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
› Author Affiliations
Further Information

Publication History

21 August 2017

10 January 2018

Publication Date:
23 April 2018 (online)

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.

 
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 11 Kelly PJ. Stereotactic biopsy and resection of thalamic astrocytomas. Neurosurgery 1989; 25 (02) 185-194 ; discussion 194–195
  • 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
  • 13 Kelly PJ, Goerss SJ, Kall BA. The stereotaxic retractor in computer-assisted stereotaxic microsurgery. Technical note. J Neurosurg 1988; 69 (02) 301-306
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 21 Hervey-Jumper SL, Berger MS. Maximizing safe resection of low- and high-grade glioma. J Neurooncol 2016; 130 (02) 269-282
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 30 Jho HD, Alfieri A. Endoscopic removal of third ventricular tumors: a technical note. Minim Invasive Neurosurg 2002; 45 (02) 114-119
  • 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