Expanded Transsphenoidal Trans-Lamina Terminalis Approach to Tumors Extending Into the Third Ventricle: Technique Notes and a Single Institute Experience

Abstract

ObjectThe trans lamina terminalis approach (TLTA) has been described as a way to remove third ventricular tumors. The aim of this paper was to analyze the feasible outcomes of TLTA applied to tumors extending into the third ventricle in our institute.MethodsSuprasellar tumors (n = 149) were treated by the extended endonasal approach from September 2019 to December 2020 in Beijing Tiantan Hospital. Eleven of the tumors were treated by TLTA or TLTA via the trans-chiasm-pituitary corridor (TCPC). The surgical technique notes of TLTA were described and indications and outcomes of the approach were analyzed.ResultsThere were 11 patients enrolled in the study, six with papillary craniopharyngiomas, two with adamantinomatous craniopharyngiomas, one with a germinal cell tumor (GCT), one with cavernous malformation and one with chordoid glioma. Four of the patients received a radical resection by TLTA alone, while seven of them received TLTA via the TCPC. Gross total resection was achieved in eight patients (72.7%), and partial resection in three patients (27.3%). Visual function was improved in four of the 11 patients (36.4%), was unchanged in five patients (45.5%), and deteriorated in two patients (18.2%). New-onset hypopituitarism occurred in seven patients (63.3%) and new-onset diabetes insipidus occurred in two patients (18.2%). Electrocyte imbalance were observed in six patients (54.5%) at post-operative week 2. There were no surgery-related deaths or cerebrospinal fluid leaks. Postoperative intracranial infection was observed in one patient (9.1%), and during the follow-up period, tumor recurrence occurred in one patient (9.1%).ConclusionThe expanded TLTA provides a feasible suprachiasm corridor to remove tumors extending into the third ventricle, especially for craniopharyngiomas. Sound understanding of the major strengths and limitations of this approach, as well as strategies for complication avoidance, is necessary for its safe and effective application.

Craniopharyngioma and the Third Ventricle: This Inescapable Topographical Relationship

“…The optimal surgical view of the brain undersurface obtained through the EEA unequivocally show the ballooned and stretched infundibulum wrapping around the lower pole of these lesions, which stay hidden within the 3V chamber ( 13 , 14 , 40 , 46 ). In 5 out of 6 strict CP cases in the series by Cao (83%) and 6 out of 9 in Zhou’s paper (66%), the lesions corresponded to the papillary type, percentages that fit well with the 82% rate of papillary lesions found in our systematic review ( 20 , 21 , 30 ). Depoujarny observed preoperatively symptoms related to hypothalamus dysfunction in 60% of their 3V CP patients overall, the most prominent being memory loss (25%), increased sleepiness (20%) and abnormal uninhibited behaviors, including hyperphagia (36%) ( 18 ).…”

“…More recently, we were able to compile and analyze comprehensively the cohort of CPs with a verified strictly 3V topography (n=245), as well as the historical cohort of well-described papillary CPs published in the medical literature (n= 350) ( 30 , 31 ). Although the strictly 3V topography has remained controversial throughout history, some authors considering it an exceptional, ectopic location ( 32 ), while others even argue over its validity ( 33 ), the surgical series by Depoujarny ( 18 ), Cao ( 20 ), and Zhou ( 21 ) contribute to verify this particularly challenging location, confirming the anatomical integrity of the 3VF found in numerous strictly 3V CPs in prior studies (see Table 1 ) ( 34 – 49 ). The optimal surgical view of the brain undersurface obtained through the EEA unequivocally show the ballooned and stretched infundibulum wrapping around the lower pole of these lesions, which stay hidden within the 3V chamber ( 13 , 14 , 40 , 46 ).…”

“…Even more importantly, a 3V-centered scheme also helps to predict the extension and strength of the CP-hypothalamic attachment, which largely determines the risk of radical removal ( 12 , 26 , 27 ). The works by Deopujarny et al., and Cao et al., whose surgical series encompass more than 800 CPs, have verified to a large extent our topographical concepts ( 18 , 20 ). The attention that should be given to the hypothalamic symptoms caused by 3V CPs and the types of CP-hypothalamus attachment associated with this topography is the main message we wish to emphasize from these studies published in Frontiers in Oncology .…”

“…and Zhou et al. papers ( 20 , 21 ). Potentially, a paradigm shift in the surgical method of choice to remove 3V CPs might occur from these studies, from the dominant use of transcranial-transventricular routes to a generalized use of the EEEA plus TLT ( 5 , 22 ).…”

“…The more accurate assessment of the CP-3VF relationship achieved through the EEA over these open craniotomy-transventricular procedures, has changed the surgical paradigm towards the standard use of this approach to safely remove CPs involving the 3V ( 7 , 8 , 13 , 40 ). Now, the expertise gained with the use of the EEEA allowed pituitary surgeons to incorporate the translaminar terminalis corridor to the technique to successfully remove strictly 3V CPs without mortality, as shown in the series by Cao (87.5% gross total removal, GTR) and Zhou (89% GTR) ( 20 , 21 ). Accordingly, should this combination of EEEA plus TLT technique be considered the definitive method capable of overcoming the impediment of CP adherence and/or infiltration into the hypothalamus intrinsic to intra-3V development?…”