The role of NeuroEndoscopyin NeuroOncology

M. TriffauxV. MarneffeA. TyberghienI. Origer

7th EANO Congress, Vienna 16/09/06

NeuroEndoscopyNeuroEndoscopy

Ventriculoscopy Pituitary Key hole surgery

Ventriculoscopy in OncologyVentriculoscopy in Oncology

• In ventricular and paraventricular tumor management

• In Endoscopic Third Ventriculostomy (ETV)

– In the same time of supratentorial procedure

– in management of hydrocephalus from posterior fossa tumor

• Rigid

• Flexible

VentriculoscopeVentriculoscope

• Image Guided surgery– Choice of the best entry point and the best trajectory

– Endoscope tracking per operative

Advantages of the rigid scopeAdvantages of the rigid scope

• Image Guided surgery

• Endoscope stability – Pneumatic arm

– microdriver

Advantages of the rigid scopeAdvantages of the rigid scope

• Image Guided surgery

• Endoscop stabilisation

• Higher quality– optical resolution

– trocars: multiple channels

AdvantagesAdvantages of the rigid scope

CaseN°

Sex/age(yrs)

location Histiologicaldiagnose

ETV Further therapy

1 M / 69 3rd V. ant. Pineocytoma II Y No

2 F / 41 3rd V. ant.. Arachnoid cyst Y No

3 F / 72 Occ. paraV. Glioblastoma N Radiation

4 M / 35 3rd V. ant. Dermoid cyst N No

5 M / 21 3rd V. post Germinoma N Radiation Chemotherapy

6 F / 16 Thalamic Astrocytoma III Y Open surgery

Clinical data 2003/2005Clinical data 2003/2005

• 21 yrs , recent diplopia

• CT MR imaging: pineal tumor whithout hydrocephalus

• Pet methionine: +

• Blood fetoproteine , HCG: nl < 1 mUI/ml

• CSF fetoproteine: nl, HCG: 3 mUI/ml

Case N° 5Case N° 5

Case N° 5Case N° 5

• Biopsy diagnosis: germinoma

• Treatment: chemotherapy & radiotherapy2 cycles carbo/ etoposide / Ifosfamide40 Gy radiotherapy

Case N° 5Case N° 5

Case N° 5Case N° 5

Initial MR Post multimodal therapy

Case N° 6Case N° 6

• 16 yrs , Parinaud’s syndrome

• CT MR imaging: left thalamic mass

hydrocephalus

• Pet FDG: – Pet methionine: +

Case N° 6Case N° 6

CT Pet FDG MR Pet met.

Case N° 6Case N° 6

J10 post biopsy & ETVPre operative

Case N° 6Case N° 6

• Biopsy diagnosis: astrocytoma III

• Treatement: conventional surgery

astrocytoma III confirmed

Case N° 6Case N° 6

• Acute hydrocephalus needs treatement:– External Ventricular drainage– VP shunt– ETV

• In pediatric series: – Majority of the authors advocate ETV prior to

definitive surgery– Some others do not justify routine preoperative ETV

• In adult patients: there is no specific data

Hydrocephalus from P-fossa tumorHydrocephalus from P-fossa tumor

CaseN°

s/age ICP Symp

ETV diagnose Open surgery

1 M/46 Y pre Lung metastase Y , radiation2 F/22 Y pre Medulloblastoma Y , chemo + radiation3 M/45 Y pre Ependymome II Y

4 M/55 Y pre Gliome II Y5 F/34 Y pre Melanocytoma Y6 F/39 Y pre Neurinoma VIII Y7 M/23 N post cavernoma Y8 F/56 Y single Breast mets. (3) palliatif

Clinical data in adult populationClinical data in adult population

• GA, supine position

• ETV with neuroballon

• Insertion of a ventricular reservoir

• Monitoring ICP 24h-48h with butterfly needle

without ventricular drainage

Surgical procedureSurgical procedure

• Complication: 1 infection (case 8: palliative)

resolved with antiobiotherapy

• No shunt

• No CSF leak after posterior fossa surgery

Out comeOut come

• Ventriculoscopy is safe and efficientin selected cases

• It is more easier with navigation endoscope guided • It takes its place in multimodal approach

• The ETV makes easier the management in P-Fossa tumors with acute hydrocephalus in adult patientsas well as in pediatric

ConclusionsConclusions