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Improvements in brain tumor surgery
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Transcript of Improvements in brain tumor surgery
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Improvements
in Brain Tumor SurgeryDr. M. Triffaux
Dr. V. Marneffe
Dr. A. Tyberghien
Dr. O. Lermen
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Improvements in Brain Tumor Surgery
• Advanced neuronavigation
– Electromagnetic navigation
– Fiber tracking MRI
– Neuro Endoscopy
• Fluorescence guided resection
• Integrat
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Hemostasis in neurosurgery
• Hemostasis: key importance for successful surgery• Prevention of bleeding is the best solution• Hemostatis methods:
– Mechanical– Chemical– Electrical
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Prevention of bleeding
• Position of the patient gravity is the best allied– head position
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Prevention of bleeding
• Minimize the risk of vessel injury– Adequate dissection techniques
• Avoid to pulling tissue• Maintaining a good visualization
– Control powered instrument (drills, Cusa,…)– atraumatic suction tip
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Hemostasis in NS
• Mechanical– Horsley’s bone wax– muscle stamps,– compression,– ligature, – clamps,– clip: Cushing’s silver clips– cottonoid ,
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Hemostasis in NS
• Chemical– Historic: alum, copper sulfate, ferric chloride,
Zenker solution
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Hemostasis in NS
• Chemical– Historic: – Organic: oxydised cellulose, gelatin,collagen,
autolog fibrin( plasmatic centrifugation)
surgicel spongostan surgiflow
original
fibrillar
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Hemostasis in NS
• Use of heat to control bleeding has been described throughout human history
• Electro surgeryProcess of electrocoagulation utilizes heat generated from an electrical current that flows through a metal probe to locally burn
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Electrosurgery in neurosurgery
• 1926 H. Cushing / W. Bovie first removal of braintumor using electrocautery
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Electrosurgery in neurosurgery
• 1926 H. Cushing / W. Bovie• 1940 J. Greenwood
introduced the concept of two point coagulation,and the bipolar
coagulation was invented.
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Electrosurgery in neurosurgery
• 1926 H. Cushing / W. Bovie• 1940 J. Greenwood• 1955 L. Malis : first commercial bipolarcoagulator
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Electrosurgery in NS
Monopolar Bipolar
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Electrosurgery in NS
Monopolar Bipolar
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But recurrent problems• Carbonization, charring required cleaning• Thermic lesion surround damage• Sticking adhesion with
tissue• get out to clean get in: reorientation• Time consuming • Coagulation failure• Frustration and fatigue for the operator
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Solutions
• Generator HF computer regulation output
types of waves
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Solutions
• Generator HF
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Solutions
• Irrigation manual needs assistanceautomaticadjustable fluid pressureadjustable flowsolutions: PL, mannitol,
pump
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Solutions
• Material of the tip:titanium, gold, stainless steel
• Coating of the tip:PTFE like Teflon
but no miracle solution
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Active Heat Transfer technology
• Old principle 1942
Now available with minimal profile: Isocool forceps
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Heat measurement
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In vitro studies
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Y. Arakawa and N. Hashimoto StudyJpn J Neurosurg (Tokyo) 14 : 698-705, 2005
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Y. Arakawa and N. Hashimoto StudyJpn J Neurosurg (Tokyo) 14 : 698-705, 2005
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Y. Arakawa and N. Hashimoto StudyJpn J Neurosurg (Tokyo) 14 : 698-705, 2005
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Y. Arakawa and N. Hashimoto StudyJpn J Neurosurg (Tokyo) 14 : 698-705, 2005
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My personal experience
• Using 1 and 0.5 mm
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My personal experience
• Procedure :– Vascular – Intracranial tumor– Spine tumor– Cerebello pontine angle
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Personal experience
• What I do with Iso Cool– More accuracy– More efficiency– More visibility– Less risk– No irrigation– Time-saving
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Illustration 1
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Illustration 2
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Illustration 3
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Illustration 4
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Personal experience
• Limits– Cost single use (300 €)– Profile
– Not easy to do without it if you have used it
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Advanced neuronavigation
• Electromagnetic Navigation
• Fiber tracking MRI
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• Neuronavigation– Optical system
camera tracking instruments
– Electromagnetic system single coil gives the position in a electromagnetic
field
Electromagnetic Navigation
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Electromagnetic Navigation• Optical system • Electromagnetic tracking
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Electromagnetic Navigation• Optical system • Electromagnetic tracking
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Electromagnetic Navigation• Optical system • Electromagnetic tracking
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Electromagnetic Navigation• Optical system • Electromagnetic tracking
• Advantages– No single use– No metal interference
• Limits– Loss of camera’s line of
sight
– Smal, non invasive– No calibration– Flexible probe
– Fero magnetic disturbence– Single use
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NeuroEndoscopy in Oncology
Ventriculoscopy Pituitary Key hole surgery
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• In ventricular and paraventricular tumor management
• In Endoscopic Third Ventriculostomy (ETV)
– In the same time of supratentorial procedure
– in management of hydrocephalus from posterior fossa tumor
Ventriculoscopy in Oncology
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• Rigid
• Flexible
Ventriculoscope
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• Image Guided surgery– Choice of the best entry point and the best
trajectory– Endoscope tracking per operative
Advantages of the rigid scope
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• Image Guided surgery• Endoscope stability
– Pneumatic arm– microdriver
Advantages of the rigid scope
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• Image Guided surgery• Endoscop stabilisation • Higher quality
– optical resolution– trocars: multiple channels
Advantages of the rigid scope
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CaseN°
Sex/age(yrs)
location Histiologicaldiagnose
ETV Further therapy
1 M / 69 3rd V. ant. Pineocytoma II Y No
2 F / 41 3rd V. ant.. Arachnoid cyst Y No
3 F / 72 Occ. paraV. Glioblastoma N Radiation
4 M / 35 3rd V. ant. Dermoid cyst N No 5 M / 21 3rd V. post Germinoma N Radiation
Chemotherapy6 F / 16 Thalamic Astrocytoma III Y Open surgery
Clinical data 2003/2005
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• 21 yrs , recent diplopia
• CT MR imaging: pineal tumor whithout hydrocephalus
• Pet methionine: +
• Blood fetoproteine , HCG: nl < 1 mUI/ml
• CSF fetoproteine: nl, HCG: 3 mUI/ml
Case N° 5
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Case N° 5
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• Biopsy diagnosis: germinoma
• Treatment: chemotherapy & radiotherapy
2 cycles carbo/ etoposide / Ifosfamide40 Gy radiotherapy
Case N° 5
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Case N° 5
Initial MR Post multimodal therapy
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Case N° 6
• 16 yrs , Parinaud’s syndrome
• CT MR imaging: left thalamic mass
hydrocephalus
• Pet FDG: – Pet methionine: +
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Case N° 6
CT Pet FDG MR Pet met.
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Case N° 6
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J10 post biopsy & ETVPre operative
Case N° 6
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• Biopsy diagnosis: astrocytoma III
• Treatement: conventional surgery
astrocytoma III confirmed
Case N° 6
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• Acute hydrocephalus needs treatement:– External Ventricular drainage– VP shunt– ETV
• In pediatric series: – Majority of the authors advocate ETV prior to
definitive surgery– Some others do not justify routine
preoperative ETV• In adult patients: there is no specific data
Hydrocephalus from P-fossa tumor
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CaseN°
s/age ICP Symp
ETV diagnose Open surgery
1 M/46 Y pre Lung metastase Y , radiation
2 F/22 Y pre Medulloblastoma Y , chemo + radiation
3 M/45 Y pre Ependymome II Y
4 M/55 Y pre Gliome II Y
5 F/34 Y pre Melanocytoma Y
6 F/39 Y pre Neurinoma VIII Y
7 M/23 N post cavernoma Y
8 F/56 Y single Breast mets. (3) palliatif
Clinical data in adult population
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• GA, supine position
• ETV with neuroballon
• Insertion of a ventricular reservoir
• Monitoring ICP 24h-48h with butterfly needle
without ventricular drainage
Surgical procedure
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• Complication: 1 infection (case 8: palliative)
resolved with antiobiotherapy
• No shunt
• No CSF leak after posterior fossa surgery
Out come
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Fiber tracking
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Fiber tracking
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Fiber tracking
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Fiber tracking
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Fiber tracking
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Fluorescence guided resection
COO -
NH 3 +CH 2C
CH 2
CH 2
O
HC
N
NH
VM
M
P
MP
V
M
CH
N
CH
NH
HC
5-aminolevulinic acid Protoporphyrin IX
Enzymes ofheme biosynthesis
Intratumoral synthesis
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Multicenter, Randomized, Balanced, Parallel, Controlled, Phase III Study: Fluorescence-Guided Surgery
Using 5-ALA
Patients with malignant gliomas• Surgical candidates• Tumor potentially resectable• Karnofsky Index ≥ 70• Age 18 - 75• Primary surgery• Informed consent
“White light group”Conventional microsurgery
+Radiotherapy
“ALA group”Fluorescence-guided
resection +Radiotherapy
Sponsor: Medac, Germany
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n (%) 139 (100) 131 (100)
≤ 55 years (%) 45 (32) 43 (33)> 55 years (%) 94 (68) 88 (67)Median (years) 60 59
“Low” [ 70, 80 ] (%) 28 (20) 31 (24) “High” [ 90, 100 ] (%) 111 (80) 100 (76)
No (%) 65 (47) 54 (41)Yes (%) 74 (53) 77 (59)
WHO °III (%) 4 (3) 5 (4)WHO °IV (%) 135 (97) 126 (96)
ALA WL
Demographic Characteristics: Intent to Treat
Age
KPS
“Eloquent”
Histology
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Complete Resections on Early Postoperative MRI
0
25
50
75
100
Perc
enta
ge
ALA WL
35%47/131
p < 0.0001chi2
65%90/139
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139 104 59 28 168
131 85 28 13 75
Progression-Free Survival (Intent to Treat)
Stummer et al. Lancet Oncol. 2006;7:392-401.
Prog
ress
ion-
free
surv
ival
(%)
100
90
80
70
60
50
40
30
20
10
0
Log rankp = 0.0078
5-aminolevulinic acid
White light
Time (months)0 3 6 9 12 15
Numbers at risk5-aminolevulinic acidWhite light
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Fluorescence guided resection
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Advanced Neurosurgery