|Year : 2019 | Volume
| Issue : 1 | Page : 72-73
Challenges in the management of intraventricular tumors in the current era
Department of Radiation Oncology, Tata Memorial Center, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
|Date of Web Publication||9-Sep-2019|
Department of Radiation Oncology, Tata Memorial Centre, 1125-Homie Bhabha Building, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishnatry R. Challenges in the management of intraventricular tumors in the current era. Cancer Res Stat Treat 2019;2:72-3
Intraventricular tumors are defined by anatomical location around the lateral and third ventricles and include both intra- and extra-axial lesions. These are usually managed with special interest because of proximity to the critical neurological structures, which makes surgical access very challenging. Limited literature that exists for these group of tumors consists mostly of case series outlining their hospital-based epidemiology and patterns of surgical care with associated outcomes.,,,,, Surgical approaches can be classified as transcallosal or transcortical, and choice of the surgical approach mainly depends on the type, size, and location of the tumor and determines associated morbidity and mortality.
With modern pre- and intraoperative image guidance, improved understanding of neuroanatomy, surgical, and anesthetic care, the extent of surgical resections and postsurgical mortalities have improved dramatically. Universally, across the pathological spectrum, maximal safe resection is the essential principle and forms the cornerstone of effective management in brain tumors. The higher the grade of a lesion, the more critical is the extent of resection for better outcomes. Various surgical approaches have been developed with open microsurgical or endoscopic ones; the choice depends on the anatomical location and careful neuroimaging planning. The most challenging anatomy examples comprise lesions around the third ventricles, crossing neural tracts, critical nuclei in the thalamus, and the hypothalamus. The postoperative mortality in the various series ranges from 2% to 7% depending on the surgical expertise, tumor selection, and technique selection.,,,,,
In the current issue of the journal, Kriankumar et al. present a series of 134 patients of intraventricular tumors treated over a 5-year period. The open approach was much preferred in lateral and anterior third ventricle tumors with significantly higher gross total and near-total excision rates (90.8%) than posterior third ventricle (69.4%). Almost 60% of the patients underwent endoscopic third ventriculostomy in those planned for endoscopic biopsy avoiding major open surgery, permanent shunt procedures (88%) for hydrocephalus patients, and other associated risks. The operative mortality rates were quite remarkable at 0.86%, and the postoperative permanent morbidity was reasonable at 6.7%.
Although the authors present commendable survival outcomes validating the choice of their surgical approach, they do not present the details of the criteria they used for selection of the surgical approach. With current improvements in magnetic resonance imaging (MRI), preoperative histological diagnosis can be ascertained with an accuracy of almost 80%–90%. Choroid plexus carcinoma is a classic case where intraoperative handling can lead to bleeding up to five times the normal total blood volume leading to one of the highest on-table mortality rates. Hence, when radiologically suspected, a safe biopsy may only be done to confirm the diagnosis followed by appropriate chemotherapy rendering lesions less vascular and much safer later for the complete resection improving the outcomes.
Contemporary to the literature,,,,,,, the current study  also showed similar epidemiology with the most commonly encountered truly intraventricular tumors being colloid cyst, subependymoma, ependymoma, neurocytoma, choroid plexus tumors, and subependymal giant cell astrocytomas (SEGA). At times, there can be tumors in the periventricular region which grow extensively into the ventricles (examples: glioma and meningiomas) and have similar challenges to surgical approach and are therefore clubbed with intraventricular tumors. The commonly occurring tumors in children and young adults are colloid cysts, ependymal tumors, choroid plexus tumors, germ cell tumors, and SEGA, whereas in adults, glioma, neurocytoma, meningioma, ependymoma, and SEGA are common.
Traditionally, midline tumors (many presenting as intraventricular tumors) were considered tumors with worse outcomes as compared to similar pathology tumors in the periphery due to an inadequate surgical extent of resection, biopsy underdiagnosis, and poor response to adjuvant treatments., Recent data suggest that molecularly midline tumors, although similar in pathology, are different molecularly and hence have poorer outcomes, this has been duly incorporated in the World Health Organization 2016 update of brain tumors. Classic examples include the presence of histone and BRAF V600E mutations in gliomas., This information can further help in prognosticating as well as sometimes modulating adjuvant therapies. In the current series, 37 patients needed adjuvant radiotherapy, but the authors do not present any molecular confirmation of histology and do not provide details on the use of chemotherapy.
To summarize, the authors present an interesting series of a large number of intraventricular tumors treated with various surgical approaches at a tertiary center in India with excellent surgical outcomes. Further details with development of some objective nomogram based on preoperative diagnosis, the extent of the tumor and intra-/extra-axial origin from preoperative MRI visualization along with clinical presentation could guide the appropriate choice of surgical approach would be warranted. Details of molecular information with detailed adjuvant treatment tailoring as per the modern approach would be more insightful with survival outcomes.
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