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A long-term evaluation of a training program on breaking bad news in pediatric neurosurgery: a pilot study

Marc Zanello, Thomas Baugnon, Alexandre Roux, and Federico Di Rocco

OBJECTIVE

Breaking bad news is a difficult task in medical practice. Several breaking-bad-news training programs have been proposed. However, long-term results of such training have rarely been investigated. The aim of this study was to compare the short- and long-term evaluations by young neurosurgeons of a training program for breaking bad news to patients and their parents.

METHODS

Between 2012 and 2015, pediatric neurosurgery residents participated in a training day on breaking bad news in pediatric neurosurgery with professional actors. A personal debriefing, followed by a theoretical session, completed the training. Immediate feedback was evaluated through a survey administered at the end of the day. Long-term results were explored via an online form sent at least 3 years after the training completion.

RESULTS

Seventeen participants from 9 different countries were interviewed. Their immediate feedback confirmed their interest. For 71% of them, the program was very interesting, and 77% were extremely satisfied or very satisfied. All trainees wanted more training sessions. At a mean of 4.5 years of follow-up (range 3–6 years), 71% of the trainees fully remembered the session. Most of them (86%) reported a positive impact of the training on their career. Only 21% had another training session on breaking bad news during their residency. At long-term analysis, fewer trainees considered the duration of the training to have been sufficient (p = 0.044).

CONCLUSIONS

Breaking-bad-news training has a positive long-term educational impact even several years later. Such a training program should be implemented into pediatric neurosurgery residency.

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Neurosurgical developments of Thierry de Martel (1875–1940), French neurosurgery pioneer, during World Wars I and II

Johan Pallud, Giorgia Antonia Simboli, Alessandro Moiraghi, Alexandre Roux, and Marc Zanello

Following France’s entry into World War I on August 3, 1914, Thierry de Martel (1875–1940), the French neurosurgery pioneer, served on the front line and was wounded on October 3, 1914. He was then assigned as a surgeon in temporary hospitals in Paris, where he published his first observations of cranioencephalic war wounds. In 1915, de Martel met Harvey Cushing at the American Hospital in Neuilly, where de Martel was appointed chief surgeon in 1916. In 1917, he published with the French neurologist Charles Chatelin a book (Blessures du crâne et du cerveau. Clinique et traitement) with the aim to optimize the practice of wartime brain surgery. This book, which included the results of more than 5000 soldiers with head injuries, was considered the most important ever written on war neurology at that time and was translated into English in 1918 (Wounds of the Skull and Brain; Their Clinical Forms and Medical and Surgical Treatment). In this book, de Martel detailed the fundamentals of skull injuries, classified the various craniocerebral lesions, recommended exploratory craniectomy for cranioencephalic injuries, recommended the removal of metal projectiles from the brain using a magnetic nail, and advocated for the prevention of infectious complications. Between the World Wars, de Martel undertook several developments for neurosurgery in France alongside neurologists Joseph Babinski and Clovis Vincent. Following France’s entry into World War II on September 3, 1939, de Martel took over as head of the services of the American Hospital of Paris in Neuilly. He updated his work on war surgery with the new cases he personally treated. Together with Vincent, de Martel presented his new approach in "Le traitement des blessures du crâne pendant les opérations militaires" ("The treatment of skull injuries during military operations") on January 30, 1940, and published his own surgical results in April 1940 in "Plan d’un travail sur le traitement des plaies cranio-cérébrales de guerre" ("Work Plan on the Treatment of Cranio-Cerebral Wounds of War"), intended for battlefield surgeons. On June 14, 1940, the day German troops entered Paris, de Martel injected himself with a lethal dose of phenobarbital. Thierry de Martel played a central role in establishing modern neurosurgery in France. His patriotism led him to improve the management of wartime cranioencephalic injuries using his own experience acquired during World Wars I and II.

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Letter to the Editor. The life and death of Thierry de Martel

Romain Carron

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Toward a transitional care from childhood and adolescence to adulthood in surgical neurooncology? A lesson from the Necker-Enfants Malades and the Sainte-Anne Hospitals collaboration

Alexandre Roux, Kévin Beccaria, Thomas Blauwblomme, Nizar Mahlaoui, Fabrice Chretien, Pascale Varlet, Stéphanie Puget, and Johan Pallud

OBJECTIVE

Transitional care in surgical neurooncology is poorly studied. However, this period is pivotal, since it allows the patient to be empowered in his or her disease management. Here, the authors describe the experience of the Necker-Enfants Malades and the Sainte-Anne Hospital collaboration.

METHODS

The mixed transitional consultations started in September 2019 in a dedicated space for transitional care, named the “La Suite” department, located in the Necker-Enfants Malades Hospital, Paris, France. The authors organized planned consultations to schedule the clinical and radiological follow-up in the adult neurosurgical department but also emergency consultations to manage tumor recurrence in young adult patients. Transitional care was performed jointly by pediatric and adult neurosurgeons who have developed clinical and research skills in the field of surgical neurooncology. Neuropathological analysis was performed by a neuropathologist who is specialized in pediatric and adult neurooncology.

RESULTS

Fourteen patients benefited from a mixed transitional consultation. All of them accepted to start their management in an adult neurosurgical environment. Eleven patients (78.6%) for whom the disease was controlled benefited from a planned consultation. Three patients (21.4%) required rapid neurosurgical management for a tumor recurrence (n = 2) or for a new primary CNS tumor (n = 1) and benefited from an emergency consultation.

CONCLUSIONS

For adult patients harboring a brain tumor during childhood or adolescence, the authors suggest that neurosurgeons specialized in adult surgical neurooncology with a full knowledge in pediatric neurooncology will combine the required skills to optimize care management for these patients within a dedicated multidisciplinary organization framework.

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Toward a transitional care from childhood and adolescence to adulthood in surgical neurooncology? A lesson from the Necker-Enfants Malades and the Sainte-Anne Hospitals collaboration

Alexandre Roux, Kévin Beccaria, Thomas Blauwblomme, Nizar Mahlaoui, Fabrice Chretien, Pascale Varlet, Stéphanie Puget, and Johan Pallud

OBJECTIVE

Transitional care in surgical neurooncology is poorly studied. However, this period is pivotal, since it allows the patient to be empowered in his or her disease management. Here, the authors describe the experience of the Necker-Enfants Malades and the Sainte-Anne Hospital collaboration.

METHODS

The mixed transitional consultations started in September 2019 in a dedicated space for transitional care, named the “La Suite” department, located in the Necker-Enfants Malades Hospital, Paris, France. The authors organized planned consultations to schedule the clinical and radiological follow-up in the adult neurosurgical department but also emergency consultations to manage tumor recurrence in young adult patients. Transitional care was performed jointly by pediatric and adult neurosurgeons who have developed clinical and research skills in the field of surgical neurooncology. Neuropathological analysis was performed by a neuropathologist who is specialized in pediatric and adult neurooncology.

RESULTS

Fourteen patients benefited from a mixed transitional consultation. All of them accepted to start their management in an adult neurosurgical environment. Eleven patients (78.6%) for whom the disease was controlled benefited from a planned consultation. Three patients (21.4%) required rapid neurosurgical management for a tumor recurrence (n = 2) or for a new primary CNS tumor (n = 1) and benefited from an emergency consultation.

CONCLUSIONS

For adult patients harboring a brain tumor during childhood or adolescence, the authors suggest that neurosurgeons specialized in adult surgical neurooncology with a full knowledge in pediatric neurooncology will combine the required skills to optimize care management for these patients within a dedicated multidisciplinary organization framework.

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Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy

Christian Sainte-Rose, Giuseppe Cinalli, Franck E. Roux, Wirginia Maixner, Paul D. Chumas, Maheir Mansour, Alexandre Carpentier, Marie Bourgeois, Michel Zerah, Alain Pierre-Kahn, and Dominique Renier

The authors conducted a study to evaluate the effectiveness of endoscopically guided third ventriculostomy in the pre- and postoperative management of hydrocephalus in pediatric patients who harbored posterior fossa tumors.

Between October 1, 1993, and December 31, 1997, a total of 206 consecutive children with posterior fossa tumors underwent surgery at Hôpital Necker-Enfants Malades in Paris. Ten patients in whom shunts were implanted at the referring hospital were excluded. The medical records and neuroimaging studies obtained in the remaining 196 patients were reviewed. These patients were categorized into three groups: 67 patients with hydrocephalus on admission in whom endoscopically guided third ventriculostomy was performed prior to tumor removal (Group A); 82 patients with hydrocephalus in whom preliminary third ventriculostomy was not performed and who were managed in a “conventional way” (Group B); and 47 patients without ventricular dilation on admission (Group C).

There was no significant difference between Group A and Group B patients with respect to age at presentation, evidence of metastatic disease, degree of tumor resection, or follow up. In the patients in Group A, however, more severe hydrocephalus was present (p < 0.01). Patients in Group C were, in this respect, different from the other two groups.

Ultimately, only four patients (6%) in Group A as compared with 22 patients (27 %) in Group B (p = 0.001) had progressive hydrocephalus requiring treatment following removal of the posterior fossa tumor. Sixteen patients (20%) in Group B underwent insertion of a ventriculoperitoneal shunt, which is similar to the incidence of this procedure reported in the literature and significantly different from that in Group A (p < 0.016). The other six patients in Group B (6%) were treated by endoscopically guided third ventriculostomy after tumor removal. In Group C, two patients (4%) with postoperative hydrocephalus underwent endoscopically guided third ventriculostomy.

In three of the patients who required placement of cerebrospinal fluid shunts several episodes of shunt malfunction occurred; these were ultimately managed by performing endoscopic third ventriculostomy and definitive removal of the shunt.

There were no cases of death and four cases of transient morbidity associated with the ventriculostomy.

Third ventriculostomy is feasible even in the presence of posterior fossa tumors (including brainstem tumors). When performed prior to posterior fossa surgery, it significantly reduces the incidence of postoperative hydrocephalus. Furthermore, it provides a valid alternative to the placement of permanent shunts in cases in which hydrocephalus develops following posterior fossa surgery, and it may negate the need for the shunt in cases in which the shunt malfunctions.

Although the authors acknowledge that the routine application of third ventriculostomy in selected patients may result in a proportion of patients undergoing an “unnecessary” procedure, they believe that because of patients' less complicated postoperative course, the low morbidity rate, and the high success rate of third ventriculostomy, further investigation of this protocol is warranted.

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Predictors of early postoperative epileptic seizures after awake surgery in supratentorial diffuse gliomas

Marc Zanello, Alexandre Roux, Gilles Zah-Bi, Bénédicte Trancart, Eduardo Parraga, Myriam Edjlali, Arnault Tauziede-Espariat, Xavier Sauvageon, Tarek Sharshar, Catherine Oppenheim, Pascale Varlet, Edouard Dezamis, and Johan Pallud

OBJECTIVE

Functional-based resection under awake conditions had been associated with a nonnegligible rate of intraoperative and postoperative epileptic seizures. The authors assessed the incidence of intraoperative and early postoperative epileptic seizures after functional-based resection under awake conditions.

METHODS

The authors prospectively assessed intraoperative and postoperative seizures (within 1 month) together with clinical, imaging, surgical, histopathological, and follow-up data for 202 consecutive diffuse glioma adult patients who underwent a functional-based resection under awake conditions.

RESULTS

Intraoperative seizures occurred in 3.5% of patients during cortical stimulation; all resolved without any procedure being discontinued. No predictor of intraoperative seizures was identified. Early postoperative seizures occurred in 7.9% of patients at a mean of 5.1 ± 2.9 days. They increased the duration of hospital stay (p = 0.018), did not impact the 6-month (median 95 vs 100, p = 0.740) or the 2-year (median 100 vs 100, p = 0.243) postoperative Karnofsky Performance Status score and did not impact the 6-month (100% vs 91.4%, p = 0.252) or the 2-year (91.7 vs 89.4%, p = 0.857) postoperative seizure control. The time to treatment of at least 3 months (adjusted OR [aOR] 4.76 [95% CI 1.38–16.36], p = 0.013), frontal lobe involvement (aOR 4.88 [95% CI 1.25–19.03], p = 0.023), current intensity for intraoperative mapping of at least 3 mA (aOR 4.11 [95% CI 1.17–14.49], p = 0.028), and supratotal resection (aOR 6.24 [95% CI 1.43–27.29], p = 0.015) were independently associated with early postoperative seizures.

CONCLUSIONS

Functional-based resection under awake conditions can be safely performed with a very low rate of intraoperative and early postoperative seizures and good 6-month and 2-year postoperative seizure outcomes. Intraoperatively, the use of the lowest current threshold producing reproducible responses is mandatory to reduce seizure occurrence intraoperatively and in the early postoperative period.

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Radiographic growth rate as a predictor of aggressiveness of diffuse gliomas without 1p19q codeletion

Arthur Leclerc, Alexandre Roux, Angela Elia, Sophie Peeters, Oumaima Aboubakr, Aziz Bedioui, Martin Planet, Joseph Benzakoun, Giorgia Antonia Simboli, Arnault Tauziede-Espariat, Alessandro Moiraghi, Pascale Varlet, Fabrice Chrétien, Catherine Oppenheim, Marc Zanello, and Johan Pallud

OBJECTIVE

The 2021 WHO classification of CNS tumors has refined the definition of adult-type diffuse gliomas without 1p19q codeletion. Nevertheless, the aggressiveness of gliomas is based exclusively on histomolecular criteria performed on a limited sample of the tumor. The authors aimed to assess whether the spontaneous radiographic tumor growth rate is associated with tumor aggressiveness and allows preoperative identification of malignancy grade of adult-type diffuse gliomas without 1p19q codeletion.

METHODS

The authors retrospectively reviewed the records of adult patients harboring a newly diagnosed supratentorial diffuse glioma without 1p19q codeletion, with available preoperative MRI follow-up between January 2008 and April 2022. The spontaneous radiographic tumor growth rate was quantified by tumor volume segmentation and regression of the evolution of the mean tumor diameter over time and was compared with clinical, imaging, histomolecular, and survival data.

RESULTS

Ninety-six patients were included. The spontaneous radiographic tumor growth rates (mean 17.8 ± 38.8 mm/year, range 0–243.5 mm/year) significantly varied according to IDH1/2 mutation (p < 0.001), grade of malignancy (p < 0.001), and presence of microvascular proliferation (p < 0.001). The spontaneous radiographic tumor growth rate allowed preoperative identification of high-grade cases: 100% of grade 3 and 4 IDH-mutant diffuse astrocytomas had a spontaneous radiographic tumor growth rate ≥ 8.0 mm/year, and 100% of IDH–wild-type glioblastomas had a spontaneous radiographic tumor growth rate ≥ 42.0 mm/year. A spontaneous radiographic growth rate ≥ 8.0 mm/year was an independent predictor of shorter progression-free (p = 0.014) and overall (p = 0.007) survival. A mitotic count threshold ≥ 4 mitoses was the optimal threshold for identifying aggressive IDH-mutant astrocytomas based on spontaneous radiographic tumor growth.

CONCLUSIONS

The spontaneous radiographic tumor growth rates could be used as an additional tool to preoperatively screen tumor aggressiveness of adult-type diffuse gliomas without 1p19q codeletion.