Recent technological advances in pediatric brain tumor surgery

Abstract

X-rays and ventriculograms were the first imaging modalities used to localize intracranial lesions including brain tumors as far back as the 1880s. Subsequent advances in preoperative radiological localization included computed tomography (CT; 1971) and MRI (1977). Since then, other imaging modalities have been developed for clinical application although none as pivotal as CT and MRI. Intraoperative technological advances include the microscope, which has allowed precise surgery under magnification and improved lighting, and the endoscope, which has improved the treatment of hydrocephalus and allowed biopsy and complete resection of intraventricular, pituitary and pineal region tumors through a minimally invasive approach. Neuronavigation, intraoperative MRI, CT and ultrasound have increased the ability of the neurosurgeon to perform safe and maximal tumor resection. This may be facilitated by the use of fluorescing agents, which help define the tumor margin, and intraoperative neurophysiological monitoring, which helps identify and protect eloquent brain.

Pediatric Central Nervous System Tumors: State-of-the-Art and Debated Aspects

“…The history and vital role of the microscope in neuro-oncology surgery is well described elsewhere ( 11 ). It provides magnification and illumination, while allowing ergonomic movement to resect tumors with increased precision.…”

“…Furthermore, two recent Cochrane reviews have highlighted the lack of evidence for intraoperative neuro-navigation in terms of tumor resection and quality of life ( 13 , 14 ). While there is a lack of evidence in support of these techniques, there is no evidence against, and most surgeons would agree, this is an invaluable resource that is a mainstay of neuro-oncology surgery ( 11 ).…”

“…Nevertheless, ioMRI also has limitations: setup and running cost is a major prohibitory factor. A two room setup (as in our unit) can offset this, as the scanner can be used as a routine diagnostic tool when not in use intraoperatively ( 11 ). Another ioMRI suite option involves a ceiling mounted, moveable ioMRI scanner between two operating theaters ( 17 ).…”

“…Echogenicity of tumors can vary depending on their type, meaning ioUS may sometimes be of little use. Furthermore, the walls of the resection cavity may be hyperechoic which can lead to overestimation of tumor residual ( 11 ).…”

“…Orally administered 5-aminolevulinic acid (5-ALA) induces fluorescent porphyrin accumulation within certain tumors, which can be visualized with a modified microscope ( 34 ). The use of 5-ALA in pediatric patients is off label, but has been described ( 11 , 35 ). An RCT in adults found 5-ALA improved the extent of tumor resection and benefitted progression free survival ( 36 ), however evidence in pediatric surgery is limited.…”