IntroductionThe management of retroinfundibular craniopharyngioma (CP) remains the ultimate challenge for both transsphenoidal and open transcranial surgery because of their anatomical location and proximity to vital neurovascular structures. In this report, we aim to describe the technique and feasibility of a novel approach, the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA), for resection of retroinfundibular CP.Case descriptionA 63-year-old women presented with progressive visual disturbance, polyuria, and spiritlessness of a 3-month duration. Imaging studies revealed a typical retroinfundibular CP containing solid and cystic components with calcification, which extended inferiorly in front of the brainstem and upward into the third ventricle. The EF-SCITA approach was attempted for resection of the tumor. During surgery, lateral prone positioning with upper flexion of the head and early CSF release allowed for download retraction of the cerebellum. This, in combination with tentorium incision, created a working corridor toward retrosellar and suprasellar spaces. This approach required working between neurovascular structures in the crural cistern, with tumor removal permitted in supra-oculomotor and infra-oculomotor spaces. After aspiration of the fluid contents through the supra-oculomotor triangle, the solid lesion was found tightly adhering to the distal part of the pituitary stalk, and subtotal resection was achieved for maintaining the integrity of pituitary function. In the immediate postoperative period, the patients exhibited oculomotor paralysis and was discharged with hormonal replacement therapy three weeks after operation. At her three-month follow-up appointment, she reported obvious vision improvement. Physical examinations showed partial alleviation of oculomotor paralysis. Pathological analyses confirmed the diagnosis of papillary CP.DiscussionThe purely EF-SCITA approach combines the advantages of both the posterolateral approach and endoscopic technique, which offers access to retrosellar and suprasellar spaces with seemingly low risks of postoperative morbidity. It would be a safe and effective alternative for the treatment of retroinfundibular CP, especially those with lateral extension to the temporal lobe or posterolateral extension to the petroclival region. Further observational studies in a larger cohort are urgently needed to assess the long-term efficacy of this minimal access approach.
IntroductionThe surgery of posterior clinoid meningioma (PCM) remains one of the most formidable challenges for neurosurgeons because of its location at great depth in the cranium and proximity to vital neurovascular structures. Herein, we aim to describe the technique and feasibility of a novel approach, the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA), for resection of this extremely rare entity.Case descriptionA 67-year-old women presented with gradually deteriorating vision in right eye for 6 months. Imaging examinations revealed a right-sided PCM, and the EF-SCITA approach was attempted for tumor resection. Tentorium incision allowed a working corridor toward the PCM in the ambient cistern through the supracerebellar space. During surgery, the infratentorial part of the tumor was found to compress the CN III and posterior cerebral artery medially and encase the CN IV laterally. Following debulking of the infratentorial tumor, the supratentorial part could be exposed and then excised, which had dense adhesions to the ICA and the initial part of the basal vein in front. After total tumor removal, its dural attachment was detected at the right posterior clinoid process and then coagulated under direct vision. The patient on follow-up at 1 month had improvement in visual acuity in right eye, with no restriction of extra-ocular movements.DiscussionEF-SCITA approach combines advantages of the posterolateral approach and endoscopic technique, allowing access to PCMs with seemingly low risks of postoperative morbidity. It would be a safe and effective alternative for resection of lesions in the retrosellar space.
Background: Liver transplantation (LT) is the optimal treatment option for hepatocellular carcinoma (HCC) meeting the Extended Liver Transplant Criteria (ELTC), but it is only offered for the minority. The optimal alternative strategy for HCCs beyond the Milan criteria (BMC) but meeting the ELTC, which is defined as modestly beyond the Milan criteria (MBMC) here, is a matter of concern. The aim of this study was to evaluate the survival benefits of LR compared with transarterial chemoembolization (TACE) for MBMC-HCCs. Methods: From January 2010 to October 2021, from fifteen Chinese hepatobiliary centres, 1110 MBMC-HCC patients with Child‒Pugh A who underwent LR (n = 424) or TACE (n = 686) were included. Overall survival (OS) benefit of LR versus TACE in the MBMC-HCC cohort was compared based on a propensity score matching (PSM) and was further validated in addition BMC-HCC cohorts selected according to other extended LT criteria (Asan criteria, up-to-7 criteria, French alpha-foetoprotein model and Metroticket 2.0 model). Results: Survival analyses in the MBMC-HCC cohort as well as other 4 BMC-HCC cohorts demonstrated that OS was significantly longer in the LR group than that in the TACE group (all log-rank P < 0.001). After a 1:1 PSM in the MBMC-HCC cohort, multivariate analysis and subsequent subgroup analyses based on tumour burden and other important covariates further confirmed the robust survival advantage of LR compared to TACE. Conclusions: LR rather than TACE is highly recommended as the preferred alternative for potential LT candidates with MBMC-HCC regardless of tumor burden.
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