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J Neurol Surg A Cent Eur Neurosurg 2018; 79(04): 330-336
DOI: 10.1055/s-0038-1641738
Surgical Technique
Georg Thieme Verlag KG Stuttgart · New York

Minimally Invasive Resection of Deep-seated High-grade Gliomas Using Tubular Retractors and Exoscopic Visualization

Rajiv Iyer
1   Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, United States
,
Kaisorn L. Chaichana
2   Mayo Clinic, Jacksonville, FL, United States
› Institutsangaben
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Publikationsverlauf

21. August 2017

10. Januar 2018

Publikationsdatum:
23. April 2018 (online)

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Abstract

Background and Study Aims/Objective Deep-seated high-grade gliomas (HGGs) represent a unique surgical challenge because they reside deep to critical cortical and subcortical structures and infiltrate functional areas of the brain. Therefore, accessing and resecting these tumors can often be challenging and associated with significant morbidity. We describe the use of minimally invasive approaches to access deep-seated HGGs to achieve extensive resections while minimizing surgical morbidity.

Materials and Methods All patients who underwent resection of a deep-seated intraparenchymal HGG with the use of a tubular retractor with exoscopic visualization from January 2016 to May 2017 were identified prospectively at a single institution. Variables evaluated included tumor location, pre- and postoperative neurologic function, extent of resection, and length of hospital stay.

Results Overall, 14 patients underwent resection of an HGG (11 glioblastomas, 3 anaplastic astrocytomas) with a tubular retractor under exoscopic visualization. Seven tumors (50%) involved the thalamus, three (21%) the motor corticospinal tract, two (14%) the inferior frontal occipital fasciculus, one (7%) each the basal ganglia and optic pathway. The median preoperative Karnofsky Performance Score (KPS) was 70 (interquartile range: 55–80), where the major presenting symptom was motor weakness in seven (50%). The average plus or minus the standard error of the mean percentage resection was 97.0 ± 1.2%. The median hospital stay was 4 days (range: 2–7). At 1 month postoperatively, median postoperative KPS (within 30 days) was 87 (range: 77–90), where eight (57%) were improved, five (36%) were stable, and one (7%) was worse postoperatively.

Conclusions Deep-seated HGGs can be accessed, visualized, and resected using tubular retractors and exoscopic visualization with minimal morbidity.

Keywords

brain path - deep-seated - exoscope - glioblastoma - minimally invasive
 

  • References

  • 1 Stupp R, Mason WP, van den Bent MJ. , et al; European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups; National Cancer Institute of Canada Clinical Trials Group. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 2005; 352 (10) 987-996
    CrossrefPubMedGoogle Scholar
  • 2 Chaichana KL, Jusue-Torres I, Navarro-Ramirez R. , et al. Establishing percent resection and residual volume thresholds affecting survival and recurrence for patients with newly diagnosed intracranial glioblastoma. Neuro Oncol 2014; 16 (01) 113-122
    CrossrefPubMedGoogle Scholar
  • 3 Lacroix M, Abi-Said D, Fourney DR. , et al. A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 2001; 95 (02) 190-198
    CrossrefPubMedGoogle Scholar
  • 4 Sanai N, Polley MY, McDermott MW, Parsa AT, Berger MS. An extent of resection threshold for newly diagnosed glioblastomas. J Neurosurg 2011; 115 (01) 3-8
    CrossrefPubMedGoogle Scholar
  • 5 McGirt MJ, Mukherjee D, Chaichana KL, Than KD, Weingart JD, Quinones-Hinojosa A. Association of surgically acquired motor and language deficits on overall survival after resection of glioblastoma multiforme. Neurosurgery 2009; 65 (03) 463-469 ; discussion 469–470
    CrossrefPubMedGoogle Scholar
  • 6 Chaichana KL, Garzon-Muvdi T, Parker S. , et al. Supratentorial glioblastoma multiforme: the role of surgical resection versus biopsy among older patients. Ann Surg Oncol 2011; 18 (01) 239-245
    PubMedGoogle Scholar
  • 7 Dziurzynski K, Blas-Boria D, Suki D. , et al. Butterfly glioblastomas: a retrospective review and qualitative assessment of outcomes. J Neurooncol 2012; 109 (03) 555-563
    CrossrefPubMedGoogle Scholar
  • 8 Balaña C, Capellades J, Teixidor P. , et al. Clinical course of high-grade glioma patients with a “biopsy-only” surgical approach: a need for individualised treatment. Clin Transl Oncol 2007; 9 (12) 797-803
    CrossrefPubMedGoogle Scholar
  • 9 Chaichana KL, Jusue-Torres I, Lemos AM. , et al. The butterfly effect on glioblastoma: is volumetric extent of resection more effective than biopsy for these tumors?. J Neurooncol 2014; 120 (03) 625-634
    CrossrefPubMedGoogle Scholar
  • 10 Cao L, Li C, Zhang Y, Gui S. Surgical resection of unilateral thalamic tumors in adults: approaches and outcomes. BMC Neurol 2015; 15: 229
    CrossrefPubMedGoogle Scholar
  • 11 Kelly PJ. Stereotactic biopsy and resection of thalamic astrocytomas. Neurosurgery 1989; 25 (02) 185-194 ; discussion 194–195
    CrossrefPubMedGoogle Scholar
  • 12 Jackson C, Gallia GL, Chaichana KL. Minimally invasive biopsies of deep-seated brain lesions using tubular retractors under exoscopic visualization. J Neurol Surg A Cent Eur Neurosurg 2017; 78 (06) 588-594
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 13 Kelly PJ, Goerss SJ, Kall BA. The stereotaxic retractor in computer-assisted stereotaxic microsurgery. Technical note. J Neurosurg 1988; 69 (02) 301-306
    CrossrefPubMedGoogle Scholar
  • 14 Labib MA, Shah M, Kassam AB. , et al. The safety and feasibility of image-guided BrainPath-mediated transsulcal hematoma evacuation: a multicenter study. Neurosurgery 2017; 80 (04) 515-524
    CrossrefPubMedGoogle Scholar
  • 15 Eliyas JK, Glynn R, Kulwin CG. , et al. Minimally invasive transsulcal resection of intraventricular and periventricular lesions through a tubular retractor system: multicentric experience and results. World Neurosurg 2016; 90: 556-564
    CrossrefPubMedGoogle Scholar
  • 16 Raza SM, Recinos PF, Avendano J, Adams H, Jallo GI, Quinones-Hinojosa A. Minimally invasive trans-portal resection of deep intracranial lesions. Minim Invasive Neurosurg 2011; 54 (01) 5-11
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 17 Recinos PF, Raza SM, Jallo GI, Recinos VR. Use of a minimally invasive tubular retraction system for deep-seated tumors in pediatric patients. J Neurosurg Pediatr 2011; 7 (05) 516-521
    CrossrefPubMedGoogle Scholar
  • 18 Chaichana KL, Cabrera-Aldana EE, Jusue-Torres I. , et al. When gross total resection of a glioblastoma is possible, how much resection should be achieved?. World Neurosurg 2014; 82 (1–2): e257-e265
    CrossrefPubMedGoogle Scholar
  • 19 McGirt MJ, Chaichana KL, Gathinji M. , et al. Independent association of extent of resection with survival in patients with malignant brain astrocytoma. J Neurosurg 2009; 110 (01) 156-162
    CrossrefPubMedGoogle Scholar
  • 20 Keles GE, Chang EF, Lamborn KR. , et al. Volumetric extent of resection and residual contrast enhancement on initial surgery as predictors of outcome in adult patients with hemispheric anaplastic astrocytoma. J Neurosurg 2006; 105 (01) 34-40
    CrossrefPubMedGoogle Scholar
  • 21 Hervey-Jumper SL, Berger MS. Maximizing safe resection of low- and high-grade glioma. J Neurooncol 2016; 130 (02) 269-282
    CrossrefPubMedGoogle Scholar
  • 22 Garrett MC, Pouratian N, Liau LM. Use of language mapping to aid in resection of gliomas in eloquent brain regions. Neurosurg Clin N Am 2012; 23 (03) 497-506
    CrossrefPubMedGoogle Scholar
  • 23 Keles GE, Lundin DA, Lamborn KR, Chang EF, Ojemann G, Berger MS. Intraoperative subcortical stimulation mapping for hemispherical perirolandic gliomas located within or adjacent to the descending motor pathways: evaluation of morbidity and assessment of functional outcome in 294 patients. J Neurosurg 2004; 100 (03) 369-375
    CrossrefPubMedGoogle Scholar
  • 24 Motomura K, Natsume A, Iijima K. , et al. Surgical benefits of combined awake craniotomy and intraoperative magnetic resonance imaging for gliomas associated with eloquent areas. J Neurosurg 2017; 127 (04) 790-797
    CrossrefPubMedGoogle Scholar
  • 25 Hatiboglu MA, Weinberg JS, Suki D. , et al. Impact of intraoperative high-field magnetic resonance imaging guidance on glioma surgery: a prospective volumetric analysis. Neurosurgery 2009; 64 (06) 1073-1081 ; discussion 1081
    CrossrefPubMedGoogle Scholar
  • 26 Stummer W, Pichlmeier U, Meinel T, Wiestler OD, Zanella F, Reulen HJ. ; ALA-Glioma Study Group. Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol 2006; 7 (05) 392-401
    CrossrefPubMedGoogle Scholar
  • 27 Andrews RJ, Bringas JR. A review of brain retraction and recommendations for minimizing intraoperative brain injury. Neurosurgery 1993; 33 (06) 1052-1063 ; discussion 1063–1064
    Google Scholar
  • 28 Jo KW, Shin HJ, Nam DH. , et al. Efficacy of endoport-guided endoscopic resection for deep-seated brain lesions. Neurosurg Rev 2011; 34 (04) 457-463
    CrossrefPubMedGoogle Scholar
  • 29 Greenfield JP, Cobb WS, Tsouris AJ, Schwartz TH. Stereotactic minimally invasive tubular retractor system for deep brain lesions. Neurosurgery 2008; 63 (04) (Suppl. 02) 334-339 ; discussion 339–340
    PubMedGoogle Scholar
  • 30 Jho HD, Alfieri A. Endoscopic removal of third ventricular tumors: a technical note. Minim Invasive Neurosurg 2002; 45 (02) 114-119
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 31 White T, Chakraborty S, Lall R, Fanous AA, Boockvar J, Langer DJ. Frameless stereotactic insertion of Viewsite Brain Access System with microscope-mounted tracking device for resection of deep brain lesions: technical report. Cureus 2017; 9 (02) e1012
    PubMedGoogle Scholar