparenchymatously. The symptoms were determined by the ventricular outflow obstruction and by the affectation of the periventricular structures. Interhemispheric transcallosal and transcortical approaches were the best surgical access routes.

Surgery of tumors of the third ventricle region.

BACKGROUND: The third ventricle is located in the center of the brain, surrounded by critical structures. The authors reported their experience in the surgical treatment of tumors originated from or expanding within the third ventricle, analysing the postoperative results and patient's outcome. MATERIAL AND METHODS: We performed a retrospective study on 120 patients, who had been operated in our neurosurgical department for tumors of the third ventricle and adjacent region over the last 21 years. According to their place of origin, these tumors were divided into primary tumors of the third ventricle (69 cases) and tumors developed from the surrounding structures (51 cases). The patients were operated on via a transcallosal-transventricular approach (58.34%), transcortical parieto-occipital approach (26.67%) or subfrontal approach (15%). Microsurgery has been used in all cases. In 20 patients (16.67%), preoperative ventricular drainage was performed. Stereotactic procedures were not used in this study. RESULTS: The overall mortality in this series was 11.67% (14 120 died). The death was directly correlated to the surgery in 8 cases, to general complications in 3 cases, to recurrence of the tumor in 2 cases, and to shunt malfunction in one case. Perioperative good evolution (GOS 5) was noted in 54 patients (45%), but at one-year follow-up, good neurological evolution was recorded in 72 patients (60%). The long-term neurological outcome recorded neurological impairments in 21.42% of patients, a permanent diabetes insipidus in 5.1% of patients and the persistence of neuropsychological deficits in 28.57%. The recurrence of the tumor has been encountered in 16 patients (13.34%). CONCLUSIONS: Transcallosal approach remains the best method for the microneurosurgical treatment of third ventricle tumors. This route provides the capability for a superior visualization of the entire cavity of the third ventricle through different corridors, and permanent neurological and neuropsychological deficits are not frequent.

Intraventricular meningiomas: a consecutive series of 22 patients and literature review.

Intraventricular meningiomas (IVMs) are rare tumors of which the majority is located in the lateral ventricles. Most published series on the subject includes only a few patients. We analyzed our series of IVMs with a special interest in clinical features, outcome, and complications related to surgery. Twenty-two patients underwent resection of IVMs from 1990 to 2010 at Oslo University Hospital. Surgical and medical records were retrospectively analyzed. The IVMs were located in the trigonum of the lateral ventricles (20/22), in the third ventricle (1/22), and in the fourth ventricle (1/22). The most common symptoms and signs were headache, vertigo, nausea/vomiting, mental disturbances, balance impairment, and corticospinal tract signs. Visual field deficit was present preoperatively in two patients. Tumors of the lateral ventricles were resected via a transcortical parieto-occipital approach; the tumors in the third and fourth ventricle via a frontal transcortical and suboccipital route, respectively. Complete tumor resection was achieved in all but one case. Histology was WHO grade I in 20/22 and grade II in 2/22. Surgical mortality was 0%. Most symptoms and signs resolved after surgery. The most common complication was visual field defect: four patients developed new-onset contralateral homonymous quadrant anopia and one patient developed hemianopia. Symptomatic IVMs should be resected, and most symptoms and signs resolve after surgery. The main challenge is to avoid damaging the geniculucalcarine tract when resecting IVMs in the trigonum. Preoperative diffusion tensor imaging-based tractography to map the geniculocalcarine tract could be a useful adjunct in the preoperative planning before selecting the surgical approach.

Gamma knife radiosurgery of recurrent atypical neurocytoma. Case report and review of the literature.

BACKGROUND AND PURPOSE: The goal of this work was to demonstrate the efficacy of stereotactic gamma knife radiosurgery (GKRS) for the treatment of neurocytoma by means of a case report and a comprehensive literature review. CASE REPORT: A locally recurrent atypical neurocytoma in the area of the left third ventricle thalamic wall occurring 7 years after primary microsurgical resection in a 59-year old woman was treated by GKRS. A marginal dose of 17 Gy was delivered to the surrounding 50% isodose. At the last follow-up, 82 months after radiosurgery, the tumor was locally controlled. For the literature review, computerized bibliographic searches of Pubmed were supplemented with hand searches of reference lists and abstracts of ASCO/ASTRO/ESTRO meetings. DISCUSSION: The present case confirms the results of the literature analysis. From 1997-2011, a total of 14 series were published providing results of GKRS in 86 patients (89 lesions). The marginal doses, which have been applied, ranged from 9.6-20.0 Gy. With median follow-up intervals between 6 and 185 months, local control was 97.2% and local tumor progression of neurocytoma after GKRS was restricted to only 4 cases. In accordance with our own experience, GKRS was not associated with a relevant early or late toxicity. CONCLUSION: GKRS can be assumed to be a safe and effective treatment modality of recurrent or residual neurocytoma.

[Ependymomas of the lateral ventricle. A series of 27 cases with review of the literature]. / Les épendymomes du ventricule latéral. Analyse de 27 cas et revue de la littérature.

Twenty-seven cases of ependymoma were collected in the French multicentric study dedicated to lateral ventricle tumors. The mean age of patients was 31,5 years. All patients underwent surgery, with complete resection of the tumor in 76% of cases. Histologic examination disclosed 23 grade 2 ependymomas and four grade 3 ependymomas. Postoperative mortality was 7%. Four patients underwent radiotherapy, and five chemotherapy. Local recurrence of the tumor occurred in seven cases, with a mean delay of 48 months. Disseminated disease within the central nervous system was found in only one patient. Median survival in all the 27 patients was 181 months, and median progression-free survival was 106 months. The relevant series of the literature are reviewed in order to precise the prognostic factors of ependymomas and therapeutic strategies.