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Surgery of Olfactory Groove Meningiomas: When in Rome, Do as the Romans Do?
Perspectives Commentary on: Olfactory Groove Meningioma: Report of 99 Cases Surgically Treated at the Catholic University School of Medicine, Rome by Pallini et al. pp. 219-231.
Surgery of Olfactory Groove Meningiomas: When in Rome, Do as the Romans Do? Karl Schaller
A
bout 130 years after the first documented—and successful—removal of an olfactory groove meningioma by Roman surgeon Francesco Durante in 1885 (3), his natural successors, neurosurgeons at the Catholic University of Rome, report on a series of 99 such cases who have been operated on through a period-of-time of 26 years.
What has happened in olfactory groove meningioma surgery since the Durante era? In a very general way, diagnosis does not only rely on clinical assumptions. Durante’s patient, and many more patients until the introduction of cranial imaging, were identified on the basis of clinical reasoning alone. Patients presented with exophtalmus, anosmia, visual loss, frontal lobe syndrome, and lethargia. Tumors were frequently of enormous size, thus rendering surgical resection a very dangerous undertaking. This is further illustrated as one of Harvey Cushing’s first patients, a (at that time) German professor from Breslau (today: Wroclaw) died from arterial bleeding because of the depth of the surgical field. It can be assumed that this was due to adherence of the tumor capsule to the neurovascular complex, notably the anterior cerebral arteries, which are often displaced significantly backward and upward. Difficulties with illumination of the depth of the surgical field rendered management of such intraoperative events hazardous, and certainly, sometimes, desperate. As for other neurosurgical diseases, the introduction of cranial magnetic resonance imaging brought the breakthrough for the diagnosis of olfactory groove meningiomas as well. Due to the slowness of growth and to the subtlety of early symptoms that may easily be overlooked, these tumors may still be of considerable size at diagnosis. Although in the past it was not rare to
Key words Olfactory groove meningiomas - Outcome predictors - Surgical approaches -
152
Abbreviations and Acronyms ENT: Ear, nose, and throat
www.SCIENCEDIRECT.com
find tumors of 5e10 cm in diameter, at present the average size is in the range of 4 cm in Western countries. The surgical approach was always an issue of debate. Francesco Durante operated on his first patient using a frontal craniectomy. Other approaches are unilateral or bilateral frontobasal, unilateral or bilateral frontal, pterional, frontal interhemispheric, and supraorbital. The key question for approach planning when it comes to resection of mid-size or large tumors is as follows: when to deal with the posteriorly displaced and partially engulfed neurovascular complex (optic nerves, chiasma, carotid and anterior cerebral arteries)—at the beginning of the operation or at the end? It is clear that with the frontobasal approach these important anatomic structures will be reached only during the late stages of the procedure. Considering my own experience—after having operated my first olfactory groove meningioma using the classic pterional craniotomy—I have now entirely switched to the anterior interhemispheric approach and thereby significantly decreased the surgical time (1, 2). Rapid transtumoral devascularization of the tumor is then followed by layerwise resection of even large meningiomas, with early visualization and control of the anterior cerebral arteries. This is a matter of surgical legacy, and in the end there is no need to be apodictic about either way to remove such tumors. What matters more, in my opinion, is that the neurosurgical community remains in the lead concerning the treatment of these tumors. To master meticulous microsurgical techniques and potential (intraoperative) complication management is the only prerequisite, which can be expected from any experienced cranial neurosurgeon. The advent of endoscopic transnasal techniques with ever-improving optics (i.e., high definition or 3dimensional vision) has opened new avenues for the treatment
Department of Neurosurgery, University of Geneva Medical Center, Geneva, Switzerland To whom correspondence should be addressed: Karl Schaller, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 2:152-153. http://dx.doi.org/10.1016/j.wneu.2014.12.004
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.12.004
PERSPECTIVES
of anterior skull base tumors. These techniques should not be applied in an uncritical manner, nor should surgical and technological advancement be left to ear, nose, and throat (ENT) surgeons alone, who are equally pushing their limits in an upward direction (4). Joint training in transnasal endoscopic techniques alone—neurosurgeons and ENT surgeons together—will possibly develop new avenues of resection techniques for benign tumors of the anterior fossa, such as olfactory groove meningiomas. This includes improvement in complication management, notably for the treatment of postoperative cerebrospinal fluid fistulae, and for reconstruction of the anterior skull base. Only long-term studies will show whether so-called minimally invasive resection techniques—be them transnasal or through mini-craniotomies—will be equally effective concerning the recurrence time and rate of these tumors. I do not have a clear solution as to how to approach these tumors. Of course it is not possible because this is a
REFERENCES 1. Mayfrank L, Gilsbach JM: Interhemispheric approach for microsurgical removal of olfactory groove meningiomas. Br J Neurosurg 10:541-545, 1996. 2. Mielke D, Mayfrank L, Psychogios MN, Rohde V: The anterior interhemispheric approach - a safe and effective approach to anterior skull base lesions. Acta Neurochir (Wien) 156:689-696, 2014.
retrospective analysis of what has been done with these tumors at institutions through almost three decades—with different surgical adjuncts and, most important—by different surgeons. Thus, it does not reflect a single surgeon’s monolithic experience, but rather an institutional approach as a whole. It is of interest to note that during the past three analyzed periods the rate of complete or almost complete (Simpson grades I and II) resection went up to 95% from 60%e 80% previously. May be this is the reason for the increase in life-threatening complications (from 15% up to 25%) from the second (1991e2000) to the third period (2001e2010) of the analysis. It is an exceptionally large series of olfactory groove meningiomas, but its institutional character through such a long period-of-time precludes from meaningful conclusions concerning future treatment improvements. The surgical ancestor, Francesco Durante, set the mark for the surgical treatment of these tumors—in Rome. Quo vadis Roma, when embarking on future treatment strategies?
3. Morales-Valero SF, van Gompel JJ, Loumiotis I, Lanzino G: Craniotomy for anterior anial fossa meningiomas: historical overview. Neurosurg Focus 36:E14, 2014.
Citation: World Neurosurg. (2015) 83, 2:152-153. http://dx.doi.org/10.1016/j.wneu.2014.12.004
4. Padhye V, Naidoo Y, Alexander H, Floreani S, Robinson S, Santoreneos S, Wickremesekera A, Brophy B, Harding M, Vrodos N, Wormald PJ: Endoscopic endonasal resection of anterior skull base meningiomas. Otolaryngol Head Neck Surg 147:575-582, 2012.
Available online: www.sciencedirect.com
Journal homepage: www.WORLDNEUROSURGERY.org
1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
WORLD FEDERATION OF NEUROSURGICAL SOCIETIES Mission Statement To facilitate the personal association of neurological surgeons throughout the world. To aid in the exchange and dissemination of knowledge and ideas in the field of neurological surgery. To encourage research in neurological surgery and allied sciences. To address issues of neurosurgical demography. To address issues of Public Health. To implement, improve and promote the standards of neurosurgical care and training worldwide.
Membership Services (www.wfns.org) Teresa Chen Hsiao-Hui (Teresa) Chen Office Manager, WFNS Central Office World Federation of Neurosurgical Societies 5 Rue du Marché 1260 Nyon, Vaud, Switzerland Tel: +41 (0) 22 3624303 Fax: +41 (0) 22 3624352 Email: [email protected]
WORLD NEUROSURGERY 83 [2]: 152-153, FEBRUARY 2015
www.WORLDNEUROSURGERY.org
153
Surgery of Olfactory Groove Meningiomas: When in Rome, Do as the Romans Do? Karl Schaller
A
bout 130 years after the first documented—and successful—removal of an olfactory groove meningioma by Roman surgeon Francesco Durante in 1885 (3), his natural successors, neurosurgeons at the Catholic University of Rome, report on a series of 99 such cases who have been operated on through a period-of-time of 26 years.
What has happened in olfactory groove meningioma surgery since the Durante era? In a very general way, diagnosis does not only rely on clinical assumptions. Durante’s patient, and many more patients until the introduction of cranial imaging, were identified on the basis of clinical reasoning alone. Patients presented with exophtalmus, anosmia, visual loss, frontal lobe syndrome, and lethargia. Tumors were frequently of enormous size, thus rendering surgical resection a very dangerous undertaking. This is further illustrated as one of Harvey Cushing’s first patients, a (at that time) German professor from Breslau (today: Wroclaw) died from arterial bleeding because of the depth of the surgical field. It can be assumed that this was due to adherence of the tumor capsule to the neurovascular complex, notably the anterior cerebral arteries, which are often displaced significantly backward and upward. Difficulties with illumination of the depth of the surgical field rendered management of such intraoperative events hazardous, and certainly, sometimes, desperate. As for other neurosurgical diseases, the introduction of cranial magnetic resonance imaging brought the breakthrough for the diagnosis of olfactory groove meningiomas as well. Due to the slowness of growth and to the subtlety of early symptoms that may easily be overlooked, these tumors may still be of considerable size at diagnosis. Although in the past it was not rare to
Key words Olfactory groove meningiomas - Outcome predictors - Surgical approaches -
152
Abbreviations and Acronyms ENT: Ear, nose, and throat
www.SCIENCEDIRECT.com
find tumors of 5e10 cm in diameter, at present the average size is in the range of 4 cm in Western countries. The surgical approach was always an issue of debate. Francesco Durante operated on his first patient using a frontal craniectomy. Other approaches are unilateral or bilateral frontobasal, unilateral or bilateral frontal, pterional, frontal interhemispheric, and supraorbital. The key question for approach planning when it comes to resection of mid-size or large tumors is as follows: when to deal with the posteriorly displaced and partially engulfed neurovascular complex (optic nerves, chiasma, carotid and anterior cerebral arteries)—at the beginning of the operation or at the end? It is clear that with the frontobasal approach these important anatomic structures will be reached only during the late stages of the procedure. Considering my own experience—after having operated my first olfactory groove meningioma using the classic pterional craniotomy—I have now entirely switched to the anterior interhemispheric approach and thereby significantly decreased the surgical time (1, 2). Rapid transtumoral devascularization of the tumor is then followed by layerwise resection of even large meningiomas, with early visualization and control of the anterior cerebral arteries. This is a matter of surgical legacy, and in the end there is no need to be apodictic about either way to remove such tumors. What matters more, in my opinion, is that the neurosurgical community remains in the lead concerning the treatment of these tumors. To master meticulous microsurgical techniques and potential (intraoperative) complication management is the only prerequisite, which can be expected from any experienced cranial neurosurgeon. The advent of endoscopic transnasal techniques with ever-improving optics (i.e., high definition or 3dimensional vision) has opened new avenues for the treatment
Department of Neurosurgery, University of Geneva Medical Center, Geneva, Switzerland To whom correspondence should be addressed: Karl Schaller, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 2:152-153. http://dx.doi.org/10.1016/j.wneu.2014.12.004
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.12.004
PERSPECTIVES
of anterior skull base tumors. These techniques should not be applied in an uncritical manner, nor should surgical and technological advancement be left to ear, nose, and throat (ENT) surgeons alone, who are equally pushing their limits in an upward direction (4). Joint training in transnasal endoscopic techniques alone—neurosurgeons and ENT surgeons together—will possibly develop new avenues of resection techniques for benign tumors of the anterior fossa, such as olfactory groove meningiomas. This includes improvement in complication management, notably for the treatment of postoperative cerebrospinal fluid fistulae, and for reconstruction of the anterior skull base. Only long-term studies will show whether so-called minimally invasive resection techniques—be them transnasal or through mini-craniotomies—will be equally effective concerning the recurrence time and rate of these tumors. I do not have a clear solution as to how to approach these tumors. Of course it is not possible because this is a
REFERENCES 1. Mayfrank L, Gilsbach JM: Interhemispheric approach for microsurgical removal of olfactory groove meningiomas. Br J Neurosurg 10:541-545, 1996. 2. Mielke D, Mayfrank L, Psychogios MN, Rohde V: The anterior interhemispheric approach - a safe and effective approach to anterior skull base lesions. Acta Neurochir (Wien) 156:689-696, 2014.
retrospective analysis of what has been done with these tumors at institutions through almost three decades—with different surgical adjuncts and, most important—by different surgeons. Thus, it does not reflect a single surgeon’s monolithic experience, but rather an institutional approach as a whole. It is of interest to note that during the past three analyzed periods the rate of complete or almost complete (Simpson grades I and II) resection went up to 95% from 60%e 80% previously. May be this is the reason for the increase in life-threatening complications (from 15% up to 25%) from the second (1991e2000) to the third period (2001e2010) of the analysis. It is an exceptionally large series of olfactory groove meningiomas, but its institutional character through such a long period-of-time precludes from meaningful conclusions concerning future treatment improvements. The surgical ancestor, Francesco Durante, set the mark for the surgical treatment of these tumors—in Rome. Quo vadis Roma, when embarking on future treatment strategies?
3. Morales-Valero SF, van Gompel JJ, Loumiotis I, Lanzino G: Craniotomy for anterior anial fossa meningiomas: historical overview. Neurosurg Focus 36:E14, 2014.
Citation: World Neurosurg. (2015) 83, 2:152-153. http://dx.doi.org/10.1016/j.wneu.2014.12.004
4. Padhye V, Naidoo Y, Alexander H, Floreani S, Robinson S, Santoreneos S, Wickremesekera A, Brophy B, Harding M, Vrodos N, Wormald PJ: Endoscopic endonasal resection of anterior skull base meningiomas. Otolaryngol Head Neck Surg 147:575-582, 2012.
Available online: www.sciencedirect.com
Journal homepage: www.WORLDNEUROSURGERY.org
1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
WORLD FEDERATION OF NEUROSURGICAL SOCIETIES Mission Statement To facilitate the personal association of neurological surgeons throughout the world. To aid in the exchange and dissemination of knowledge and ideas in the field of neurological surgery. To encourage research in neurological surgery and allied sciences. To address issues of neurosurgical demography. To address issues of Public Health. To implement, improve and promote the standards of neurosurgical care and training worldwide.
Membership Services (www.wfns.org) Teresa Chen Hsiao-Hui (Teresa) Chen Office Manager, WFNS Central Office World Federation of Neurosurgical Societies 5 Rue du Marché 1260 Nyon, Vaud, Switzerland Tel: +41 (0) 22 3624303 Fax: +41 (0) 22 3624352 Email: [email protected]
WORLD NEUROSURGERY 83 [2]: 152-153, FEBRUARY 2015
www.WORLDNEUROSURGERY.org
153