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Diana A. Roth O’Brien, Sydney M. Kaye, Phillip J. Poppas, Sean S. Mahase, Anjile An, Paul J. Christos, Benjamin Liechty, David Pisapia, Rohan Ramakrishna, AG Wernicke, Jonathan P. S. Knisely, Susan C. Pannullo, and Theodore H. Schwartz

OBJECTIVE

Publications on adjuvant stereotactic radiosurgery (SRS) are largely limited to patients completing SRS within a specified time frame. The authors assessed real-world local recurrence (LR) for all brain metastasis (BM) patients referred for SRS and identified predictors of SRS timing.

METHODS

The authors retrospectively identified BM patients undergoing resection and referred for SRS between 2012 and 2018. Patients were categorized by time to SRS, as follows: 1) ≤ 4 weeks, 2) > 4–8 weeks, 3) > 8 weeks, and 4) never completed. The relationships between timing of SRS and LR, LR-free survival (LRFS), and survival were investigated, as well as predictors of and reasons for specific SRS timing.

RESULTS

In a cohort of 159 patients, the median age at resection was 64.0 years, 56.5% of patients were female, and 57.2% were in recursive partitioning analysis (RPA) class II. The median preoperative tumor diameter was 2.9 cm, and gross-total resection was achieved in 83.0% of patients. All patients were referred for SRS, but 20 (12.6%) did not receive it. The LR rate was 22.6%, and the time to SRS was correlated with the LR rate: 2.3% for patients receiving SRS at ≤ 4 weeks postoperatively, 14.5% for SRS at > 4–8 weeks (p = 0.03), and 48.5% for SRS at > 8 weeks (p < 0.001). No LR difference was seen between patients whose SRS was delayed by > 8 weeks and those who never completed SRS (48.5% vs 50.0%; p = 0.91). A similar relationship emerged between time to SRS and LRFS (p < 0.01). Non–small cell lung cancer pathology (p = 0.04), earlier year of treatment (p < 0.01), and interval from brain MRI to SRS (p < 0.01) were associated with longer intervals to SRS. The rates of receipt of systemic therapy also differed significantly between patients by category of time to SRS (p = 0.02). The most common reasons for intervals of > 4–8 weeks were logistic, whereas longer delays or no SRS were caused by management of systemic disease or comorbidities.

CONCLUSIONS

Available data on LR rates after adjuvant SRS are often obtained from carefully preselected patients receiving timely treatment, whereas significantly less information is available on the efficacy of adjuvant SRS in patients treated under “real-world” conditions. Management of these patients may merit reconsideration, particularly when SRS is not delivered within ≤ 4 weeks of resection. The results of this study indicate that a substantial number of patients referred for SRS either never receive it or are treated > 8 weeks postoperatively, at which time the SRS-treated patients have an LR risk equivalent to that of patients who never received SRS. Increased attention to the reasons for prolonged intervals from surgery to SRS and strategies for reducing them is needed to optimize treatment. For patients likely to experience delays, other radiotherapy techniques may be considered.

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Mark Lee, Hazel T. Rivera-Rosario, Matthew H. Kim, Gregory P. Bewley, Jane Wang, Zellman Warhaft, Bradley Stylman, Angela I. Park, Aoife MacMahon, Ashutosh Kacker, and Theodore H. Schwartz

OBJECTIVE

The authors developed a negative-pressure, patient face-mounted antechamber and tested its efficacy as a tool for sequestering aerated particles and improving the safety of endonasal surgical procedures.

METHODS

Antechamber prototyping was performed with 3D printing and silicone-elastomer molding. The lowest vacuum settings needed to meet specifications for class I biosafety cabinets (flow rate ≥ 0.38 m/sec) were determined using an anemometer. A cross-validation approach with two different techniques, optical particle sizing and high-speed videography/shadowgraphy, was used to identify the minimum pressures required to sequester aerosolized materials. At the minimum vacuum settings identified, physical parameters were quantified, including flow rate, antechamber pressure, and time to clearance.

RESULTS

The minimum tube pressures needed to meet specifications for class I biosafety cabinets were −1.0 and −14.5 mm Hg for the surgical chambers with (“closed face”) and without (“open face”) the silicone diaphragm covering the operative port, respectively. Optical particle sizing did not detect aerosol generation from surgical drilling at these vacuum settings; however, videography estimated higher thresholds required to contain aerosols, at −6 and −35 mm Hg. Simulation of surgical movement disrupted aerosol containment visualized by shadowgraphy in the open-faced but not the closed-faced version of the mask; however, the closed-face version of the mask required increased negative pressure (−15 mm Hg) to contain aerosols during surgical simulation.

CONCLUSIONS

Portable, negative-pressure surgical compartments can contain aerosols from surgical drilling with pressures attainable by standard hospital and clinic vacuums. Future studies are needed to carefully consider the reliability of different techniques for detecting aerosols.

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Theodore H. Schwartz and Michael W. McDermott

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Theodore H. Schwartz and Michael W. McDermott

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Benjamin I. Rapoport, Michael W. McDermott, and Theodore H. Schwartz

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Benjamin I. Rapoport, Michael W. McDermott, and Theodore H. Schwartz

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Michelle Roytman, Andrew B. Tassler, Ashutosh Kacker, Theodore H. Schwartz, Georgiana A. Dobri, Sara B. Strauss, Alyssa M. Capalbo, Rajiv S. Magge, Marissa Barbaro, Eaton Lin, Joseph R. Osborne, and Jana Ivanidze

BACKGROUND

Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is a rare sinonasal neuroectodermal malignancy with a slow onset of symptoms, favorable 5-year survival, and a propensity for delayed locoregional recurrence. Current treatment options include resection, adjuvant radiotherapy, and/or chemotherapy; however, because of its rarity and location, determining the optimal treatment for ENB has been challenging.

OBSERVATIONS

ENBs strongly express somatostatin receptors (SSTRs), particularly SSTR2, providing a molecular target for imaging and therapy.

LESSONs

The authors present a case series of ENBs imaged with [68Ga]-DOTATATE PET/MRI and PET/CT and discuss the emerging role of [68Ga]-DOTATATE PET for ENB diagnosis, staging, and treatment response monitoring.

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Alexander Micko, Benjamin I. Rapoport, Brett E. Youngerman, Reginald P. Fong, Jennifer Kosty, Andrew Brunswick, Shane Shahrestani, Gabriel Zada, and Theodore H. Schwartz

OBJECTIVE

Incomplete resection of skull base pathology may result in local tumor recurrence. This study investigates the utility of 5-aminolevulinic acid (5-ALA) fluorescence during endoscopic endonasal approaches (EEAs) to increase visibility of pathologic tissue.

METHODS

This retrospective multicenter series comprises patients with planned resection of an anterior skull base lesion who received preoperative 5-ALA at two tertiary care centers. Diagnostic use of a blue light endoscope was performed during EEA for all cases. Demographic and tumor characteristics as well as fluorescence status, quality, and homogeneity were assessed for each skull base pathology.

RESULTS

Twenty-eight skull base pathologies underwent blue-light EEA with preoperative 5-ALA, including 15 pituitary adenomas (54%), 4 meningiomas (14%), 3 craniopharyngiomas (11%), 2 Rathke’s cleft cysts (7%), as well as plasmacytoma, esthesioneuroblastoma, and sinonasal squamous cell carcinoma. Of these, 6 (21%) of 28 showed invasive growth into surrounding structures such as dura, bone, or compartments of the cavernous sinus. Tumor fluorescence was detected in 2 cases (7%), with strong fluorescence in 1 tuberculum sellae meningioma and vague fluorescence in 1 pituicytoma. In all other cases fluorescence was absent. Faint fluorescence of the normal pituitary gland was seen in 1 (7%) of 15 cases. A comparison between the particular tumor entities as well as a correlation between invasiveness, WHO grade, Ki-67, and positive fluorescence did not show any significant association.

CONCLUSIONS

With the possible exception of meningiomas, 5-ALA fluorescence has limited utility in the majority of endonasal skull base surgeries, although other pathology may be worth investigating.

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Alexander Micko, Benjamin I. Rapoport, Brett E. Youngerman, Reginald P. Fong, Jennifer Kosty, Andrew Brunswick, Shane Shahrestani, Gabriel Zada, and Theodore H. Schwartz

OBJECTIVE

Incomplete resection of skull base pathology may result in local tumor recurrence. This study investigates the utility of 5-aminolevulinic acid (5-ALA) fluorescence during endoscopic endonasal approaches (EEAs) to increase visibility of pathologic tissue.

METHODS

This retrospective multicenter series comprises patients with planned resection of an anterior skull base lesion who received preoperative 5-ALA at two tertiary care centers. Diagnostic use of a blue light endoscope was performed during EEA for all cases. Demographic and tumor characteristics as well as fluorescence status, quality, and homogeneity were assessed for each skull base pathology.

RESULTS

Twenty-eight skull base pathologies underwent blue-light EEA with preoperative 5-ALA, including 15 pituitary adenomas (54%), 4 meningiomas (14%), 3 craniopharyngiomas (11%), 2 Rathke’s cleft cysts (7%), as well as plasmacytoma, esthesioneuroblastoma, and sinonasal squamous cell carcinoma. Of these, 6 (21%) of 28 showed invasive growth into surrounding structures such as dura, bone, or compartments of the cavernous sinus. Tumor fluorescence was detected in 2 cases (7%), with strong fluorescence in 1 tuberculum sellae meningioma and vague fluorescence in 1 pituicytoma. In all other cases fluorescence was absent. Faint fluorescence of the normal pituitary gland was seen in 1 (7%) of 15 cases. A comparison between the particular tumor entities as well as a correlation between invasiveness, WHO grade, Ki-67, and positive fluorescence did not show any significant association.

CONCLUSIONS

With the possible exception of meningiomas, 5-ALA fluorescence has limited utility in the majority of endonasal skull base surgeries, although other pathology may be worth investigating.

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Theodore H. Schwartz and Michael W. McDermott

The Simpson grading scale, developed in 1957 by Donald Simpson, has been considered the gold standard for defining the surgical extent of resection for WHO grade I meningiomas. Since its introduction, the scale and its modifications have generated enormous controversy. The Simpson grade is based on an intraoperative visual assessment of resection, which is subjective and notoriously inaccurate. The majority of studies in which the grading system was used were performed before routine postoperative MRI surveillance was employed, rendering assessments of extent of resection and the definition of recurrence inconsistent. The infiltration and proliferation potential of tumor components such as hyperostotic bone and dural tail vary widely based on tumor location, as does the molecular biology of the tumor, rendering a universal scale for all meningiomas unfeasible. While extent of resection is clearly important at reducing recurrence rates, achieving the highest Simpson grade resection should not always be the goal of surgery.

Donald Simpson’s name and his scale deserve to be recognized and preserved in the historical pantheon of pioneering and transformative neurosurgical concepts. Nevertheless, his eponymous scale is no longer relevant in modern meningioma surgery. While his message of maximizing extent of resection and minimizing morbidity is still germane, a single measure using subjective criteria cannot be applied universally to all meningiomas, regardless of location. Meningioma surgery should be performed with the goal of achieving maximal safe resection, ideally guided by molecularly tagged fluorescent labeling and assessed using objective criteria, including postoperative MRI as well as molecularly tagged scans such as [68Ga]-DOTATATE-PET.