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Radical resection of nongerminomatous pineal region tumors via the occipital transtentorial approach based on arachnoidal consideration: experience on a series of 143 patients

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Abstract

Backgroud

The role of radical resection for nongerminomatous pineal region tumors is still controversial. The purpose of this study was to present the surgical results in a large series and evaluate the feasibility of radical surgical strategy.

Methods

We retrospectively reviewed the records of 143 patients with nongerminomatous pineal region tumors surgically treated via an occipital transtentorial approach between 2000 and 2011. The tumor was small (<2 cm) in 14.7 % of patients, medium (2–4 cm) in 52.4 %, and large (>4 cm) in 32.9 %.

Results

Gross total tumor removal was achieved in 91.6 % of patients, subtotal in 7.0 %, and partial in 1.4 %. Histological diagnosis was nongerminomatous germ cell tumor in 41.3 %, pineal parenchymal tumor in 14.7 %, glial tumors in 28.7 %, and miscellaneous in 15.4 %. The overall complication and mortality rate was 18.2 % and 0.7 %, respectively. Permanent morbidity occurred in 5.6 % of patients, including hemianopsia in 3.5 % and Parinaud syndrome in 2.1 %. Hydrocephalus was resolved in 82.1 % without surgery for the CSF diversion. Sixty-eight patients with malignant tumors underwent radiotherapy; 35 also received adjuvant chemotherapy. One hundred thirty patients were successfully followed up with a mean duration of 43 months. Finally, 86.9 % of the patients achieved a favorable functional outcome (mRS ≤ 2), 3.1 % had an mRS score of 3, 1.5 % had an mRS score of 4, and 8.5 % had died (mRS = 6).

Conclusions

Radical surgery was recommended as the optimal treatment for nongerminomatous pineal region tumors. Favorable results could be achieved by experienced neurosurgeons. Hydrocephalus could be cured by radical tumor removal in the majority of cases. The occipital transtentorial approach was indicated for most pineal region tumors, but surgeon’s preference and experience should also be considered. New understanding of the arachnoid membranes of this region may be helpful for tumor resection.

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Acknowledgments

We are grateful to Xiaoyu Qiu and Yiping Mo (Medical Secretary, Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China) for their help with the data collection.

Disclosure

The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.

Conflicts of interest

None.

Author information

Correspondence to Songtao Qi.

Additional information

Drs. Songtao Qi, Jun Fan, and Xi-an Zhang contributed equally to this work.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Surgical case illustration. An occipital transtentorial approach was performed in a patient with a mixed germ cell tumor in pineal region. As shown by the preoperative MRI, the tumor arose within the arachnoid envelope wrapping the vein of Galen and its tributaries. Therefore, the envelope was dissected carefully prior to the tumor resection. After the deep veins had been totally released, a satisfactory exposure of the tumor could be achieved, and the retraction of veins could be reduced to minimize the risk of injury. During the procedure, the pineal vein was identified, coagulated, and separated from the tumor. Once all tumor-brain interfaces had been dissected, the tumor was removed en bloc. The adjacent neurovascular structures remained intact after tumor resection. Early postoperative MRI showed total removal of the tumor. Histology-specific adjuvant therapy was then performed as planned. A 5-year follow-up postoperative MRI presented no tumor recurrence. (WMV 16,185 kb)

Video 1

Surgical case illustration. An occipital transtentorial approach was performed in a patient with a mixed germ cell tumor in pineal region. As shown by the preoperative MRI, the tumor arose within the arachnoid envelope wrapping the vein of Galen and its tributaries. Therefore, the envelope was dissected carefully prior to the tumor resection. After the deep veins had been totally released, a satisfactory exposure of the tumor could be achieved, and the retraction of veins could be reduced to minimize the risk of injury. During the procedure, the pineal vein was identified, coagulated, and separated from the tumor. Once all tumor-brain interfaces had been dissected, the tumor was removed en bloc. The adjacent neurovascular structures remained intact after tumor resection. Early postoperative MRI showed total removal of the tumor. Histology-specific adjuvant therapy was then performed as planned. A 5-year follow-up postoperative MRI presented no tumor recurrence. (WMV 16,185 kb)

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Qi, S., Fan, J., Zhang, X. et al. Radical resection of nongerminomatous pineal region tumors via the occipital transtentorial approach based on arachnoidal consideration: experience on a series of 143 patients. Acta Neurochir 156, 2253–2262 (2014). https://doi.org/10.1007/s00701-014-2224-4

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Keywords

  • Arachnoid membrane
  • Occipital transtentorial approach
  • Pineal region tumors
  • Surgery