Improvements in brain tumor surgery

Improvements

in Brain Tumor SurgeryDr. M. Triffaux

Dr. V. Marneffe

Dr. A. Tyberghien

Dr. O. Lermen

Improvements in Brain Tumor Surgery

• Advanced neuronavigation

– Electromagnetic navigation

– Fiber tracking MRI

– Neuro Endoscopy

• Fluorescence guided resection

• Integrat

Hemostasis in neurosurgery

• Hemostasis: key importance for successful surgery• Prevention of bleeding is the best solution• Hemostatis methods:

– Mechanical– Chemical– Electrical

Prevention of bleeding

• Position of the patient gravity is the best allied– head position

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

Hemostasis in NS

• Mechanical– Horsley’s bone wax– muscle stamps,– compression,– ligature, – clamps,– clip: Cushing’s silver clips– cottonoid ,

Hemostasis in NS

• Chemical– Historic: alum, copper sulfate, ferric chloride,

Zenker solution

Hemostasis in NS

• Chemical– Historic: – Organic: oxydised cellulose, gelatin,collagen,

autolog fibrin( plasmatic centrifugation)

surgicel spongostan surgiflow

original

fibrillar

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

Electrosurgery in neurosurgery

• 1926 H. Cushing / W. Bovie first removal of braintumor using electrocautery

Electrosurgery in neurosurgery

• 1926 H. Cushing / W. Bovie• 1940 J. Greenwood

introduced the concept of two point coagulation,and the bipolar

coagulation was invented.

Electrosurgery in neurosurgery

• 1926 H. Cushing / W. Bovie• 1940 J. Greenwood• 1955 L. Malis : first commercial bipolarcoagulator

Electrosurgery in NS

Monopolar Bipolar

Electrosurgery in NS

Monopolar Bipolar

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

Solutions

• Generator HF computer regulation output

types of waves

Solutions

• Generator HF

Solutions

• Irrigation manual needs assistanceautomaticadjustable fluid pressureadjustable flowsolutions: PL, mannitol,

pump

Solutions

• Material of the tip:titanium, gold, stainless steel

• Coating of the tip:PTFE like Teflon

but no miracle solution

Active Heat Transfer technology

• Old principle 1942

Now available with minimal profile: Isocool forceps

Heat measurement

In vitro studies

Y. Arakawa and N. Hashimoto StudyJpn J Neurosurg (Tokyo) 14 : 698-705, 2005

Y. Arakawa and N. Hashimoto StudyJpn J Neurosurg (Tokyo) 14 : 698-705, 2005

Y. Arakawa and N. Hashimoto StudyJpn J Neurosurg (Tokyo) 14 : 698-705, 2005

Y. Arakawa and N. Hashimoto StudyJpn J Neurosurg (Tokyo) 14 : 698-705, 2005

My personal experience

• Using 1 and 0.5 mm

My personal experience

• Procedure :– Vascular – Intracranial tumor– Spine tumor– Cerebello pontine angle

Personal experience

• What I do with Iso Cool– More accuracy– More efficiency– More visibility– Less risk– No irrigation– Time-saving

Illustration 1

Illustration 2

Illustration 3

Illustration 4

Personal experience

• Limits– Cost single use (300 €)– Profile

– Not easy to do without it if you have used it

Advanced neuronavigation

• Electromagnetic Navigation

• Fiber tracking MRI

• Neuronavigation– Optical system

camera tracking instruments

– Electromagnetic system single coil gives the position in a electromagnetic

field

Electromagnetic Navigation

Electromagnetic Navigation• Optical system • Electromagnetic tracking

Electromagnetic Navigation• Optical system • Electromagnetic tracking

Electromagnetic Navigation• Optical system • Electromagnetic tracking

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

NeuroEndoscopy in Oncology

Ventriculoscopy Pituitary Key hole surgery

• 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

• Rigid

• Flexible

Ventriculoscope

• Image Guided surgery– Choice of the best entry point and the best

trajectory– Endoscope tracking per operative

Advantages of the rigid scope

• Image Guided surgery• Endoscope stability

– Pneumatic arm– microdriver

Advantages of the rigid scope

• Image Guided surgery• Endoscop stabilisation • Higher quality

– optical resolution– trocars: multiple channels

Advantages of the rigid scope

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

• 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

Case N° 5

• Biopsy diagnosis: germinoma

• Treatment: chemotherapy & radiotherapy

2 cycles carbo/ etoposide / Ifosfamide40 Gy radiotherapy

Case N° 5

Case N° 5

Initial MR Post multimodal therapy

Case N° 6

• 16 yrs , Parinaud’s syndrome

• CT MR imaging: left thalamic mass

hydrocephalus

• Pet FDG: – Pet methionine: +

Case N° 6

CT Pet FDG MR Pet met.

Case N° 6

J10 post biopsy & ETVPre operative

Case N° 6

• Biopsy diagnosis: astrocytoma III

• Treatement: conventional surgery

astrocytoma III confirmed

Case N° 6

• 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

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

• GA, supine position

• ETV with neuroballon

• Insertion of a ventricular reservoir

• Monitoring ICP 24h-48h with butterfly needle

without ventricular drainage

Surgical procedure

• Complication: 1 infection (case 8: palliative)

resolved with antiobiotherapy

• No shunt

• No CSF leak after posterior fossa surgery

Out come

Fiber tracking

Fiber tracking

Fiber tracking

Fiber tracking

Fiber tracking

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

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

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

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

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

Fluorescence guided resection

Advanced Neurosurgery