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Regrowth factors of WHO grade I skull base meningiomas following incomplete resection

Hun Ho Park, Jihwan Yoo, Hyeong-Cheol Oh, Yoon Jin Cha, Se Hoon Kim, Chang-Ki Hong, and Kyu-Sung Lee

OBJECTIVE

The role of adjuvant radiation therapy following incomplete resection of WHO grade I skull base meningiomas (SBMs) is controversial, and little is known regarding the behavior of residual tumors. The authors investigated the factors that influence regrowth of residual WHO grade I SBMs following incomplete resection.

METHODS

From 2005 to 2019, a total of 710 patients underwent surgery for newly diagnosed WHO grade I SBMs. The data of 115 patients (16.2%) with incomplete resection and without any adjuvant radiotherapy were retrospectively assessed during a mean follow-up of 78 months (range 27–198 months). Pre-, intra-, and postoperative clinical and molecular factors were analyzed for relevance to regrowth-free survival (RFS).

RESULTS

Eighty patients were eligible for analysis, excluding those who were lost to follow-up (n = 10) or had adjuvant radiotherapy (n = 25). Regrowth occurred in 39 patients (48.7%), with a mean RFS of 50 months (range 3–191 months). Significant predictors of regrowth were Ki-67 proliferative index (PI) ≥ 4% (p = 0.017), Simpson resection grades IV and V (p = 0.005), and invasion of the cavernous sinus (p = 0.027) and Meckel’s cave (p = 0.027). After Cox regression analysis, only Ki-67 PI ≥ 4% (hazard ratio [HR] 9.39, p = 0.003) and Simpson grades IV and V (HR 8.65, p = 0.001) showed significant deterioration of RFS. When stratified into 4 scoring groups, the mean RFSs were 110, 70, 38, and 9 months for scores 1 (Ki-67 PI < 4% and Simpson grade III), 2 (Ki-67 PI < 4% and Simpson grades IV and V), 3 (Ki-67 PI ≥ 4% and Simpson grade III), and 4 (Ki-67 PI ≥ 4% and Simpson grades IV and V), respectively. RFS was significantly longer for score 1 versus scores 2–4 (p < 0.01). Tumor consistency, histology, location, peritumoral edema, vascular encasement, and telomerase reverse transcriptase promoter mutation had no impact on regrowth.

CONCLUSIONS

Ki-67 PI and Simpson resection grade showed significant associations with RFS for WHO grade I SBMs following incomplete resection. Ki-67 PI and Simpson resection grade could be utilized to stratify the level of risk for regrowth.

In Journal of Neurosurgery Volume 137: Issue 6 (Dec 2022)

Free access

Extended endoscopic transorbital approach with superior-lateral orbital rim osteotomy: cadaveric feasibility study and clinical implications (SevEN-007)

*Jaejoon Lim, Kyoung Su Sung, Woohyun Kim, Jihwan Yoo, In-Ho Jung, Seonah Choi, Seung Hoon Lim, Tae Hoon Roh, Chang-Ki Hong, and Ju Hyung Moon

OBJECTIVE

The endoscopic transorbital approach (ETOA) has been developed, permitting a new surgical corridor. Due to the vertical limitation of the ETOA, some lesions of the anterior cranial fossa are difficult to access. The ETOA with superior-lateral orbital rim (SLOR) osteotomy can achieve surgical freedom of vertical as well as horizontal movement. The purpose of this study was to confirm the feasibility of the ETOA with SLOR osteotomy.

METHODS

Anatomical dissections were performed in 5 cadaveric heads with a neuroendoscope and neuronavigation system. ETOA with SLOR osteotomy was performed on one side of the head, and ETOA with lateral orbital rim (LOR) osteotomy was performed on the other side. After analysis of the results of the cadaveric study, the ETOA with SLOR osteotomy was applied in 6 clinical cases.

RESULTS

The horizontal and vertical movement range through ETOA with SLOR osteotomy (43.8° ± 7.49° and 36.1° ± 3.32°, respectively) was improved over ETOA with LOR osteotomy (31.8° ± 5.49° and 23.3° ± 1.34°, respectively) (p < 0.01). Surgical freedom through ETOA with SLOR osteotomy (6025.1 ± 220.1 mm3) was increased relative to ETOA with LOR osteotomy (4191.3 ± 57.2 mm3) (p < 0.01); these values are expressed as the mean ± SD. Access levels of ETOA with SLOR osteotomy were comfortable, including anterior skull base lesion and superior orbital area. The view range of the endoscope for anterior skull base lesions was increased through ETOA with SLOR osteotomy. After SLOR osteotomy, the space for moving surgical instruments and the endoscope was widened. Anterior clinoidectomy could be achieved successfully using ETOA with SLOR osteotomy.

The authors performed ETOA with SLOR osteotomy in 6 cases of brain tumor. In all 6 cases, complete removal of the tumor was successfully accomplished. In the 3 cases of anterior clinoidal meningioma, anterior clinoidectomy was performed easily and safely, and manipulation of the extended dural margin and origin dura mater was possible. There was no complication related to this approach.

CONCLUSIONS

The authors evaluated the clinical feasibility of ETOA with SLOR osteotomy based on a cadaveric study. ETOA with SLOR osteotomy could be applied to more diverse disease groups that do not permit conventional ETOA or to cases in which surgical application is challenging. ETOA with SLOR osteotomy might serve as an opportunity to broaden the indication for the ETOA.

In Journal of Neurosurgery Volume 137: Issue 1 (Jul 2022)

Free access

Endoscopic transorbital approach to the insular region: cadaveric feasibility study and clinical application (SevEN-005)

Eui Hyun Kim, Jihwan Yoo, In-Ho Jung, Ji Woong Oh, Ju-Seong Kim, Jin Sook Yoon, Ju Hyung Moon, Seok-Gu Kang, Jong Hee Chang, and Tae Hoon Roh

OBJECTIVE

The insula is a complex anatomical structure. Accessing tumors in the insula remains a challenge due to its anatomical complexity and the high chance of morbidity. The goal of this study was to evaluate the feasibility of an endoscopic transorbital approach (ETOA) to the insular region based on a cadaveric study.

METHODS

One cadaveric head was used to study the anatomy of the insula and surrounding vessels. Then, anatomical dissection was performed in 4 human cadaveric heads using a dedicated endoscopic system with the aid of neuronavigation guidance. To assess the extent of resection, CT scanning was performed before and after dissection. The insular region was directly exposed by a classic transcranial approach to check the extent of resection from the side with a classic transcranial approach.

RESULTS

The entire procedure consisted of two phases: an extradural orbital phase and an intradural sylvian phase. After eyelid incision, the sphenoid bone and orbital roof were extensively drilled out with exposure of the frontal and temporal dural layers. After making a dural window, the anterior ramus of the sylvian fissure was opened and dissected. The M2 segment of the middle cerebral artery (MCA) was identified and traced posterolaterally. A small corticectomy was performed on the posterior orbital gyrus. Through the window between the lateral lenticulostriate arteries and M2, the cortex and medulla of the insula were resected in an anteroposterior direction without violation of the M2 segment of the MCA or its major branches. When confirmed by pterional craniotomy, the sylvian fissure and the MCA were found to be anatomically preserved. After validation of the feasibility and safety based on a cadaveric study, the ETOA was successfully performed in a patient with a high-grade glioma (WHO grade III) in the right insula.

CONCLUSIONS

The transorbital route can be considered a potential option to access tumors located in the insula. Using an ETOA, the MCA and its major branches were identified and preserved while removal was performed along the long axis of the insula. In particular, lesions in the anterior part of the insula are most benefited by this approach. Because this approach was implemented in only one patient, additional discussion and further verification is required.

In Journal of Neurosurgery Volume 135: Issue 4 (Oct 2021)

Free access

Patterns of recurrence according to the extent of resection in patients with IDH–wild-type glioblastoma: a retrospective study

Jihwan Yoo, Seon-Jin Yoon, Kyung Hwan Kim, In-Ho Jung, Seung Hoon Lim, Woohyun Kim, Hong In Yoon, Se Hoon Kim, Kyoung Su Sung, Tae Hoon Roh, Ju Hyung Moon, Hun Ho Park, Eui Hyun Kim, Chang-Ok Suh, Seok-Gu Kang, and Jong Hee Chang

OBJECTIVE

In glioblastoma (GBM) patients, controlling the microenvironment around the tumor using various treatment modalities, including surgical intervention, is essential in determining the outcome of treatment. This study was conducted to elucidate whether recurrence patterns differ according to the extent of resection (EOR) and whether this difference affects prognosis.

METHODS

This single-center study included 358 eligible patients with histologically confirmed isocitrate dehydrogenase (IDH)–wild-type GBM from November 1, 2005, to December 31, 2018. Patients were assigned to one of three separate groups according to EOR: supratotal resection (SupTR), gross-total resection (GTR), and subtotal resection (STR) groups. The patterns of recurrence were classified as local, marginal, and distant based on the range of radiation. The relationship between EOR and recurrence pattern was statistically analyzed.

RESULTS

Observed tumor recurrence rates for each group were as follows: SupTR group, 63.4%; GTR group, 75.3%; and STR group, 80.5% (p = 0.072). Statistically significant differences in patterns of recurrences among groups were observed with respect to local recurrence (SupTR, 57.7%; GTR, 76.0%; STR, 82.8%; p = 0.036) and distant recurrence (SupTR, 50.0%; GTR, 30.1%; STR, 23.2%; p = 0.028). Marginal recurrence showed no statistical difference between groups. Both overall survival and progression-free survival were significantly increased in the SupTR group compared with the STR and GTR groups (p < 0.0001).

CONCLUSIONS

In this study, the authors investigated the association between EOR and patterns of recurrence in patients with IDH–wild-type GBM. The findings not only show that recurrence patterns differ according to EOR but also provide clinical evidence supporting the hypothesized mechanism by which distant recurrence occurs.

In Journal of Neurosurgery Volume 137: Issue 2 (Aug 2022)

Free access

Immediate postoperative measurement of thyroid-stimulating hormone as an early predictor of remission in thyroid-stimulating hormone–secreting pituitary adenomas

Soo Heon Kim, Cheol Ryong Ku, Minkyun Na, Jihwan Yoo, Woohyun Kim, In-Ho Jung, Kyung Won Kim, Ju Hyung Moon, Daham Kim, Eun Jig Lee, Sun Ho Kim, and Eui Hyun Kim

OBJECTIVE

Thyroid-stimulating hormone (TSH)–secreting pituitary adenoma (TSHoma) is a rare type of pituitary adenoma; thus, little is known about TSHomas. The purpose of this study was to analyze clinical characteristics and therapeutic outcomes of TSHomas based on a single-center experience. The authors also searched for reliable preoperative and early postoperative factors that could predict long-term endocrinological remission.

METHODS

The clinical, radiological, and pathological characteristics and surgical and endocrinological outcomes of 31 consecutive cases of TSHomas that were surgically treated between 2005 and 2017 were reviewed retrospectively. Preoperative factors were evaluated for their ability to predict long-term remission by comparing remission and nonremission groups. TSH and free thyroxine levels were measured at 2, 6, 12, 18, and 24 hours after surgery to determine whether they could predict long-term remission.

RESULTS

Gross-total removal of tumor was achieved in 28 patients (90.3%), and 26 patients (83.9%) achieved endocrinological remission by surgery alone based on long-term endocrinological follow-up (median 50 months, range 32–81 months). The majority of the tumors were solid (21/31, 67.7%), and en bloc resection was possible in 16 patients (51.6%). Larger tumor size and tumor invasion into cavernous sinus and sphenoid sinus were strong predictors of lower rates of endocrinological remission. Immediate postoperative TSH level at 12 hours after surgery was the strongest predictor, with a 0.62 μIU/mL cutoff. Postoperative complications included CSF rhinorrhea in one patient and epistaxis in another patient, who underwent additional surgical treatment for the complications.

CONCLUSIONS

Tumor size and extent are major prognostic factors for both extent of resection and endocrinological remission. The consistency of TSHomas was more likely to be solid, which makes extracapsular dissection more feasible. Long-term remission of TSHomas could be predicted even during the early postoperative period.

In Journal of Neurosurgery Volume 134: Issue 3 (Mar 2021)

Free access

Immediate postoperative measurement of thyroid-stimulating hormone as an early predictor of remission in thyroid-stimulating hormone–secreting pituitary adenomas

Soo Heon Kim, Cheol Ryong Ku, Minkyun Na, Jihwan Yoo, Woohyun Kim, In-Ho Jung, Kyung Won Kim, Ju Hyung Moon, Daham Kim, Eun Jig Lee, Sun Ho Kim, and Eui Hyun Kim

OBJECTIVE

Thyroid-stimulating hormone (TSH)–secreting pituitary adenoma (TSHoma) is a rare type of pituitary adenoma; thus, little is known about TSHomas. The purpose of this study was to analyze clinical characteristics and therapeutic outcomes of TSHomas based on a single-center experience. The authors also searched for reliable preoperative and early postoperative factors that could predict long-term endocrinological remission.

METHODS

The clinical, radiological, and pathological characteristics and surgical and endocrinological outcomes of 31 consecutive cases of TSHomas that were surgically treated between 2005 and 2017 were reviewed retrospectively. Preoperative factors were evaluated for their ability to predict long-term remission by comparing remission and nonremission groups. TSH and free thyroxine levels were measured at 2, 6, 12, 18, and 24 hours after surgery to determine whether they could predict long-term remission.

RESULTS

Gross-total removal of tumor was achieved in 28 patients (90.3%), and 26 patients (83.9%) achieved endocrinological remission by surgery alone based on long-term endocrinological follow-up (median 50 months, range 32–81 months). The majority of the tumors were solid (21/31, 67.7%), and en bloc resection was possible in 16 patients (51.6%). Larger tumor size and tumor invasion into cavernous sinus and sphenoid sinus were strong predictors of lower rates of endocrinological remission. Immediate postoperative TSH level at 12 hours after surgery was the strongest predictor, with a 0.62 μIU/mL cutoff. Postoperative complications included CSF rhinorrhea in one patient and epistaxis in another patient, who underwent additional surgical treatment for the complications.

CONCLUSIONS

Tumor size and extent are major prognostic factors for both extent of resection and endocrinological remission. The consistency of TSHomas was more likely to be solid, which makes extracapsular dissection more feasible. Long-term remission of TSHomas could be predicted even during the early postoperative period.

In Journal of Neurosurgery Publish Before Print