Neurooncology Department of Neurosurgery FH Brno 15 FN%20Brno_modra_obdelnik Neurosurgery in the Past… o Armamentarium chirurgicum, Johannes Scultetus (1655) The Beginnings of Modern Neurosurgery o oVictor Horsley (1857-1916) nfirst specialized neurosurgeon, the founder of modern neurosurgery n1887 spinal tumor from laminectomy, transcranial pituitary tumor surgery o o The Beginnings of Modern Neurosurgery o oPierre Paul Broca: o 1876 –localization and drainage o of brain abscess oWilliam Macewan: o1879-localization and excision of brain tumor (meningioma) o1883-spinal laminectomy o Localization of Function Paul Pierre Broca (1824–1880) Jean-Martin Charcot (1825–1893) John Hughlings Jackson (1835-1911) Cerebral localization of function. David Ferrier 1881, International Medical Congress, London Harvey Cushing (1869-1939) 1.Neuroepithelial Tumors 1.Astrocytic Tumors 38% 2.Oligodendroglial Tumors 3% 3.Oligoastrocytic Tumors 1% 4.Ependymal Tumors 2,3% 5.Choroid Plexus Tumors 0,3% 6.Tumors of the Pineal Region 7.Neuronal and Mixed Neuronal-Glial Tumors 8.Other Neuroepithelial Tumors 9.Embryonal tumors 2.Tumors of Cranial and Paraspinal Nerves 7% 3.Tumors of Meningothelial Cells 26% 4.Tumors of the Haematopoietic System 3,5% 5.Germ Cell Tumors 6.Tumors of the Sellar Region 7.Metastatic Tumors o WHO Classification, Incidence Meningioma Classification of meningiomas The incidence of meningioma is given 7-8 per 100 000, but much of it is asymptomatic (perhaps up to 70 %...) Meningioma T1KL1 Meningioma oGrade I: Meningiomas with low risk of recurrence or aggressive behavior o (Meningiomafibrous (fibroblastic), Transitional, (mixed)Psammomatous, Angiomatous, Microcystic, Secretory, Lymphoplasmacyte-rich, Metaplastic) o oGrade II: Meningiomas with high risk of recurrence or aggressive behavior o (Atypical, Clear cell, Chordoid) o oGrade III: Meningiomas with very high risk of recurrence or aggressive behavior o (Rhabdoid, Papillary, Anaplastic (malignant)) Meningeoma - localisation Classification of meningiomas The Goal of Procedure oRemoval of a meningioma - radical resection to prevent recurrence 1.Total tumor resection, the dura mater and cranial bone resection, replacement of dura and bone by autogenous or arteficial grafts 2.Total tumor resection, coagulation of dura mater and restoration of bone 3.Total, without resection of dura, possibility of extradural residue of meningioma (cavernos sinus) 4.Partial tumor resection 5.Simple decompresion or biopsy only pepan Convexity meningeomy Convexity meningioma • Resection of convexity meningiomas Parasagital meningeoma Large parasagittal meningioma Resection of parasagittal meningiomas Meningeoma pre/post surgery Clinoidal meningioma Clinoidal meningioma Meningeoma – appr. Resection of meningiomas of the anterior and anterolateral skull base Meningeoma infratentorial Cerebellopontine angle meningioma Foramen magnum meningioma Case 1 – meningiom G I oGigantický owahed Case 2 - meningeom G I 3a kopie 1b kopie 2b kopie Glioma o40 - 50% primary brain tumors 1) Low-grade glioma oPilocytic Astrocytoma(G1) oDiffuse Astrocytoma (G2) – fibrillary, protoplasmatic, gemistocytic oOligoastrocytoma (G2) oOligodendroglioma (G2) oEpendymoma (G2) 2) High-grade glioma oAnaplastic Astrocytoma (G3) oGlioblastoma Multiforme (G4) oAnaplastic Oligodendroglioma (G3) oAnaplastica Ependymoma (G3) o Intraaxial brain tumors –cells migration image The Goals of Malignant Tumor Surgery oCan never remove all of the tumor oHow much can be removed depends on: othe type of glioma, oLocation within the brain o The Goals of Malignant Tumor Surgery 1.Providing diagnosis 2.Relieving symptomatic mass effect 3.“Setting up” postoperative externally delivered therapies 4.Prolonging of survival through cytoreduction 5.Applying locally-delivered therapies Providing Diagnosis oGlioma*MTS*abscess*lymfoma oHigh grade glioma – improvement of neurological symptoms oLow grade - removal of the epileptogenic area Relieving Mass Effect Preparing for Adjuvant Therapy oResection and TMZ – EORTC 26981 (Stupp) o o 2-year survival median survival o +TMZ -TMZ +TMZ -TMZ oGTR 37% 14% 18m 14m oSTR 23% 9% 14m 12m oB 10% 5% 9m 8m Application of Topical Therapy oGliadel (Carmustin) o o o o o oCerepro -sitimagene ceradenovec (GMO adenovirus + gancyklovir) – 3/2010 cancelation of authorization Prolonging Survival – Cytoreduction Extent of Resection Value Do 1985 1986-1990 1990-1995 1996-2000 LAWS SOFFIETTI PHILIPPON PIEPMEIER WHITTON ITO KARIM STEIGER SHAW BAHARY NORTH NICOLATO SCERATTI LEIGHTON PEIPMEIER JANNY PERAUD MEDBURY RAJAN VAN VEELEN WHITTON EYRE SHAW MIRALBELL LOTE SHAW SHIBAMOTO RUDOLER + - Indications for Surgery o oLow grade gliomy nmaximum profits given the relatively long median survival nquality of life preservation nthe concept of brain plasticity n Indications for Surgery o oHigh grade gliomy nKPS nresecability n n n n image image PET Topinka PET C 1 C -11-Methionin PET, ? 2011, MOU Brno fMRI: DTI tractografy 1. optická dráha AmpapaPavel_082827530000_0002 AmpapaPavel_082827530000_0009 AmpapaPavel_082827530000_0008 AmpapaPavel_082827530000_0004 fMRI: DTI tractografy 2 kortikospinální dráha Nový obrázek (5) Nový obrázek (3) Nový obrázek (1) fMRI: DTI tractografy 3 kortikospinální dráha fMRI: 3. VFT (test slovní plynulosti) centrum řeči §Frameless §The origin is a „frame" placed firmly against the patient's head Location of instruments is registered by the camera, tools are freely moving Obrázek navigace Obrázek navigace 2 Intraoperative Navigation obličej 2 3 4 5 SNAP037 o The Principles of Work with Navigation o Obrázek2 Obrázek2 Obrázek2 Obrázek2 Obrázek2 obličej Šikmá jemná mřížka pentero II Pentero III SNAP0303 SNAP0304 The image in the navigation monitor follow the movement of the microscope obličej Pentero IV Projection of lesion area to the field of view under the microscope obličej Pentero IV Nový obrázek (3) Nový obrázek (5) Nový obrázek (7) Nový obrázek (8) Projection the border of tumor in the relationship to focus Intraoperative imaging §MRI On-line display the progress of tumor resection § Snímek 011 iMR Fluorescent Technology §5-ALA causes the accumulation of porphyrins in tumor cells § Porphyrins are visualized in a modified microscope §The boundaries of the tumor are better seen, because they are different colors from the surrounding tissue § § §Visualization of the tumor using 5-ALA - insight into the resection cavity Patient_1_2007-09-12_10-43-02_V_0001 Patient_1_2007-09-12_10-43-02_V_0001 po Surgery 5-ALA, Results of the Study (322 patients) Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial.Stummer W, Pichlmeier U, Meinel T, Wiestler OD, Zanella F, Reulen HJ; ALA-Glioma Study Group. Neurochirurgische Klinik, Heinrich-Heine University, Dusseldorf, Germany Electrophysiological methods oEMG oNAP oMEP (including D-wave, I-wave) oSEP oAEP (BAEP, ABR) oVEP oEEG oEcoG PRSEP oDBS oMER ISISMER Monitoring in general anesthesia oMEP- monitoring of motor pathway oSEP –phase reversal – Localization of the central sulcus oDirect stimulacion – motor cortex, nuclei of cranial nerves, ( IV. ventricle), stimulacion of white matter – subcortical structures SEP, PRSEP orecording cortical potentials due to stimulation of peripheral nerves (medianus, tibialis) 1746-160X-2-20-2-l img-phase-reversal Awake craniotomy oTIVA –Total Intravenous Anesthesia –propofol, ramifentanyl oSpontaneous ventilation throughout surgery oLocal anesthesia of the skin flap and dura mater oMaximum patient comfort o Indicace of „awake surgery“ - localizacion o ocortex area of speech osuplementar motor cortex oInzular cortex osomatosensory and motor cortex o o Case 1 Case 3 Case 1 Case 1 Conclusion oComplex use of monitoring procedures, functional MRI and navigation technology in brain glioma surgery leads to clearly improved the extent of resection oEspecially in low grade gliomas allows in combination with early postoperative MR examination to achieve significantly better radicality than in the past o