Improvements in brain tumor surgery

Improvements

in Brain Tumor SurgeryDr. M. Triffaux

Dr. V. Marneffe

Dr. A. Tyberghien

Dr. O. Lermen

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It's a pleasure for me to discuss with you to day about improvement in B T S I am trying to give you, my personal experience in this surgery and my opinion about some new devolopment in this surgery

Improvements in Brain Tumor Surgery

• Advanced neuronavigation

– Electromagnetic navigation

– Fiber tracking MRI

– Neuro Endoscopy

• Fluorescence guided resection

• Integrat

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there are three parts in my presentationfirst I wouldl talk about hemostasis in neurosurgery and particulary the place of the bipolarcoagulationSecondly:iimprovements in neuronavigation with EM NNV and as well the new possibility to merge MRI images of fiber tracking there is very interesting for surgery in eloquent area and in the end flurescence guided resection with 5 ALA for glioblastoma

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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But when you are in face of bleeding there are three ways to stop it.

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of course

Prevention of bleeding

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

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take the time to have a good instalation

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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to avoid to suck up little vessels in to the suction tube

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on the other hand

Hemostasis in NS

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

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But this prenventive approaches are not always enough You must do have something else

Hemostasis in NS

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

Zenker solution

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these materials have the ability to contract organic tissue and subsequently reduce hemorrhage.potassium bichromate, sodium sulfate & water

Hemostasis in NS

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

autolog fibrin( plasmatic centrifugation)

surgicel spongostan surgiflow

original

fibrillar

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to promote

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

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C & B were the pioniers in this DOMAINE they made the first..


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

introduced the concept of two point coagulation,and the bipolar

coagulation was invented.


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

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was the first to set on the market a bipolr coagulator

Electrosurgery in NS

Monopolar Bipolar

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monopolar generators pass electrical current through a single active pen electrode to a grounding plate which acts as a dispersive electrode.monopolar cutting is based on vaporisation of tissue by an advencing sparck with a high output impedance

Electrosurgery in NS

Monopolar Bipolar

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in bipolar electrosurgery all of the current flow takes place between the two tips of the forceps & no ground pad is required

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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most of the time with the heat produced

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these facts can to resutlt

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but recurrent problems persist

Solutions

• Generator HF computer regulation output

types of waves

Solutions

• Generator HF

Solutions

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

pump

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you can cool down your tips

Solutions

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

• Coating of the tip:PTFE like Teflon

but no miracle solution

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polytetrafluoroethylenelike a pan Tefal

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




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

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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

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there are two topics in this partfirst EM NNV and secondly the possibility to merge

• 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


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patient tracker rigidly positionned to the patient head'sMobile localizerencompasses the patient anatomyand EM devices in a low-energy field.registration wand is pointing device



• 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


• Image Guided surgery• Endoscop stabilisation • Higher quality

– optical resolution– trocars: multiple channels


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

Health & Medicine

Improvements in brain tumor surgery