Laser interstitial thermal therapy followed by minimal-access transsulcal resection for the treatment of large and difficult to access brain tumors

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Laser interstitial thermal therapy (LITT), sometimes referred to as “stereotactic laser ablation,” has demonstrated utility in a subset of high-risk surgical patients with difficult to access (DTA) intracranial neoplasms. However, the treatment of tumors larger than 10 cm<jats:sup>3</jats:sup> is associated with suboptimal outcomes and morbidity. This may limit the utility of LITT in dealing with precisely those large or deep tumors that are most difficult to treat with conventional approaches. Recently, several groups have reported on minimally invasive transsulcal approaches utilizing tubular retracting systems. However, these approaches have been primarily used for intraventricular or paraventricular lesions, and subtotal resections have been reported for intraparenchymal lesions. Here, the authors describe a combined approach of LITT followed by minimally invasive transsulcal resection for large and DTA tumors.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The authors retrospectively reviewed the results of LITT immediately followed by minimally invasive, transsulcal, transportal resection in 10 consecutive patients with unilateral, DTA malignant tumors &gt; 10 cm<jats:sup>3</jats:sup>. The patients, 5 males and 5 females, had a median age of 65 years. Eight patients had glioblastoma multiforme (GBM), 1 had a previously treated GBM with radiation necrosis, and 1 had a melanoma brain metastasis. The median tumor volume treated was 38.0 cm<jats:sup>3</jats:sup>.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>The median tumor volume treated to the yellow thermal dose threshold (TDT) line was 83% (range 76%–92%), the median tumor volume treated to the blue TDT line was 73% (range 60%–87%), and the median extent of resection was 93% (range 84%–100%). Two patients suffered mild postoperative neurological deficits, one transiently. Four patients have died since this analysis and 6 remain alive. Median progression-free survival was 280 days, and median overall survival was 482 days.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Laser interstitial thermal therapy followed by minimally invasive transsulcal resection, reported here for the first time, is a novel option for patients with large, DTA, malignant brain neoplasms. There were no unexpected neurological complications in this series, and operative characteristics improved as surgeon experience increased. Further studies are needed to elucidate any differences in survival or quality of life metrics.</jats:p></jats:sec>

The Association Between Common Clinical Characteristics and Postoperative Morbidity and Overall Survival in Patients with Glioblastoma

“…Our results show that the complexity of medical comorbidities (as measured by the CCI) and the levels and stability of systolic blood pressure and blood glucose significantly predict postoperative morbidities in GBM patients. Previous studies reported associations between the extent of tumor resection and resection methods and postoperative complications . Our study results also concurred with the current literature that postoperative complications may negatively affect the delivering of adjuvant treatments for GBM patients .…”

Combined Surgical Resection and Laser Interstitial Thermal Therapy for Glioblastoma: Technical Note

“…Similarly, Wright et al described the efficacy of transsulcal resection followed by LITT for optimization of EOR for large difficult-to-access intracranial neoplasms. 32 A combined approach to operative reduction of tumor burden can likewise achieve sufficient ablation/ resection in surgical candidates with partially deep-seated GBM, particularly for patients in whom a > 78% threshold of tumor resection/ablation cannot be achieved by resection or LITT alone.…”

Management of Intracranial Metastatic Disease With Laser Interstitial Thermal Therapy

“…Post-LITT edema may potentially be more fulminant than post-craniotomy edema due to the lack of any decompression with LITT alone. A prolonged steroid course (2–3 weeks) or a minimally invasive craniotomy and limited resection immediately following LITT of larger tumors may represent strategies to mitigate this phenomenon ( 20 , 21 ).…”