Search

Background: Endoscopic third ventriculostomy (ETV) for obstructive hydrocephalus and endoscopic biopsy (EB) for intraventricular and paraventricular tumors are standard therapies because they are minimally invasive procedures. Although EB-associated hemorrhagic risk has been well documented, there have been only a few reports on hemorrhagic risk associated with ETV. We conducted a single-institution retrospective study on the incidence of hemorrhage secondary to EB and/or ETV., Methods: We retrospectively reviewed patient characteristics, procedure, pathological findings, and complications including hemorrhage of 100 patients with intraventricular and paraventricular tumors who underwent EB and/or ETV at our institution from 2000 to 2020., Results: EB/ETV combined surgery (combined group), EB-alone surgery (EB-alone group), and ETV-alone surgery (ETV-alone group) were performed in 44 (44%), 24 (24%), and 32 (32%) patients, respectively, and all procedures were successful. The rates of definitive and suggestive diagnoses in EB were 76.5% and 23.5%, respectively. Adverse events were observed in 6 patients. In the combined group, acute obstruction of the ETV stoma was observed in 1 patient and transient double vision was observed in 1 patient. Transient aqueductal stenosis/obstruction was observed in 2 patients in the EB-alone group. In the ETV-alone group, hemorrhage was observed in 2 patients; these patients developed intratumoral hemorrhage despite ETV-alone surgery. Subsequently, these 2 patients underwent tumor removal, and the histopathological diagnosis was atypical teratoid/rhabdoid tumor in both., Conclusions: For obstructive hydrocephalus with atypical teratoid/rhabdoid tumor, physicians must be aware of the risk of postoperative intratumoral hemorrhage after performing ETV., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The safety of transsphenoidal surgery (TSS) for pituitary adenoma in elderly populations is becoming a new topic in our aging society. However, previous studies did not focus on the surgical procedures in elderly patients. We attempted to clarify the safety of TSS and the influence of pseudocapsular resection in elderly patients with non-functioning pituitary adenoma (NFPA)., Methods: A total of 284 patients undergoing initial TSS for NFPA were categorized into two groups as follows: 1) Elderly group (n = 69; age ≥ 70 years); and 2) Younger group (n = 215; age < 70 years). Furthermore, all patients were newly divided into the two following categories: 1) Resected group (n = 121, with total pseudocapsule resection); and 2) Non-Resected group (n = 163, without total pseudocapsule resection). The main outcome measure was the incidence of perioperative complications and the rate of severe growth hormone deficiency (sGHD) after TSS., Results: There were no significant differences in the rates of perioperative complication between the Elderly and Younger groups. Furthermore, pseudocapsular resection did not increase the surgical risks in either group. On the other hand, sGHD only showed a significant improvement in the Younger group. The only factor predicting the new development of sGHD following TSS was an older age, not pseudocapsule resection., Conclusions: Aging does not increase the perioperative complications of TSS for NFPA; however, aging has a negative influence on the postoperative function of GH secretion. In contrast, pseudocapsular resection does not have any negative influence on the perioperative complications or postoperative function of GH secretion, even in elderly patients, based on the authors' experience and surgical technique., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: The term "growing teratoma syndrome (GTS)" has been used as follows: patients with germ cell tumor (GCT) who present with enlarging original/metastatic masses during or after appropriate systemic chemotherapy despite normalized serum markers. In other words, the definition of the term GTS is not fully established. We analyzed and reviewed our case series regarding GTS that developed after the treatment of central nervous system (CNS) nongerminoatous germ cell tumors (NGGCTs)., Methods: Our institutional review board approved this retrospective study. Between 2003 and 2018, we treated 16 patients (16 males; age ranging from 5.4 to 51.9 years, median 13.8) with CNS-NGGCT at our institution. We reviewed those patients and also reviewed the literature about GTS of CNS. We defined primary GTS (p-GTS) as the enlargement of cyst size and/or solid tumor occurred during treatment in the absence of marker elevation, and recurrent GTS (r-GTS) as the enlargement of teratoma after complete response of initial tumors., Results: Among 16 patients with CNS-NGGCT, we surgically confirmed mature/immature teratoma components in 15 patients. Two patients underwent surgical removal of tumor before neoadjuvant therapy, and among the rest 14 patients, 6 developed p-GTS, and 2 patients underwent salvage surgery during chemo-/chemoradiotherapy. Those with histologic diagnosis of immature teratoma during salvage surgery had a shorter interval from the initiation of chemoradiotherapy compared with mature teratoma (P < 0.05). One patient developed r-GTS. In the literature review, most of the p-GTS consisted of enlargement with the multicystic component. Histologic diagnosis of immature teratoma during salvage surgery was observed in earlier stages of chemoradiotherapy (P < 0.05, log-rank test). Previous history of p-GTS might be a risk factor of r-GTS., Conclusions: The incidence of p-GTS, enlargement of the cystic component during treatment, is not rare. Physicians need to be aware of this important phenomenon., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Xanthogranuloma is a chronic inflammatory mass characterized by cholesterol crystal deposition, which is rarely seen in the sellar region. The objective of this study is to identify the clinical features and cause of sellar xanthogranulomas., Methods: We retrospectively analyzed manifestation, radiographic, and endocrinologic presentation in 9 patients (7 women and 2 men) whom we had previously treated., Results: The patients were between 26 and 73 years of age (median, 56 years). The chief symptoms were visual symptoms in 3, polyuria in 3, headache in 4, and tiredness in 4 patients. Perimetry found visual field deficit in 6 patients. Anterior pituitary provocation tests disclosed impairment of ≥1 hormone in all patients: growth hormone in 8 patients and adrenocorticotropic hormone-cortisol axis in 8 patients. The lesions were suprasellar in 2 patients, intrasellar in 2 patients, and intrasuprasellar region in 5 patients. Three of the lesions were solid and 6 were single cystic to multicystic. Very low intensity area on T2-weighted magnetic resonance imaging was observed in 4 lesions. Postcontrast study performed in 7 lesions showed enhancement in solid parts or cyst walls. Surgical decompression improved visual disturbance in half of the patients but rarely improved hormonal deficits. Follow-up (median, 47 months) found no recurrence of the lesion. In addition to these 9 cases, we found 2 xanthogranulomatous lesions pathologically associated with ciliated epithelia, which also presented with severe hypopituitarism., Conclusions: Xanthogranuloma seems to be the last stage of the chronic inflammation affecting Rathke cleft cyst or craniopharyngioma presenting with severe anterior pituitary insufficiency., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Older patients are increasingly presenting for surgery with intracranial meningioma because of progress with diagnostic imaging and longer life expectancy. However, older patients have many problems, such as comorbidities and reduced physiological capacity reflected in the frailty index. This study examines the factors affecting clinical deterioration after surgery in older patients, particularly factors associated with frailty., Methods: Two hundred sixty-five patients older than 65 years underwent surgical resection of meningioma at Hiroshima University and related hospitals between 2000 and 2016. Karnofsky Performance Status (KPS) scores before and after surgery were evaluated. Factors related to the deterioration of KPS were analyzed with multivariate logistic regression modeling, including body mass index and serum albumin., Results: KPS score deteriorated compared with preoperative score in 56 patients at discharge and in 40 patients at 3 months later, and 2 patients died within 1 year after surgery. Multivariate logistic regression analysis in addition to preoperative body mass index and serum albumin indicated skull base tumor location (odds ratio [OR], 4.67; 95% confidence interval [CI], 2.02-10.8) and serum albumin (OR, 2.38; 95% CI, 1.06-5.34) were risk factors for deterioration of KPS score at discharge. Age (OR, 0.91; 95% CI, 0.85-0.98), skull base tumor location (OR, 4.32; 95% CI, 1.45-12.9), tumor size (OR, 1.03; 95% CI, 1.00-1.05), and serum albumin (OR, 3.53; 95% CI, 1.29-9.61) were significant risk factors for perioperative intracranial complications., Conclusions: Skull base tumor location and serum albumin correlated with deterioration of clinical status after surgery., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The differentiation of germinoma from other tumors by conventional magnetic resonance imaging (MRI) can be very difficult. The purpose of our study was to determine whether diffusion-weighted imaging (DWI) and single-voxel proton magnetic resonance spectroscopy (1H-MRS) could provide additional useful information for a definitive diagnosis of germinomas., Methods: Our hospital's Institutional Review Board approved this retrospective study. We reviewed imaging studies of 26 patients with histologically confirmed germinomas who were treated at our hospital between 2003 and 2016. We also studied 25 patients with pineal tumors, which included 14 nongerminomatous germ cell tumors (NGGCTs), 9 pineal parenchymal tumors (PPTs; including 3 pineocytomas, 4 PPTs of intermediate differentiation [PPTID], and 2 pineoblastomas) and 2 meningiomas. Patients underwent conventional MRI and advanced MRI, including DWI and/or 1H-MRS., Results: The germinoma group comprised 24 males and 2 females, ranging in age from 9.1 to 37.7 years (average, 17.5 years; median, 14.6 years). The NGGCT group was all male, ranging in age from 5.4 to 51.9 years (mean, 20.1 years; median, 14.1 years). In the PPT group, patient age ranged from 4.5 to 64.7 years (mean, 29.9 years; median, 30.7 years). High lipid peaks detected on 1H-MRS were observed in 16 of 16 examined germinomas. In contrast, in the pineocytomas, PPTID, pineoblastomas, and meningiomas, lipid peaks were small or absent in 10 of 10 examined tumors. In the NGGCT group, high lipid peaks on 1H-MRS were observed in 11 of 12 examined tumors; however, no tumors showed high intensity on DWI, with all low to high mixed intensity. ADC was statistically lower in the germinoma group compared with the NGGCT group (P = 0.0002)., Conclusions: Lower ADC values and high lipid peaks detected on 1H-MRS are characteristics of germinomas., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: A neuroendoscopic biopsy has become common for the diagnosis of ventricular tumors. However, its utility in patients with germ cell tumors (GCTs) has not been well discussed. We examined the usefulness and pitfalls of neuroendoscopic biopsies of intraventricular GCTs at a single institution., Methods: We retrospectively studied 21 consecutive patients diagnosed with GCTs by a neuroendoscopic biopsy of the ventricular region via the lateral ventricle. We examined the localization of tumors, histologic diagnoses using biopsies, surgical complications, and consistency of the diagnosis at the latest follow-up., Results: Tumor specimens were obtained from a pineal lesion (n = 20), neurohypophysial lesion (n = 5), and lateral ventricular wall lesion (n = 2). In 5 patients, the specimens were obtained from multiple areas. The initial diagnoses were pure germinoma (n = 16), immature teratoma (n = 1), yolk sac tumor (n = 1), and mixed GCT (n = 3). Six of 21 patients needed a second transcranial removal of enhanced residual lesions in the course of the treatment. A discrepancy in the histologic diagnosis between 2 surgeries occurred in 3 patients: All 3 patients had a new diagnosis of teratoma component following transcranial surgery. No postoperative mortality or permanent morbidity related to the neuroendoscopic procedures was noted., Conclusion: Neuroendoscopic biopsies are safe and useful for obtaining reliable histologic diagnoses in the management of GCTs. However, for GCTs with mixed histology, biopsies are susceptible to diagnostic errors, especially missing detecting a component of teratoma., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: The differential diagnosis of neurohypophysial lesions is difficult, and surgical biopsies are indispensable in the histologic diagnosis of some patients. Although pituitary stalk biopsies are uniformly performed, there is a considerable risk that they will result in impaired hormonal secretion. We attempt to clarify the usefulness and safety of posterior pituitary lobe biopsy by transsphenoidal surgery (TSS)., Methods: The cases of 11 consecutive patients who underwent posterior pituitary lobe biopsies by TSS were retrospectively studied. Patients with cystic sellar lesions were excluded. We examined the clinical findings, endocrinologic data, magnetic resonance imaging findings, and histologic diagnoses of the patients. The locations of neurohypophysial lesions and the histologic diagnoses by posterior pituitary lobe biopsies were examined., Results: The major preoperative clinical symptoms were diabetes insipidus (DI) (90.9%), followed by anterior pituitary lobe dysfunction (hypopituitarism) (54.5%). In all the patients, the lesions occupied the pituitary stalk and the posterior pituitary lobe, and the bright spot, which would indicate a normal posterior pituitary gland, disappeared on T1-weighted imaging. The posterior pituitary lobe specimens could be histologically diagnosed in all these cases. DI persisted in 10 patients with preoperative DI after the biopsy, whereas the 1 patient without preoperative DI did not suffer from DI after the biopsy., Conclusions: A posterior pituitary lobe biopsy by TSS may be an alternative to pituitary stalk biopsy in patients with neurohypophysial lesions., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to clarify the correlation between clinical features (especially cyst formation and cavernous sinus invasion) and minor secretion of anterior pituitary hormones, especially adrenocorticotropic hormone (ACTH) and gonadotropin, by clinically nonfunctioning pituitary adenomas (CNFPAs) in cell culture., Methods: We examined anterior pituitary hormones secreted by samples from 63 cases of CNFPAs grown in cell culture. Magnetic resonance imaging, including determination of the Knosp grade, cystic changes, and intraoperative cavernous sinus invasion, was performed., Results: Detection of minor hormone secretion using cell culture showed that 61.9% (39/63) of CNFPAs secreted luteinizing hormone, follicle-stimulating hormone, and thyroid-stimulating hormone, 44.4% (28/63) secreted ACTH, 57.1% (36/63) secreted prolactin, and 28.6% (18/63) secreted growth hormone; only 1 case of the null-cell adenoma was observed (1.6%). Cystic changes, Knosp grade 4 status, and cavernous sinus invasion were predominantly observed in cases of ACTH-secreting adenomas. Gonadotropin-secreting adenomas showed opposite characteristics to ACTH-secreting adenomas., Conclusions: Minor secretion of ACTH and gonadotropin may be related to clinical features, especially cystic changes and invasiveness of CNFPAs, suggesting that our cell culture method could be helpful for elucidating the mechanisms of pituitary cyst formation and the invasiveness of CNFPAs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Pseudocapsular resection is a useful surgical technique for removing functioning pituitary adenomas; however, the significance of this procedure in nonfunctioning pituitary adenomas (NFPAs) had not been discussed in detail. We clarify the safety of pseudocapsular resection in NFPAs based on the incidence of surgical complications and evaluation of pituitary function., Methods: In 143 patients, initial surgery for NFPAs was performed with preoperative and postoperative pituitary provocation tests. Patients were categorized into 3 groups: total group (n = 65), in which the pseudocapsule was totally removed; partial group (n = 11), in which the pseudocapsule was partially removed; and nonremoval group (n = 67), in which the pseudocapsule was not removed or did not exist. The main outcome measure was the incidence of surgical complications and postoperative pituitary functions., Results: Intraoperative cerebrospinal fluid leakage and temporary diabetes insipidus occurred more frequently in the total group than in the nonremoval group; however, the differences were not statistically significant. There was no difference in the incidence of any other complications, including postoperative cerebrospinal fluid leakage and permanent diabetes insipidus, between the total and nonremoval groups. Postoperative anterior pituitary function improved to the same degree in both the total and the nonremoval groups. Univariate and multivariate analyses revealed that pseudocapsular resection was not a factor in the postoperative deterioration of pituitary function., Conclusions: Pseudocapsular resection in NFPAs does not increase the risk of surgical complications or aggravate postoperative pituitary function., (Copyright © 2016 Elsevier Inc. All rights reserved.)