Expanding indications for the extended endoscopic endonasal approach to hypothalamic gliomas: preliminary report

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>In the last decade the indications for the endoscopic endonasal approach have been progressively expanded to include lesions that have not been traditionally considered amenable to resection through the transsphenoidal route. In this study, the authors analyze their experience with hypothalamic gliomas treated via the endoscopic endonasal approach.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Consecutive cases of hypothalamic gliomas treated since 2007 via an endoscopic endonasal approach were reviewed. Preoperative and postoperative neuroimaging as well as endocrinological, neurological, and visual symptoms were analyzed to assess the surgical outcome. Signs and symptoms of hypothalamic dysfunction including body mass index (BMI), memory, sleep-wake rhythm, and polyphagia were prospectively collected pre- and postoperatively to assess hypothalamic function. Quality of life was evaluated using the Katz scale.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>In the initial phase the endoscopic endonasal approach was adopted in 3 cases with a palliative intent, to obtain a biopsy sample or for debulking of the mass followed by radio- or chemotherapy. In 2 later cases it was successfully adopted to achieve gross-total tumor resection. Complications consisted of 2 postoperative CSF leaks, which required an endoscopic endonasal reintervention. Visual deficit improved in 3 cases and normalized in the other 2. Four patients developed diabetes insipidus, and 3 an anterior panhypopituitarism. All patients had a moderate increase in BMI. No patients presented with any other signs of hypothalamic damage, and their quality of life at follow-up is normal.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Despite the limitations of a short follow-up and small sample, the authors’ early experience with the endoscopic endonasal approach has revealed it to be a direct, straightforward, and safe approach to third ventricle astrocytomas. It allowed the authors to perform tumor resection with the same microsurgical technique: dissecting the tumor with 2 hands, performing a central debulking, and controlling the bleeding with bipolar coagulation. The main limitations were represented by some anatomical conditions, such as the position of the chiasm and the anterior communicating artery complex and, finally, by the challenge of watertight plastic repair. To definitively evaluate the role of this approach in hypothalamic gliomas, a comparison with transcranial series would be necessary, but due to the rarity of these cases such a study is still lacking. The authors observed that more aggressive surgery is associated with a worse endocrinological outcome; thus they consider it to be an open question (in particular in prepubertal patients) whether radical removal is an advisable goal for hypothalamic gliomas.</jats:p></jats:sec>

Operative Procedure in a Suprasellar Paediatric Lesion of the Optic Chiasm with Hydrocephalus Caused by a Papillary Glioneuronal Tumour

“…The recommended practice is to open the arachnoid over the part of the tumour that is visible. If the surgery is performed in order to obtain a biopsy sample, a Weil forceps is used to remove small fragments, while haemostasis is achieved with bipolar coagulation [4]. For tumour removal, hydro-dissection seemed particularly useful for exploring and removing residues in our case.…”

“…For a complete tumour resection combined with minimal post-surgical morbidity, ExTSS allows us to have maximum exposure of the operating field and to identify the anatomical relationships between the tumour and surrounding structures. We followed a similar technique to that described by Zoli et al [4]. Zoli et al [4] highlighted that when considering an endoscopic endonasal approach to the third ventricle, it is crucial to ascertain the position of the chiasm relative to the tumour and the tuberculum.…”

“…Prior to surgery, it is crucial to obtain high-resolution imaging studies and to analyse them carefully. Moreover, considerable experience and acumen are necessary in order to achieve aggressive tumour resection without compromising function [4]. In some cases, a CT is performed to give complementary information, for example, in craniopharyngiomas (CP), it is helpful to see the calcifications.…”

Pediatric Optic Pathway/Hypothalamic Glioma

“…Zoli et al reported that this approach is useful in hypothalamic gliomas for central debulking and even gross-total removal of the tumor. 38) Their initial experience may suggest that the endoscopic endonasal approach may allow the surgeon to remove the tumor with a microsurgical technique as well. However, their study includes only a small number of patients and the method remains only a possibility at this time.…”

Calvian Endo-pen: New Coagulation Forceps for Endoscopic Endonasal Transsphenoidal Surgery

“…In addition to typical skull base tumors, such as pituitary adenomas, chordomas, craniopharyngiomas, or meningiomas, resection of hypothalamic gliomas was described. 8 In all these procedures surgical hemostasis is achieved by bipolar coagulation. There are many prerequisites for bipolar coagulations forceps in general, but a few more are added during EETS.…”