Intradural extramedullary tumors in adults

Meningioma, nerve sheath tumors, and filum terminale ependymoma account for over 90% of primary intradural extramedullary tumors in adults. The demographics, radiological evaluation, and surgical techniques employed for their removal are reviewed in this article. The authors' approach to intraspinal tumors with extraspinal extension is discussed.     

Uncommon tumors of the skull base and uncommon approaches to them

The recognition of a number of uncommon tumors of the skull base is now relatively simple because of three-dimensional computed tomography and magnetic resonance imaging with enhancement. The radiographic classification of these tumors is reviewed, and their treatment is discussed. Although the basic approach to these tumors is the same--radical surgery with decompression of neural and vascular structures--the authors present various operative techniques for gaining access to and removing these tumors. They also examine the role of radiotherapy in supplementing surgical treatment.     

Surgery for primary cardiac tumors. Clinical experience and surgical results in 60 patients

BACKGROUND: We reviewed our clinical experience with primary cardiac tumors, attempting to clarify the surgical management of these rare entities. METHODS: Between October 1978 and November 1999, we experienced 60 surgical cases of primary cardiac tumors. There were 23 male and 37 female patients (age range, 7 months to 84 years). Tumors included the following 3 groups: myxomas (n=49), nonmyxoma benign tumors (n=3), and malignant tumors (n=8). We reviewed the presenting symptoms, diagnostic data, anatomical findings, and surgical techniques, and evaluated the surgical RESULTS. Late follow-up was 95% complete (mean follow-up, 7.7+/-7.1 years). RESULTS: Tumors produced obstructive, embolic, and/or constitutional symptoms in most cases. Generally, echocardiography alone gave sufficient information for operation. Full-thickness excision was performed in 42 patients with myxoma. Complete excision was achieved in all of the nonmyxoma benign tumors and in none of the malignancies. Early mortalities in the 3 groups were 8.2% (4/49), 0% (0/3), and 12.5% (1/8), respectively. Late mortalities were 9.5% (4/42), 0% (0/3), and 100% (7/7), respectively. One patient with myxoma had recurrence, the cause of which was likely to be inadequate resection. The late deaths in patients with malignancies were due to metastasis or local recurrence. CONCLUSIONS: Benign tumors are generally curable if surgically excised. Preoperative refractory cardiac dysfunction or embolism should be avoided by the accurate evaluation on echocardiography. The prognosis of malignant tumors is poor if they are only debulked. However, aggressive surgery that can palliate obstruction and allow time for adjuvant therapy should be carried out.     

Thoracoscopic removal of intrathoracic neurogenic tumors: a combined Chinese experience

OBJECTIVE: To review the surgical and clinical results of minimally invasive resection of intrathoracic neurogenic tumors using a video-assisted thoracoscopic technique. SUMMARY BACKGROUND DATA: Thoracoscopy has emerged as a possible means for diagnosing and managing various intrathoracic disorders. Benign intrathoracic tumors often are ideal lesions for resection using a video-assisted technique. The authors report on their combined experience with the thoracoscopic resection of 143 intrathoracic neurogenic tumors. METHODS: Between March 1992 and February 1999, 143 patients with intrathoracic neurogenic tumors were diagnosed and underwent resection using video-assisted thoracoscopic techniques in three teaching centers. Case selection, surgical technique, and clinical results were reviewed. RESULTS: The average age of the patients was 40.8 years; 57.3% were male. Thirty-eight patients (27%) had symptoms attributable to the masses. Seventy-two masses were neurofibromas, 33 were neurilemmomas, 7 were paragangliomas, and 31 were ganglioneuromas. All but seven tumors were located in the posterior mediastinum. The masses were on average 3.5 cm in greatest diameter. The mean surgical time was 40 minutes, and the average hospital stay was 4.1 days. There were no major postoperative complications or recurrences to date. Nine patients reported paresthesias over the chest wall during a mean follow-up of 29 months. CONCLUSIONS: Resection of intrathoracic neurogenic tumors using a thoracoscopic technique based on standard surgical indications would seem to be appropriate. Most of these masses are benign and readily removed. For dumbbell tumors, a combined thoracic and neurosurgical approach is mandatory.     

Accuracy of Preoperative Imaging of Hepatic Tumors With Helical Computed Tomography

Background The accuracy of preoperative computed tomography (CT) scans in the era of modern imaging techniques with helical, high-resolution CT has not been adequately assessed. We reviewed the data from our departmental prospective database with the hypothesis that intraoperative ultrasonography (IOUS) still detects more hepatic tumors than are evident on preoperative helical CT scans. Methods All patients who underwent surgical resection and/or radiofrequency ablation of primary or metastatic hepatic tumors between January 2001 and July 2002 were included in the review. All patients had preoperative helical CT imaging followed by hepatic IOUS. The number of malignant lesions and evidence of local disease identified by the preoperative CT scan versus IOUS and surgical exploration were compared. Results In this time period, 250 patients underwent surgical resection and/or radiofrequency ablation of hepatic tumors. In 67 (27%) of these patients, IOUS identified more hepatic tumors than were seen on preoperative helical CT scan. In eight patients (3%), CT underestimated local extension of the disease into the diaphragm. The incidence of inaccurate preoperative prediction of the extent of disease increased significantly with a greater number of hepatic tumors. Conclusions IOUS identified additional hepatic tumors in 27% of patients who underwent hepatic resection after state-of-the-art preoperative CT imaging. This study provides evidence that IOUS remains an essential part of the complete assessment of hepatic malignancies in patients who receive surgical treatment.     

Fibrosarcoma of the sacrum in a child: management by sacral resection and reconstruction

We describe the diagnosis and surgical management of fibrosarcoma of the sacrum in a pediatric patient. We retrospectively reviewed the literature and a case report. Total sacrectomy is a viable treatment option in the management of large malignant sacral tumors. The techniques used in adult patients can be extended to and improved upon for pediatric patients. The input of multiple surgical specialties is essential in the management of these lesions.     

Technical aspects and surgical strategy for removal of corticotroph pituitary adenoma

The development of transsphenoidal microsurgery and the refinement of endocrinological and radiological diagnostic procedures have afforded therapeutic options appropriate for each individual case in patients with pituitary-dependent hypercortisolism. Compared with other secreting pituitary tumors, the corticotroph adenoma seems to be the most biologically active tumor. Clinical evidence of hypercortisolism mainly occurs at an early stage of tumor growth when the tumor is very small, below the detection threshold of modern imaging techniques. While the treatment of large tumors remains difficult due to the non-discrete boundary lines of the tumor and extension or invasion, surgical removal of very tiny tumors requires reliable preoperative or peroperative identification in order to achieve total tumor resection for clinical remission and pituitary preservation to prevent hypopituitarism. We reviewed all the current surgical techniques or clever surgical procedures used to achieve both goals with the lowest complication rate. We report here the state-of-the-art of surgical management of corticotroph pituitary adenoma focusing on preoperative radiological and biological data required for performing guided intrasellar surgical exploration and reliable tumor identification. Different technical aspects of the nasosphenoidal approaches are reported as well as the modified transdiaphragmatic or transtubercular transcisternal approaches to tumors in a suprasellar localization or lying along the pituitary stalk. The advantages of minimally invasive surgical techniques such as intrasellar endoscopic surgery are discussed. Adapted surgical techniques for second transnasal surgery indicated for recurrent tumors are described. Guidelines are given for peroperative tumor identification with macroscopic assessment or histological control with frozen section biopsies. Different techniques for tumor removal are discussed from selective microadenomectomy to enlarged pituitary resection and total hypophysectomy. Methods for preoperative guidance of total tumor removal are proposed including histological or biological assessment of normal adjacent pituitary tissue. the strategy of surgical intrasellar exploration and tumor resection is outlined using a set of algorithms. The first is devoted to positive preoperative documentation of the tumor. The second is proposed for the surgical scenario where there is no preoperative MRI evidence of the tumor. Special strategies are discussed for ectopic adenoma or multiple tumors. Revision surgical management after surgical failure or tumor recurrence is described. Special guidelines for surgical treatment of large clinically silent corticotroph macroadenomas are given with emphasis on the high risk of recurrence in comparison with other silent pituitary tumors such as gonadotroph or immunonegative adenomas.     

Parapharyngeal space tumors: the infratemporal fossa approach

Tumors of the parapharyngeal space, although mostly benign in their histopathology, present a challenge to the surgeon due to the limited access. Multiple approaches have been described in the literature for the extirpation of these tumors. The usual anatomic division of the parapharyngeal space into prestyloid and poststyloid spaces does not help the clinician determine which approach to use for a specific tumor. We have reviewed our 10-year experience at the University of Zurich. The usual presentation of the patients and the histopathologic characteristics of their tumors are compared. The radiological evaluation of these patients, their perioperative course, and complications are analyzed. The different surgical techniques used to treat the 72 patients in our series are described, with a special emphasis on the infratemporal fossa approach. Furthermore, a clinical division of the parapharyngeal space in the superior-inferior axis is established. The usefulness of this classification in helping the surgeon to decide which surgical approach is the most suitable for a particular lesion is discussed.     

Management of Carotid Body Paragangliomas and Review of a 30-Year Experience

Carotid body tumors are rare neoplasms and must be considered in the evaluation of all lateral neck masses; early surgical removal has been recommended. In this study, the medical records of 29 patients with 34 carotid body paragangliomas who were treated at our institution between 1971 and 2001 were retrospectively reviewed. An overview is provided of this lesion, including diagnosis, classification, metastatic potential, possible secretory function, operative techniques, and nonsurgical methods of management. Carotid body tumors may be familial and are more often bilateral in these instances; five patients (17%) had bilateral tumors in this series. The criterion for malignancy is demonstrated by metastatic tumor in lymph nodes or distant organs. Three patients (10%) had malignant tumors, one with hepatic metastases. One patient (3%) in our series exhibited abnormal serotonin production. Vascular reconstruction was necessary in eight cases (28%). No stroke occurred, however, two arterial thromboses (7%), five permanent cranial nerve deficits (17%), and one death (3%) from massive pulmonary embolism were seen. Our experience demonstrates that early operative management is warranted to avoid the possibility of eventual metastasis and progressive local invasion to the point of inoperability.     

Cysts in malignant gliomas. Identification by computerized tomography

The clinical course, computerized tomography (CT) scans, and postmortem reports for 265 patients treated for malignant brain tumors were reviewed. Forty-one patients underwent reoperation for tumor recurrence and one had needle aspiration as a diagnostic procedure; of these patients, seven (3% of 265 and 17% of 42) were diagnosed as harboring tumor cysts and 10 (25% of 41) as having necrotic tumor centers. The CT scans on the 17 patients harboring tumors with surgically confirmed cysts and necrotic centers were reviewed; criteria for distinguishing between cysts and central necrosis are suggested. The relative benefits of repeated aspiration and surgical therapy for these cystic lesions are discussed.     

Bladder Augmentation Techniques in Women

Augmentation cystoplasty is performed in women for a variety of indications, including neurogenic bladder dysfunction, inflammatory diseases, small fibrosed bladders, idiopathic urge incontinence and enuresis. The preoperative evaluation, surgical techniques and postoperative management are reviewed. Complications of stone formation, urinary tract infections, mucus production, metabolic disturbances, hematuria and dysuria syndrome, tumors and perforations are addressed. In addition, alternative techniques such as ureterocystoplasty, autoaugmentation, seromuscular cystoplasty and the future of augmentation of the bladder utilizing techniques of tissue engineering are discussed. The management of pregnancy in women who have previously undergone augmentation cystoplasty is also reviewed.     

Extended sternotomy with lateral neck incision: An alternative approach for children with large apical chest masses with thoracic inlet involvement

Pediatric tumors in the apex of the thoracic cavity are often diagnosed late due to the absence of symptoms. These tumors can be quite large at presentation with involvement of the chest wall, sympathetic chain, spine, and aortic arch. The tumors can also extend into the thoracic inlet and encircle the brachial plexus. Depending on the diagnosis, treatment may involve chemotherapy with subsequent surgery or require primary resection. Optimal exposure to resect large apical tumors with thoracic inlet extension is a surgical challenge. To date, several surgical techniques have been described to resect these tumors – including both anterior and posterior thoracic approaches. Each of these techniques can be limited by inadequate exposure of the mass. We describe an alternative approach to surgical resection of these masses that employs an extended sternotomy with a lateral neck incision. This report details two successful resections of large left apical masses with thoracic inlet involvement in children using this technique (Level of evidence 4).     

The Role of Extensive Lymphadenectomy in Upper Tract Malignant Disease

Upper tract malignancies represent an estimated 5 %–10 % of urothelial cancers, with roughly 3,000 new cases per year in the United States. These tumors often present at an advanced stage, with invasion and lymph node metastases. There are no large randomized prospective studies demonstrating the benefit of lymph node dissection in upper tract urothelial cancer, and as such, definitive guidelines on the surgical template and timing are lacking. Laparoscopic and robotic-assisted surgical techniques are well-established for nephroureterectomy, but are also emerging for retroperitoneal lymph node dissection. The treatment of these tumors still needs to be tailored based on patient and tumor characteristics. The purpose of our review is to update findings on the utility, techniques, and outcomes of lymphadenectomy for upper tract urothelial cancer.     

Tumors of the lateral ventricles

Tumors are only rarely found in the lateral ventricles. Although various oncotypes of these tumors differ in growth rate and invasiveness they present the same clinical pattern with the same diagnostic and surgical problems. Thus we can consider them as a group. This series comprises 51 primary tumors arising strictly from the structures of the lateral ventricles, the majority from the trigone, operated on between 1952 and 1988: 20 meningiomas, 19 ependymomas, 9 papillomas of the choroid plexuses, and 3 subependymomas. As most of these tumors were benign, the response to surgical treatment was, as other authors have found, good with permanent cure or long survival in the majority of cases. Advances in neuroradiological techniques have greatly facilitated the work-up and differential diagnosis of these tumors. Of the various surgical approaches, the parieto-occipital is preferred by our department, even for tumors of the dominant hemisphere. Our operative mortality of 10.6% tallies with that of other workers.     

Solitary fibrous tumors of the meninges

Central nervous system solitary fibrous tumors are a new pathological entity. To our knowledge, only 60 meningeal solitary fibrous tumors both in the spinal cord and in the brain have been described in the literature. The 56 previously reported cases of meningeal solitary fibrous tumors are critically reviewed. In addition, we report four new cases of solitary fibrous tumors of the meninges. There is a slight male prepoderance. Meningeal solitary fibrous tumors show a tendency to arise in the posterior fossa (26%) and spine (25%). The treatment was mainly total surgical excision. Radiotherapy was given only to four patients with tumors involving the cerebral parenchyma. Sporadic cases of recurrence and distant metastasis have been reported. The prognosis of meningeal solitary fibrous tumors is still unknown because the follow-up of the reported cases is short. It is probable that cases of solitary fibrous tumors of the meninges have been misdiagnosed as other tumors in the past. The best management of these tumors seems to be total surgical excision whenever possible. It is important that every new case of meningeal SFT be reported to throw light on this particular tumor and to affirm its status as a clinicopathological entity.     

Infralabyrinthine approach to skull-base lesions

New surgical techniques have extended the head and neck surgeon's domain to include various skull-base lesions. The infralabyrinthine approach incorporates these techniques and can be used to resect benign and malignant tumors involving the base of the temporal bone. Lesions of the internal carotid artery near the carotid foramen are also readily accessible. The main surgical steps in the infralabyrinthine approach include (1) mastoidectomy, (2) anterior transposition of the facial nerve, (3) neck dissection, (4) removal of the lateral tympanic bone, (5) exposure of the jugular foramen, and (6) exposure of the intratemporal carotid artery. Details of the infralabyrinthine approach are illustrated by photographs of surgical and cadaver dissections. Examples of various lesions successfully treated by this technique are presented. The important surgical anatomy of the infralabyrinthine compartment of the skull base is reviewed, with particular attention paid to the internal carotid artery, which, like the facial nerve, demands an intimate familiarity on the part of the temporal bone surgeon.     

Parotid neoplasms: a report of 250 cases and review of the literature.

A 25-year experience with parotid tumors was reviewed. From a total of 250 neoplasms, 173 were histologically benign and 77 were malignant. Benign mixed tumors accounted for 59% of all lesions. Clinical parameters used to diagnose parotid neoplasms were found to be unreliable in determining whether a given tumor was benign or malignant. The mean age for malignant lesions was 10 years greater than for benign lesions. The phenomenon of malignant transformation of a benign tumor was considered in four patients. Complete surgical excision is the safest and preferred method for diagnosis. Preoperative needle or incisional biopsy are associated with a high degree of local recurrence. The appropriate management of any parotid tumor is predicated on special histological type. Local excision or enucleation no longer have a place in the surgical management of benign parotid tumors. Postoperative tumor recurrence and morbidity are directly related to awareness of surgical anatomy and pursuit of correct surgical techniques for adequate resection. The five-year recurrence rate for 102 benign mixed tumors was 6%. Recurrence in malignant tumors varied with specific histological types but was generally high. Five-year survival for all malignant parotid tumors was 48%.     

Primary retroperitoneal tumors in adults: report of 11 cases

The primitive retroperitoneal tumors are tumors which diagnosis isolate and thus the prognosis is poor. The authors assess the resectability of these tumors and the therapeutic results. We performed a retrospective study during 5 years, 11 patients were reviewed, in the unit of visceral surgical emergency of UHC Ibn-Rochd in Casablanca. The median age was 44 years old. The revealing signs were pains (67%), abdominal mass (54%), and compressive signs in 78%. The diagnosis was based on the computerized tomography in 10 cases (90%), the ultrasound sonography in 3 cases, and the IVU in 3 cases when it was necessary. The treatment was surgical in all cases. The resection was curative in 58%, 1 patient received chemotherapy. Histologically, the mesenchymatous variety was the most frequent (68%) and almost malignant (80%), the ectodermic origin was noted in 3 cases, and the vestigial in 1 case. The long-term follow-up was characterized by recurrence in 4 cases and 3 patients were lost to follow-up. The prognosis of the primitive retroperitoneal tumors is poor, because of a late diagnosis, and the malignant, and recurrent potential of these tumors.     

Islet cell tumors of the pancreas: the medical oncologist's perspective.

Islet cell tumors of the pancreas are rare, indolent, neuroendocrine tumors. Approximately 50% of the patients diagnosed with these tumors present with symptoms related to various biologically active hormones that are secreted by these neoplasms. Currently, the only curative treatment for islet cell tumors is complete surgical resection. Management of metastatic disease is conservative. Initial treatment of these tumors includes expectant observation and medical management of symptoms with clinical monitoring and serial CT scans to assess tumor growth. Patients with rapidly progressive disease, with local symptoms caused by tumor bulk, or with uncontrolled symptoms related to hormone secretion require more aggressive medical or surgical intervention. The somatostatin analogue octreotide may help control hormone secretion and stabilize tumor growth. Patients refractory to octreotide with tumor predominantly in the liver are potential candidates for mechanical ablative techniques, such as hepatic arterial embolization. Radiofrequency ablation and cryosurgical techniques may also be useful, although specific data are limited. Surgical resection of metastatic disease may offer palliative relief of symptoms related to hormone secretion in carefully selected patients. Chemotherapy may be used for palliation when ablative techniques have failed or when significant extrahepatic disease is present. Streptozicin-based combinations remain the first line standard, but major objective responses are less common than had been previously thought. Because of the overall modest success of current chemotherapeutic regimens, patients with advanced disease in need of treatment should be encouraged to enroll in clinical trials testing newer antineoplastic agents or newer treatment strategies.     

Usefulness of direct electrical stimulations during surgery for gliomas located within eloquent brain regions

Glioma surgery in functional areas has undergone a dramatic development these last few years, thanks to improvements in both intraoperative functional imaging and direct electrical stimulation of cortical areas or association pathways. The goal of these techniques to achieve complete as possible surgical removal of tumors located in eloquent areas (sensitive, motor and language areas) with minimal risk of permanent sequelae. To be reliable, a rigorous methodology is required. Current cortical mapping is very easy to achieve, whereas mapping of association pathways will require much more experience. In case of tumors located in somatosensorial or language areas, the difficulties related to accurate sub cortical localization are combined with these of local anesthesia and the best task choice to evaluate the integrity of cognitive functions. These functional techniques allow total or sub total removal in 52% to 76.2% of patients. Transient worsening is observed in 13% to 80% of the patients; the rate of permanent sequelae averages 4%.