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Tiit Mathiesen, Per Grane, Lars Lindgren and Christer Lindquist

✓ A continuous follow-up review of colloid cysts including aspects of natural history and evaluation of treatment options is necessary to optimize individual treatment. Thirty-seven consecutive patients with colloid cyst of the third ventricle seen at Karolinska Hospital between 1984 and 1995 were reviewed. Five patients were admitted in a comatose state, and two died despite emergency ventriculostomy. Three had recurrent cysts following previous aspiration procedure. During the study period, patients underwent a total of 10 ventriculostomies, 10 aspirations, 26 microsurgical operations, and two shunt operations.

Twenty-four of 26 microsurgical operations were transcallosal and two were transcortical. Twenty-four operations (22 transcallosal and two transfrontal approaches) without permanent morbidity were performed by four surgeons. Transient memory deficit from forniceal traction was noted in 26%. The remaining two transcallosal operations, which led to permanent morbidity or mortality, were performed by two different surgeons. Aspiration of cysts performed by four different surgeons carried a 40% risk of transient memory deficit (10% permanent) and an 80% recurrence rate. One patient was found to be cured on radiological studies obtained at the 5-year follow-up review.

Seven cysts were followed by means of radiological studies with no treatment for 6 to 37 months. Five of these cysts grew, indicating that younger patients with colloid cysts will probably need surgical treatment.

The main causes of unfavorable results were: 1) failure to investigate symptoms that proved fatal; 2) subtotal resection; and 3) surgical complications. Transcallosal microsurgery produced excellent results when performed by experienced surgeons. A colloid cyst of the foramen of Monro is a disease that should be detected before permanent neurological damage has occurred. Permanent morbidity or mortality should not be accepted in modern series of third ventricle colloid cysts.

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Bengt Karlsson, Kaj Ericson, Lars Kihlström and Per Grane

✓ In a series of 22 patients treated with gamma knife surgery for brain metastasis in whom biopsy specimens were obtained via stereotactically guided procedures before the radiosurgical treatment was administered, two cases with evidence of tumor seeding were observed on subsequent follow-up examination. These findings contradict the opinion that the risk for tumor spread after a biopsy is negligible. This evidence may be explained by the fact that radiosurgery leaves the surrounding tissue unaffected by the treatment, which results in preserved anatomy around the tumor. This allows the surgeon to define the previous biopsy channel and, consequently, whether a distant tumor recurrence may have resulted from tumor seeding related to the biopsy procedure. Additionally, radiosurgical treatment leaves tumor cells that may have been spread as a result of the biopsy unaffected, giving them the potential to divide and develop into a new tumor. In contrast to this, microsurgical removal of the tumor will affect the surrounding tissue, making it impossible to detect whether new metastases are resulting from seeding. Furthermore, conventional fractionated radiation therapy will sterilize tumor cells that may have spread, thus making it impossible for these cells to regrow.

The authors conclude that the risk for tumor seeding following a stereotactically guided biopsy may be higher than previously assumed.

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Tiit Mathiesen, Per Grane, Christer Lindquist and Hans von Holst

✓ Sixteen patients treated between 1969 and 1989 for a colloid cyst of the foramen of Monro by stereotactically guided aspiration (not stereotactic extirpation) were evaluated to assess the long-term outcome of the procedure. Thirteen of these patients required reoperation due to an acute comatose state, failure to achieve permanent reduction of the cyst, or symptomatic hydrocephalus. Of these 13, six were treated twice and two were treated three times by stereotactic aspiration. Five patients underwent microsurgical extirpation and three had a shunt placed following a failed aspiration. Failure of the first procedure was detected within the first 2 months after treatment in eight patients and after more than 6 years in seven. Following stereotactic aspiration, three patients experienced a temporary memory deficit and confusion and one patient suffered a central pain syndrome. Eleven of the 26 procedures were followed by a recurrence 6 to 15 years after treatment; seven recurrent cysts were detected after more than 8 years. Of the patients with recurrences, three did not undergo repeat surgery but showed an increase in cyst size at the latest follow-up examination. It is suggested that radical removal by open or stereotactically guided microsurgery is the method of choice since stereotactic aspiration fails to offer a radical or permanent treatment for colloid cysts of the third ventricle.

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