Radiotherapy (RT) is one of the cornerstones in the current treatment paradigm for glioblastoma (GBM). However, little has changed in the management of GBM since the establishment of the current protocol in 2005, and the prognosis remains grim. Radioresistance is one of the hallmarks for treatment failure, and different therapeutic strategies are aimed at overcoming it. Among these strategies, nanomedicine has advantages over conventional tumor therapeutics, including improvements in drug delivery and enhanced antitumor properties. Radiosensitizing strategies using nanoparticles (NP) are actively under study and hold promise to improve the treatment response. We aim to describe the basis of nanomedicine for GBM treatment, current evidence in radiosensitization efforts using nanoparticles, and novel strategies, such as preoperative radiation, that could be synergized with nanoradiosensitizers.
OBJECTIVE Minimally invasive endoscope-assisted approaches to the anterior skull base offer an alternative to traditional open craniotomies. Given the restrictive operative corridor, appropriate case selection is critical for success. In this paper, the authors present the results of three different minimal access approaches to meningiomas of the anterior and middle fossae and examine the differences in the target areas considered appropriate for each approach, as well as the outcomes, to determine whether the surgical goals were achieved. METHODS A consecutive series of the endoscopic endonasal approach (EEA), supraorbital approach (SOA), or transorbital approach (TOA) for newly diagnosed meningiomas of the anterior and middle fossa skull base between 2007 and 2022 were examined. Probabilistic heat maps were created to display the distribution of tumor volumes for each approach. Gross-total resection (GTR), extent of resection, visual and olfactory outcomes, and postoperative complications were assessed. RESULTS Of 525 patients who had meningioma resection, 88 (16.7%) were included in this study. EEA was performed for planum sphenoidale and tuberculum sellae meningiomas (n = 44), SOA for olfactory groove and anterior clinoid meningiomas (n = 36), and TOA for spheno-orbital and middle fossa meningiomas (n = 8). The largest tumors were treated using SOA (mean volume 28 ± 29 cm3), followed by TOA (mean volume 10 ± 10 cm3) and EEA (mean volume 9 ± 8 cm3) (p = 0.024). Most cases (91%) were WHO grade I. GTR was achieved in 84% of patients (n = 74), which was similar to the rates for EEA (84%) and SOA (92%), but lower than that for TOA (50%) (p = 0.002), the latter attributable to spheno-orbital (GTR: 33%) not middle fossa (GTR: 100%) tumors. There were 7 (8%) CSF leaks: 5 (11%) from EEA, 1 (3%) from SOA, and 1 (13%) from TOA (p = 0.326). All resolved with lumbar drainage except for 1 EEA leak that required a reoperation. CONCLUSIONS Minimally invasive approaches for anterior and middle fossa skull base meningiomas require careful case selection. GTR rates are equally high for all approaches except for spheno-orbital meningiomas, where alleviation of proptosis and not GTR is the primary goal of surgery. New anosmia was most common after EEA.
The neuroendoscopic transorbital approach (TOA) has recently been popularized as a minimal access approach to areas of the skull base that are not easily reached with endonasal or supraorbital approaches. 1,2 Studies have demonstrated the feasibility of TOA as a highly versatile alternative to larger transcranial approaches for achieving maximal safe resection, particularly in the medial middle fossa. [3][4][5][6][7][8][9] Overall, the TOA has shown lower morbidity than traditional skull base procedures, faster postoperative healing, improved postoperative pain scores, and shorter hospitalizations. 5,[10][11][12] Advantages include smaller skin incision, less cosmetic deformity, reduced risk of frontalis nerve palsy, temporalis muscle wasting, brain retraction, and less damage to surrounding neurovascular structures. 6 Meningiomas arising from the middle fossa floor are uncommon and importantly distinct entities from those arising from convexity dura, sphenoid wing, or tentorium. These skull base tumors arise lateral to the cavernous sinus wall, posterior to the sphenoid wing, and medial to the frontotemporal convexity. A variety of approaches have been described, including frontotemporal (pterional), temporal, subtemporal, transzygomatic, or oribitozygomatic craniotomies; however, these approaches often require extensive frontal and temporal lobe retraction, and in some cases, corticectomy is needed to achieve gross total resection. 9,12-14 For these tumors, the TOA offers an anterior corridor, down the long axis of the tumor that obviates the need for frontal/temporal lobe retraction and eliminates or minimizes cortical resection. Here, we present the first reported operative video detailing the advantages of the TOA for resection of a meningioma arising from the middle fossa floor and lateral wall of the cavernous sinus. The patient consented to the procedure. The participants and any identifiable individuals consented to publication of his/her image.
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