Surgical resection of unilateral thalamic tumors in adults

Surgical treatment of adult thalamic tumors must be individualized according to tumor location. Low-grade tumors and total/subtotal resection ... Skiptomaincontent Advertisement SearchallBMCarticles Search Surgicalresectionofunilateralthalamictumorsinadults:approachesandoutcomes DownloadPDF DownloadPDF Researcharticle OpenAccess Published:07November2015 Surgicalresectionofunilateralthalamictumorsinadults:approachesandoutcomes LeiCao1,ChuzhongLi2,YazhuoZhang2&SongbaiGui1  BMCNeurology volume 15,Article number: 229(2015) Citethisarticle 6410Accesses 24Citations 1Altmetric Metricsdetails AbstractBackgroundThethalamictumorswerelesscommoninadultsandthisstudyaimedtodeterminetheclinicalfeatures,surgicalapproaches,andoutcomesofadultthalamictumors,whichhavenotbeenwell-describedintheliterature.MethodsWereviewedtheclinicalpresentation,surgicalapproach,perioperativemortalityandmorbidity,andoutcomesof111operatedpatients(71males,40females;meanageatpresentation,33.4 ± 13.2 years)withunilateralthalamictumor.ResultsThemostcommonclinicalpresentationswereincreasedintracranialpressure(65 %)andmotordeficits(40 %).Fivesurgicalapproacheswereuseddependingontumorlocation;themostcommonwasthetransparieto-occipitalapproach(47.7 %).Accordingtoperi-andpost-operativemagneticresonanceimagingfindings,thetumorsweretotallyresectedin29cases(26.1 %),subtotallyresectedin54cases(48.6 %),andpartiallyresectedin21cases(18.9 %).Fivepatientsdiedduringtheperioperativeperiod(4.5 %,5/111).Themostcommonmorbiditywasmotordeficits(21.7 %,23/106).Accordingtohistologicalfindings,therewere50high-gradeand61low-gradetumors.Mediansurvivalofpatientswithlow-andhigh-gradetumorswere40and12 months,respectively(meanfollow-up,37.3 months).Survivalwassignificantlylongerincasesoftotalorsubtotalresection(median,28 months)comparedtopartialresectionorbiopsy(median,12 months).Survivalwaspoorerinadultsthaninpreviousreportedpediatrics.ConclusionsSurgicaltreatmentofadultthalamictumorsmustbeindividualizedaccordingtotumorlocation.Low-gradetumorsandtotal/subtotalresectionseemtobepredictorsofbettersurgicaloutcomes.Nevertheless,theoutcomeofadultpatientswerestillworsethanpediatricpatients. 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BackgroundThalamictumorsarerare,comprising5 %ofallbraintumors,andcanoccurinallagegroups,butaremorecommoninchildrenthaninadults[1,2].Inthepast,theoutcomeofthalamictumorswasgenerallypoorbecausetheyaredeep-seatedandsurroundedbyvitalstructures,suchastheinternalcapsuleandsubthalamus,andtherisksofpostoperativemorbidityandmortalitywerehigh[3,4].However,recentimprovementsinneuroimagingandsurgicaltechniqueshavemadesurgicalresectionofthalamictumorsfeasibleinchildrenandhavereducedthemorbidityandmortalityratesassociatedwiththisapproach[2,5–9].Forunilateralthalamictumors,manystudieshavereportedthatsurgicalresectioncanimprovesurvivalofpatientswithlowmorbidityandmortality,sotheyrecommendthatsurgicalresectionshouldbeperformedincombinationwithadjuncttherapies,suchasradiotherapyandchemotherapy,basedonthehistologicalcharacteristicsofthetumors[10–12].Thalamictumorshavereceivedmuchlessattentioninadultsthaninpediatricpatients.Moreover,theclinicalcharacteristics,operativeindications,postoperativemorbidityandmortalityrates,prognosis,andoutcomeofunilateralthalamictumorsinadultsmaydifferfromthoseofpediatricpatients.Ithasbeenreportedthatthalamictumorscanberesectedviaseveraldifferentapproaches,althoughtheindicationsforsurgeryarenotwell-describedforadults.Correspondingly,thecharacteristics,treatmentapproach,andprognosisforunilateralthalamictumorsinadultsneedtobebetterdefined.Tothebestofourknowledge,thepresentseriesof111adultswithunilateralthalamictumorsisthelargesttobereviewed,andbothindicationsforsurgeryandclinicalresultswereexamined.MethodsPatientpopulationThisretrospectivemedicalrecordreviewwasperformedinaccordancewithtenantsoftheDeclarationofHelsinki.AllpatientsgaveinformedconsentandthestudyprotocolwasapprovedbytheEthicalReviewBoardofBeijingTiantanHospital.Operatedcasesinvolvingadultpatients(>18 yearsold)withunilateralthalamiclesionswhopresentedtotheCapitalMedicalUniversityBeijingTiantanHospitalforthefirsttimebetween2003and2010wereretrospectivelyreviewed(n = 111).Tumorsarisingfromadjacentstructures(basalganglia,opticpathways,hypothalamus,ventricle,brainstem,andpinealregion)andinvolvingthethalamicregionwereexcluded.Withregret,the“onlyobserved”patientswerenotincluded.ClinicalandimagingdataClinicaldata,includingageatpresentation,durationandtypeofsymptoms,treatmentreceived,extentofresection,symptomimprovement,andstatusattheendofthefollow-upperiod,wererecorded.Allpatientsunderwentmagneticresonanceimaging(MRI)beforetreatmentandduringthefollow-upperiod.Specialattentionwasgiventothetumorepicenter,itsextensiontoadjacentstructures,andtheextentoftumorremoval.Thetumorvolumewascalculatedusingthefollowingformula:axial*coronal*sagittal/2(referringtothelargestdiameters),asdescribedbyKramm[13].SurgicaltreatmentBasedonthelocationofthetumorinthethalamusandsurroundingstructures,transfrontal,transcallosal,transtemporal,subtemporal,andtransparieto-occipitalapproacheswereused.Inaddition,stereotacticbiopsywasperformedwhenthepatientsweretooweaktoundergocraniotomy.Neuronavigationorultrasonographywasappliedintraoperativelytopositionthetranscorticalpointanddefinethetumormargins.Intraoperativeelectrophysiologywasusedtoidentifysensorimotorpathwaysin46casessince2007.High-gradetumorsweretreatedbyadditionaladjunctiveradiotherapyorchemotherapy.Theextentofresectionwasdefinedaspartial(<90 %),subtotal(>90 %),ortotalbasedonbothpostoperativeimaging(evaluatedbythreeexperiencedradiologistsatourinstitute)andintraoperativeevaluations(evaluatedbytheoperator).ThequalityoflifeofeachpatientbeforeandaftersurgerywasevaluatedusingtheKarnofskyperformancestatus(KPS)score.HistopathologicalanalysisTumordiagnoseswerereviewedbythreeexperiencedneuropathologistsatourinstituteaccordingtotheWHO2007classificationstandardsforcentralnervoussystemtumors[14].SurvivalanalysisOfthe111patientsofthisseries,86underwentfollow-upmonitoringaftersurgery.CorrelationsweremadeusingunivariateanalysisaccordingtotheKaplan–Meiermethod.Thethresholdforstatisticalsignificancewasap-valueof ≤ 0.05.ResultsClinicalpresentationBetween2003and2010,111adultpatientswithunilateralthalamictumorsunderwentsurgicalresectionatourhospital.Thisgroupincluded71malesand40females(ratio:1.8:1).In51/111patients(45.9 %),thetumorwasontheleftside.Themeanageatpresentationwas33.4 ± 13.2 years(range,18–64years)andthemeandurationofsymptomswas3.6 ± 6.4 months(range,0.25–19months).For28/111patients(25 %),thetumorwaspresentforlessthan1 monthpriortodiagnosis,for55/111patients(50 %)thetumorwaspresentfor1–2monthspriortodiagnosis,andfor28/111patients(25 %)thetumorwaspresentformorethan2 monthspriortodiagnosis.ThesymptomsreportedforthepresentcohortarelistedinTable 1.Themostcommonpresentationwasincreasedintracranialpressure(ICP)(72/111,65 %),whichwascharacterizedbyheadaches,vomiting,andpapilledema.Motordeficitswerealsoacommonpresentation(44/111,40 %).Table1Clinicalfeaturesfor111adultswithunilateralthalamictumorsFullsizetableAllpatientsunderwentMRIbeforesurgery.Specialattentionwasgiventothevolumeandlocationofeachtumor.Themeantumorvolumewas38.4 ± 28.9 cm[3](range,4–140 cm[3]).TumorswerealsodividedintotwomajorgroupsbasedontheirlocationintheMRimages.Tumorswithanepicenterinthethalamicregionwereinonegroup,whiletumorsarisingfromthejunctionofthethalamusandcerebralpeduncle—withmostoftheirmassbeinginthethalamicregion—wereincludedinthesecondgroup.Inthefirstgroup(n = 84),thetumorepicenterwaslocatedintheanteriorthalamicnuclei(n = 20),thelateralnuclei(n = 7),themedialnuclei(n = 18),orthepulvinar(n = 39).Inthisgroup,thetumorsalsoextendedintheanteriororsuperiordirectiontowardsthefronthornofthelateralventricle(n = 14),mediallytowardthethirdventricle(n = 11),laterallytowardtheadjacentlobeorgyrus(n = 7),andposteriorlytowardtheparietalandtemporallobes(n = 29).Inthesecondgroup(n = 27),thetumorsoriginatedfromthethalamusandextendedtothemidbrain.TumorresectionAccordingtothelocationofeachtumoronthepreoperativeMRimages,severalsurgicalapproacheswereused.Incaseswheretheepicenterwaslocatedintheanteriorthalamuswith/withoutanteriorextensiontothefontalhornofthelateralventricleorcallosum,theanteriortranscallosalapproachwasused,providedthatthetumorextendedtowardthelateralventriclewithoutcausinginjurytothehemispheretissueorcorticalincision.Incaseswherethetumorextendedtoofarlaterally,atransfrontalapproachwasusedtoreachthefrontalhornofthelateralventricle,thentheventriclefloorwasincisedandthetumorwasexposed.Atranscallosalapproachwasusedin13cases(12 %),whileatransfrontalapproachwasusedin7cases(6 %)(Fig. 1).Incaseswherethetumorepicenterwaslocatedinthemedialthalamicregionwithorwithoutextensionintothethirdventricle,thetranscallosalapproachwasused(17,15 %)(Fig. 2).Astereotacticbiopsywasperformedinasinglecase(0.9 %).Incaseswherethetumorepicenterwaslocatedinthelateralthalamicregionwith/withoutlateralextensiontothebasalganglia,adjacentlobes,orgyrus,andwhenthetumorextendedbeneaththetemporalcortex,thetrans-temporalmiddlegyrusapproachwasused.Thetranstemporalapproachwasusedin7cases(6 %)(Fig. 3).Fortumorslocatedinthepulvinarwithposteriorextensiontowardadjacentstructures,atransparieto-occipitaltransventricularapproachwasused.Forthisapproach,thecortexwasincisedfromtheborderoftheparieto-occipitallobesandthesulcuswasdissectedtoreducecorticalinjuryandreducetheriskofpostoperativeseizuresandhemianopsia.Thetransparieto-occipitalapproachwasusedin37cases(33 %)andstereotacticbiopsywasperformedintwo(Fig. 4).Fig.1aDifferentsurgicalapproachestoanteriorthalamictumorswereshowedinthediagram.bAnanaplasticastrocytomaarisingfromanteriorthalamuswasresectedtotallyviaananteriortranscallosalapproach.cAnotheranaplasticastrocytomawasresectedtotallyviaatransfrontalapproachFullsizeimageFig.2aDifferentsurgicalapproachestomedialthalamictumorswereshowedinthediagram.bAnanaplasticastrocytomawasresectedtotallyviaananteriortranscallosalapproach.Thetumorextendsmediallytothethirdventricle,asseenonthepreoperativeMRimage.ThetopofthetumorisexposedafteranincisionintothecallosumFullsizeimageFig.3aDifferentsurgicalapproachestolateralthalamictumorswereshowedinthediagram.bTheanaplasiaastrocytomaarosefromthelateralpartofthethalamusandwasremovedbytranstemproalapproachsubtotallyFullsizeimageFig.4aDifferentsurgicalapproachestothalamictumorsarisingfrompulvinarwereshowedinthediagram.bAglioblastomaarosefromtheposteriorpartofthethalamusandextendedposteriorlytothelateralventricle,andwasremovedtotallyviaatransparieto-occipitalapproach.ThecortexwasincisedwiththehelpofneuronavigationFullsizeimageFortumorsarisingfromthejunctionofthethalamusandcerebralpedunclewithmostoftheirmasslocatedinthethalamicregion,thetransparieto-occipitalapproachwasusedtoremovethethalamicpartofthetumor.Theinferiorpartthatslightlyextendedtothecerebralpedunclewasalsoexposedandremoved.Ifthetumoroccupiedthecisternaambiensandextendedinferiorlytotheinfratentorialarea,thetumorcouldbeexposedbyelevatingthetemporallobeandmakingatentorialincisionviaasubtemporalapproach.Ifthetumorextendedtothethalamicandpeduncletoasimilarextent,thetranstemporalapproachwasagoodchoiceforbothregions.Overall,thetransparieto-occipitalapproachwasusedin16cases(14 %),thetranstemporalapproachwasusedin2cases(2 %),thesubtemporalapproachwasusedin6cases(6 %)(Fig. 5),andastereotacticbiopsywasperformedin3cases(3 %).Fig.5aDifferentsurgicalapproachestothalamictumorsarisingfromjunctionofpulvinarthalamusandcerebralpedunclewereshowedinthediagram.bAnastrocytomawasremovedsubtotallyviaatranstemporalapproach.Thetumorarosefromthejunctionofthalamusandcerebralpeduncleandextendedtobothsidesequally,andbothpartswerewellexposedviathetranstemporalapproach.cTheinferiorpartofanotherastrocytomawaswellexposedandremovedviaasubtemporalapproach.ThepostoperativeMRimageshowsthatsomeresidualtumorwasstillpresentinthethalamicregionFullsizeimageBasedonboththesurgicalfindingsandpost-operativeMRIfindings,completetumorresectionwasachievedin29cases(26.1 %),subtotalresectionwasachievedin54cases(48.6 %),andpartialresectionwasachievedin21cases(18.9 %).InTable 2,dataregardingtumorlocationandtheextentofresectionaresummarized.Takentogether,theseresultsindicatethatitwasdifficulttoachievetotalandsubtotalresectionwhentumorinfiltrationreachedthemidbrain.Table2Extentofresectionbasedontheanatomiclocationofthe111adultunilateralthalamictumorsFullsizetablePerioperativemorbidityandmortalityFivepatientsdiedduringtheperioperativeperiod,twoasaresultofcomaandthreeasaresultofcerebralswellingandinfarction.Table 3summarizesthepostoperativeclinicalfeaturesoftheother106patientsupondischarge.Forsensoryfunction,visualability,andICP,80/106cases(84.9 %),100/106cases(94.4 %),and100/106cases(94.4 %)showednodecreaseorimprovementinthesefunctionalcategories,respectively.Regardingmotordeficits,onlypatientswithpreoperativemotordeficits(n = 44)couldbeevaluatedforimprovementinmotordeficits,yetall106patientscouldbeevaluatedfordeteriorationofmotordeficits.Therefore,preoperativemotordeficitswerefoundtoimprovefollowingsurgeryin15/44cases,whilemotordeficitsdeterioratedin23/106cases(Table 3).Forthelatter,myodynamicmusclestrengthwasalsofoundtoslightlyrecoverin15ofthesecaseswithin3 months.Asignificantfunctionaldecreaseinpatientswithdeterioratedmotordeficitswasobservedwhentheintra-operativeelectrophysiologicalmonitorwasused(18casesinnon-electrophysiologicalstagevs.5casesinelectrophysiologicalstage).Inaddition,newsensorydeficitsweredetectedin16cases(13casesinnon-electrophysiologicalstagevs.3casesinelectrophysiologicalstage),whileasignificantincreaseinICPwasfoundin6cases(thesepatientsunderwentcranialdecompression),andhemianopiadevelopedin6cases.Othercomplicationsincludedspeechdisorders,memorydisorders,involuntarymovements,spasticity,seizures,andbehavioralproblems,whichwereobservedindividuallyorincombinationin16cases.Table3Postoperativeclinicalfeaturesof106adultswithunilateralthalamictumorsFullsizetablePerioperativehydrocephaluswasencounteredbeforeandaftersurgicalresection.In42caseswherehydrocephaluswasidentifiedpreoperatively,fourpatientsunderwentventriculo-peritoneal(VP)shuntplacementsurgeryatanotherhospitalfortreatmentofsevereICPsymptoms.In28oftheremaining38cases,thehydrocephalusimprovedwithoutVPshuntplacementaftertumorresection.Intheother10cases,thehydrocephalusdidnotimproveandeventuallyaVPshuntwasrequired.Aftertumorresection,ventricleenlargementwasobservedinsixpatientsthatdidnotexhibitpreoperativehydrocephalus,includingfivepatientswhorequiredaVPshuntandonepatientwhounderwentplacementofanexternalventriculardrain.Histopathologicalfindings,adjuvanttreatment,andsurvivalanalysisHistopathologyconfirmedthefollowingtumortypesinthepresentseries:88astrocytomas,5oligodendrogliomas,12oligoastrocytomas,3ependymomas,2gangliogliomas,and1primaryneuroectodermaltumor(Table 4).Ofthesetumors,50werehigh-gradeand61werelow-grade.Allpatientswithhigh-gradetumorsorprogressivelow-gradetumorscompletedpostoperativeradiotherapyand/orchemotherapy,exceptforfivepatientswhodiedduringtheperioperativeperiod.Inaddition,20patientswerelosttofollow-up.Oftheremaining86patients,40hadhigh-gradetumorsand44hadlow-gradetumors.Table4Histologicalclassificationofadultunilateralthalamicgliomasofthepresentcohort(n = 111)FullsizetableOnly18patientswerealiveatthetimeofthelastfollow-up(meanfollow-upduration,37.3 months;range,6–98months).Themediansurvivaltimesforpatientswithlow-andhigh-gradetumorswere40and12 months,respectively.The1-and3-yearsurvivalratesofpatientswithlow-gradetumorswere94.7 % ± 3.6 %and57.7 % ± 8.1 %,respectively,whichwerehigherthanthoseofpatientswithhigh-gradetumors(43.2 % ± 7.5 %and6.8 % ± 3.8 %,respectively;P 40patients)(Table 5).Motor,sensory,andvisualdeficitswereobservedincaseswherethetumorshadcompressedadjacentstructures,especiallytheposteriorlimboftheinternalcapsule.Afterdecompression,functionwasfoundtoimprove.Motorandsensorydeficitswerethemostcommonmorbidities.Abouthalfofthepatientshadtransienthemiparesis,whichmayhavebeencausedbypostoperativecerebralswellingthatinfluencedtheposteriorlimbsoftheinternalcapsule.Sensorydeficitswereduetocentralthalamicradiationinjuriesandvisualfielddeficitswerecausedbyvisualradiation.Aphasicproblemscanbecausedbypulvinarinjuries,asthepulvinaristhesiteofneuronalprojectiontothelanguagecenters[19].Thehighrateofpostoperativesensorimotorandvisualdeficitsmaybeduetothecerebralswellingorheatinjurycausedbybipolarcoagulation.Moreover,theunavailabilityofintraoperativeelectrophysiologyintheearlystagewasalsoanotherfactorimpactingpostoperativefunctionaldeficits.CerebralswellingwasonereasonforthepostoperativeincreaseinICP,whichcanusuallybereversedusingmedicaltherapyorcranialdecompression.AnothercauseofincreasedICPwaspostoperativehydrocephalus.Inthisseries,hydrocephaluswastreatedbytumorresectionin74 %ofpatients,asCSFdrainagecanbere-establishedaftertumorresection.Insixpatients,theCSFpathwaywasstillobstructedpostoperativelyasaresultofcerebralswellingorgliosissurroundingtheaqueductorinterventricularforamenofMonro,requiringCSFdiversion.Therefore,inourexperience,preoperativeshuntingofthalamictumorsarenotnecessaryduetothepotentialforneurologicaldegradationorsubsequentshuntblockade.SimilarfindingswerepublishedbyGole[20].Theoutcomesofthethalamictumorsexaminedinthisserieswerefoundtocorrelatewiththehistopathologicalresultsandthemediansurvivalperiodforpatientswithlow-gradetumorswaslongerthanthatforpatientswithhigh-gradetumors,consistentwithpreviousreports[2,5,7,21].Theoverallsurvivaloflow-gradetumorsinadultsisreportedlylowerthanthatinchildren,perhapsduetothelowerdegreeofneuroplasticityinadultscomparedtochildren[21].Forpatientswithhigh-gradetumors,theoverallsurvivalperiodwas12 months,similartothatobservedforchildren.Patientswhounderwenttotalorsubtotalresectionalsoachievedabettersurvivalratethanthosewhounderwentpartialresectionorbiopsy.Thisfindingisconsistentwiththeresultsofotherstudies,whichfoundthatmaximalsaferesectionofthalamictumorsisfeasibleandgenerallyresultsinabetteroutcome[10,19,22,23].Thesefindingssupportasurgicalapproachformanagementofthesetumorsandimplythatextendedtumorresectioncanimproveprognosis.ConclusionsDeep-seatedthalamictumors,especiallyinadults,areachallengeformanyneurosurgeons.Basedonthefindingsfromthepresentseries,surgicalremovalappearstobeanappropriatetreatmentforthalamictumorsinadults.Moreover,theappropriatesurgicalapproachshouldbedeterminedbasedonthelocationofthetumoranditsrelationshipwithsurroundingstructures.Theextentoftumorresectionandhistologicalclassificationarealsotwoveryimportantfactorstoconsiderwhendeterminingtheprognosisofpatientswiththalamictumors.Nevertheless,furtherstudieswillbenecessarytoimprovethepooroutcomesofadultswiththalamictumors. 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ReprintsandPermissionsAboutthisarticleCitethisarticleCao,L.,Li,C.,Zhang,Y.etal.Surgicalresectionofunilateralthalamictumorsinadults:approachesandoutcomes. BMCNeurol15,229(2015).https://doi.org/10.1186/s12883-015-0487-xDownloadcitationReceived:11February2015Accepted:31October2015Published:07November2015DOI:https://doi.org/10.1186/s12883-015-0487-xSharethisarticleAnyoneyousharethefollowinglinkwithwillbeabletoreadthiscontent:GetshareablelinkSorry,ashareablelinkisnotcurrentlyavailableforthisarticle.Copytoclipboard ProvidedbytheSpringerNatureSharedItcontent-sharinginitiative KeywordsAdultThalamictumorUnilateralSurgicalapproachClinicalresult DownloadPDF Advertisement BMCNeurology ISSN:1471-2377 Contactus Submissionenquiries:[email protected] Generalenquiries:[email protected]