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MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH
HANOI MEDICAL UNIVERSITY
DO MANH THANG
ASSESSMENT OF CLINICAL AND MAGNETIC RESONANCE IMAGING CHARACTERISTICS AND EVALUTION THE RESULTS OF MICROSURGICAL SUPRASELLAR MENINGIOMA
Specialism : NeuroSurgery Code
ABSTRACT OF MEDICAL DOCTORAL THESIS
HANOI – 2019
THE THESIS HAS BEEN COMPLETED AT: HANOI MEDICAL UNIVERSITY
Supervisor: Ass Prof. Kieu Dinh Hung, MD, PhD. Ass Prof Ha Kim Trung, MD, PhD
Reviewer 1: Reviewer 2: Reviewer 3: The thesis will be present in front of board of university examiner and reviewer lever hold at Hanoi Medical University.
The thesis could be found in: 1. National Library 2. Library of Hanoi Medical University LIST TOPICS OF SCIENTIFIC PUBLICATION
Do Manh Thang, Kieu Dinh Hung (2011), Evalution the results of surgery treatment meningioma in Ha Noi Medical University Hospital, Journal of Medicine Viet Nam, July – Number 2, 13-16.
Do Manh Thang, Kieu Dinh Hung (2011), Diagnose meningioma in Ha Noi Medical University Hospital, Journal of Medicine Viet Nam, July – Number 2, 42-45.
Do Manh Thang (2017), Results of microsurgical treatment suprasella meningioma, Journal of Medicine Viet Nam, October, Volume 459, 62-68.
Do Manh Thang (2018), Evaluation of prognostic factors influencing microsurgical visual outcome suprasellar meningioma, Journal of Medicine Viet Nam, September, Volume 470, 188-194.
1 INTRODUCTION Meningioma is the primary brain tumor with the origin of papillary cells of arachnoid mater. The supra sella meningioma is the tumor from dura mater superior to pituitary. There are 3 original sites: tubercle of pituitary gland (tuberculumn sallae), diaphragm of pituitary (diaphragm sellae) and the superior platform of sphenoid sinus (planum sphenoid). The main sign is blurred vision. The early sign is vision loss of one site, and it could be easily to misdiagnose with ophthalmologic diseases. Then, in well-developed disease, the rest site could be affected. Thanks for the imaging diagnosis development (computed tomography, and magnetic resonance imaging), early diagnosis could be archived easily and precisely. The specificity could reach 100% in MRI diagnosis. Up to now, the most common treatment is surgery. The technique has been progressed because of microscopic in surgery, suction ultrasound machine, navigation system. These increased the possibility to remove entire tumor and low down the complication. However, the outcome significantly bases on the early diagnosis. It also the most concern of neurosurgery surgeon. Because of this reason, this research named “Assessment of clinical and magnetic resonance imaging characteristics and the outcome of supra sellar tumor removal surgery” aimed to: 1.
Assessment of clinical and magnetic resonance imaging characteristics of supra sellar tumor.
Assessment the outcome of microsurgery of supra sellar tumor.
2 The contributions of thesis: - Assessment of epidemic and clinical characteristics of supra sellar tumor. - Assessment the value of diagnostic tests, computed tomography and magnetic resonance imaging characteristics, and planning for surgery. - Long observation period (29,5) could evaluate the outcome (the progression of vision…) The design of thesis: The thesis includes 119 pages, 48 tables, and 46 pictures and 3 graph. The introduction (3 pages), Chapter 1: General description (55 pages), Chapter 2: Objects and Methodology (10 pages); Chapter 3: Results (18 pages), Chapter 4: Discussion (30 pages); Conclusion (2 pages); Proposal (1 page); The patient chart (5 pages); The related publications (1 page); The references (120 publication: 6 Vietnamese, 114 English). CHAPTER 1: GENERAL DESCRIPTION 1.1. The current researches of supra sellar tumor. 1.1.1. The supra sellar tumor in previous publications In 1614, Felix Plater was the first scientist who described precisely this tumor. The tubercullum sallar meningioma was described by Stirlig and Edin in 1897. In 1916, Cushing was the first surgeon who removed the tubercullum sallar meningioma, he showed that the tumor developed from tubercullum sallae to schism. In 1922, Harvey Cushing was the primary scientist who proved the meningioma originates from the villous cells of arachnoid membrane.
3 1.1.2. The studies of supra sellar meningioma in Viet Nam - From 1997 to 2003, Vo Van Nho, Cho Ray hospital performed surgery for 35 patients with the total tumor removal archieved 97,14% (69) - In 2009, the conference of Neurology in Vietnam, Ly Ngoc Lien reported the microsurgery for supra sellar tumor. 1.2. The differences between the tuberculum sellar meningioma and suprasella meningioma. The two types of tumors are totally different origin 1.3. The anatomy of suprasellar area 1.3.1. Characteristics of suprasellar area. The suprasellar area is located in the center of skull base. From anterior to posterior, there are planum sphenoidale, tuberculum sellae, diaphragma of sellae consequently. The inferior of diaphragm is the pedicle and posterior tuberculum The borderline of sellae - The lateral is the carotid artery and cavernous vein - The anterior is the optic nerve and arachnoid membrane - The posterior is the pedicle and the optic chiasm, the A1 of anterior cerebral artery, and the anterior communicating artery - The inferior is the pituitary gland Therefore the unique way to approach the tumor is the anterior lateral of the planum spenoidale. The dura mater of supra sellae is fluctuating and has orifices for pineal pedicle, artery and nerve passing through. 1.3.2. The related structure of supra sellae area - The optic nerve and schism
4 - The olfactory nerve - Artery: the anterior cerebral artery, the middle cerebral artery, optic artery, the Heubner artery. - Pituitary and pituitary pedicle 1.4. The histopathology of meningioma The meningioma of skull base is normally benign World health organization (WHO) proposed 3 types of classification in 1979, 1993 and re-edited in 2000 - The benign meningioma, low recurrence WHO grade I - The meningioma with high recurrence WHO grade II - The meningioma with super high recurrence WHO grade III 1.5. The risk factors - Gene and chromosome - Hormonal factors: Progesteron and Estrogen play an important role - Radiation - Head trauma 1.6. Clinical signs and symptoms It is characteristic of poor signs and symptoms. The chief complain is vision loss. Headache is caused by the irritation of tumor with meninges without increasing intra-cerebral pressure. Others are epilepsy, insomnia… More rarely, endocrines disturbance could present. 1.7. Imaging diagnosis Magnetic resonance imaging is 100% specificity. In T1: Tumor has equal or low signal in comparison with gray matter. In T2: Tumor has equal or lower signal than gray matter. After contrast injection, the tumor has high intake and dural tail sign (specific sign of
5 meninges tumors in MRI). The tumor vascular could be visualized, thickening the skull base and edema the surrounding structure 1.8. Treatment 1.8.1. Surgery The main treatment is surgery. There is a large amount of techniques. However the purpose are vision progression and low down the complications. 6 pathways: - Frontal-temporal approach (Pterion) - Unisubfrontal approach - Bisubfrontal approach - Through eyebrows (Keyhole) - Interhemispheric fissure approach - Endonasal Transphenoidale The Simpson classification: Level I: Whole tumor and dura mater removal Level II: Whole tumor removal and ablation of dura mater Level III: Whole tumor removal, without dura mater intervention Level IV: Partial tumor removal Level V: Simple pressure release 1.8.2. Others - Radiation - Gamma knife - Proton radiation
6 CHAPTER 2: OBJECTS AND METHODOLOGY 2.1. Objects Patients diagnosed and performed surgery with histopathology confirm of meningioma at Neurosurgery department of Viet Duc hospital from 04/2012 to 10/2016. 2.2. Methodology: 2.2.1. Design: - Description, prospective, without control study - There was 57 patients was 2.2.2 Sample size According to formulation
n: sample size α: confidence index p: success proportion Evaluated sample size was at least 54 patients 2.3. Contents Purpose 1: 2.3.1. Characteristics of objects - The frequency of supra sellar tumor among meninges tumors - Sex and age - Chief complain - The duration from blurred vision to administration 2.3.2. Clinical signs and symptoms - The clinical characteristics at administration time - The clinical characteristics before surgery according Glasgow coma scale - The clinical characteristics after discharge according Karnofsky scale
7 The outcome was classified into 3 groups: Good outcome: 80-100 grade Average outcome: 50-70 grade Not good outcome: 0-40 grade 2.3.3. Magnetic resonance imaging The characteristics of supra sellar tumor on MRI - Intake of the contrast: strong, normal, averagr - Clear border line, equal signal in T1, and slightly increase signal in T2 - The density of signal: homogenous or not - Dural tail sign - Edema the surrounding structure Location of tumor on MRI - Pineal tubercle - Diaphragm of sella - Planum sphenoidale - Pineal tubercle and diagphragma - Tubercle and planum Size of tumor - < 2 cm - 2-3 cm - 3-4 cm - > 4 cm The purpose 2 2.3.4. The outcome evaluation 22.214.171.124. Indication - The diagnosis of supra sellar tumor before surgery - Without comorbidities
8 - Without senior patients - Acceptance for surgery 126.96.36.199. Patients evaluation before surgery - MRI evaluation following coronal and sagittal slides: size, location, and the root of tumor conform operation - The invasion of tumor - The relation of tumor with optic nerve, optic chiasma, anterior cerebral artery, optic artery, internal carotid artery, cavernous, ventricle III, pedicle adenoma - The vascularization inside tumor - Microscopic NC4, Vario 700, Pentaro 8, Leika. 188.8.131.52. The surgical approaches - Frontal-temporal approach - Bisubfrontal approach - Unisubfrontal approach - Keyhole - Temporal approach * Evaluation after surgery The outcome according to Simpson - The relation of size and level of tumor removal - The relation of location and level of tumor removal - The relation of surgical approach and level of tumor removal Complication Histopathology results The patient status after discharge Outcome evaluation: The average duration of re-examination was 29.5 months. Patients was received vision evaluation and MRI
9 2.4. Data analysis - 57 patients in study was analyzed by SPSS 16.0 and Exel 2010 - 43 re-examined patients was analyzed by Stata 14.0 CHAPTER 3: RESULTS 3.1. Clinical results 3.1.1. Age The supra sellar tumor was common in middle aged patients 4050 years old. The youngest was 27 years old, the oldest was 67 years old, the average was 48,6 years old 3.1.2. Gender The female/male ratio was 4,7/1. Female was acquired more than male 3.1.3. The duration of preoperative symptoms to admission. The duration of preoperative symptom to admission < 12 months mostly. The average duration was 11,9 months 3.1.4. Clinical signs and symptoms The visual impairment was common (93% patients), also headache (96,5%). The others was not specific, there was no case with pituitary dysfunction. 3.2. Magnetic resonance characteristics 3.2.1. The location of tumor conform operation The supra sellar tumor originating from diaphragm sella was the most common 47.35% (both C1 and C2)
10 3.2.2. The size The most common size was 2-4 cm (68,41%), the average size was 2,9 cm. The smallest size was 1 cm, the largest size was 4,9 cm. 3.2.3. Others The supra sellar tumor with high intake of contrast The homogenous signal was 79% The appearance of dural tail sign and without dural tail The edema of cerebral structure surrounding the tumor only in 4 patients and all of them was the supra sellar tumor from planum sphenoidale. The tumor relative with around organize in MRI The tumor relative with around organize in operation 3.3. The outcome 3.3.1. The approaching pathway The approaching pathway The most common was frontal temporal pathway 3.3.2. The outcome following Simpson classification There was no patient with tumor removal Simpson I. Total tumor removal with ablation the dural mater was 54,38% patients. Partial tumor removal was 43,85% 3.3.3. The size and tumor removal The tumor removal was not related to the size of tumor, no statistically significant p=0,48
11 3.3.4. The location and tumor removal The tumor removal did not relate with the location of tumor, no statistically significant p = 0,13 3.3.5. The approach and tumor removal The approaching way did not relate to the tumor removal, no statistically significant p = 0,12 3.4. The histopathology The supra sellar tumor was mostly benign Grade I, among this the epithelial tumor was 57,89%. 3.5. Complication There was two case with intra-cerebral hematoma, one of this had to perform the second surgery. One case with meningitis, antibiotics prescribed. Only one death case because of contusion, patients died in the second surgery. The others had good outcome. 3.6. Clinical status after discharge Because of the treatment median duration was 6,5 days, therefore after discharge, it could not easy to evaluate the vision. 3.7. The recurrence The average duration for re-assessment was 29.51 months, there was 3 in 47 patients indicated recurrence. The proportion of recurrence was 6,38%
12 3.8. Long-term observation and vision progression 3.8.1. The continuous variable The average age of patients was 49 ± 11 years old. Duration of incubation was 10,5 ± 10,3 months. The average size of tumor was 2,9 ± 0,9 cm. The smallest was 1 cm, and the largest was 4,7 cm 3.8.2. The un-continuous variable Gender, Visual impairment, Location, Approaching way, Tumor removal, Histopathology, Visual recovery. 3.8.3 Single variable analysis the factors relating to visual recovery In single variable analysis, the long duration from visual impairment to admission significantly related to vision poor recovery 3.9. The visual recovery after re-assessment Recovery 62,62%, No change 25,37%, worse 11,95% 3.9.1. Age and recovery The recovery did not relate to the age of patients, no statistically significant, p=0,77 3.9.2. Gender and recovery The visual recovery did not relate to the sex, no statistically significant p = 0,14 3.9.3. The duration of preoperative symptom to admission and recovery The earlier admission, the more visual recovery, statistically significant, p = 0,009
13 3.9.4. The location and recovery The sequence of location with high outcome was A + B and A, C2 and B+C, B + C1. However the amount of patients with sphenoid, diaphragm of sella, tubercle of sella + planum sphenoidale was small, no statistically significant p = 0,93 3.9.5. Tumor size and recovery The visual outcome did not relate to tumor size, no statistically significant p = 0,39 3.9.6. The approaching way and recovery The visual outcome did not relate to pathway, no statistically significant p = 0,84 3.9.7. Tumor removal and recovery The tumor removal did not relate to visual recovery, no statistically significant p = 0,24 CHAPTER 4: DISCUSSION 4.1. The clinical characteristics of supra sellar tumor 4.1.1. The epidemic characteristics The supra sellar tumor took 2-10% of meningioma Results: The supra sellar tumor/meningioma = 13,38% This result was the same with others study such as Lindsay 1984 (10,7%), Rachneewan 2013 (18%) but lower than Duong Dai Ha 2010 (33,78%)
14 4.1.2. Gender Female was higher proportion than male (female/male = 4,7/1). This result was higher than Chuan Weiwang 4/1 and Micrrocerrahi 3,5/1; lower than Racheneewan 6/1 ( Table 4.1) 4.1.3. Age In female and male, the average age was 48,1 and 48,6 years old. This result was suitable with Cushing period the average age was 40-50, and Liu Yi 2014 (48,5 years old) 4.1.4. The duration of preoperative symptom to admission In the study, patients from visual impairment to admission before 12 months took 64,39%. The average duration from blurred vision to admission was 11,9 months. This result was suitable with the others: Ratchaneewan 208, Microcerrahi 2008, Nevo Margalit 2013. 4.1.5. Clinical characteristic Blurred vision was the most common chief complain. The silent development of tumor caused the gradual progress of signs and symptoms. In this study, 57 patients with 114 eyes, there was 4 patients with normal eye (8 normal eyes). And 53 patients (106 eyes) with mono or bilateral damage 93% (81 eyes damaged with 9 blinded eyes, and 72 blurred eyes). In comparison with Jose Alberto 91,3% patients with blurred eye, Seung joo Lee 95% blurred eye, higher than Hischam 87,1%, Martin 77%. However in the report of Naoki and Mostapha the visual impairment was 100%.
15 Head ache took 95,6% of chief complain. This insidious symptoms was not be well noticed and could be misdiagnose with other disease In conclusion, blurred vision and head ache always went together. Physician should consider to indicate earlier MRI. The others: epilepsy and endocrine disturbance,… was rare. 4.1.6. Magnetic resonance imaging: 184.108.40.206. The location of supra sellar tumor In this study, the supra sellar tumor in diaphragm area was divided into two locations: C1 ( the tumor locating posterior, anterior and inferior the schism) and the C2 (the tumor locating inferior and posterior the schism). The results of our research: The C location including C1 (7%), C2 (40,35%). The pituitary pedicle (24,56%) (B), planum sphenoidale (5,26%) (A), pituitary pedicle and diaphragm (19,3%), pedicle and planum sphenoidale (3,5%). In 2014, Liu Yi proposed the C location (C1 10%, C2 43%). B: 25%. A: 21%, Ratchaneewan 2013: Location A+B: 6,25%. B+C: 40,63%. B: 15,63%. C: 6,25%. In conclusion, the supra sellar tumors mostly originate from the diaphragm of pituitary, and rarely from the planum sphenoidale. According to many authors, the location of tumor could predict the possibility of recovery. Liu Yi proposed the sequence of good outcome: planum sphenoidale (A), diaphragm posterior to schism
16 (C2), pituitary pedicle (B), diaphragm of pituitary anterior the schism (C1). This also in our study. 220.127.116.11. The size of tumor In this study, the tumor size 2-3 cm took 35,08%, 3-4 cm took 33,33%. The average size was 29 mm. The smallest tumor was 10 mm, and the largest was 49 mm. In comparison with Seungjoo Lee, Ratchaneewan, Uchick, Pietro: 28,6 mm; 2,7 mm; 2,6 mm; 26,5 respectively. 18.104.22.168. The magnetic resonance imaging characteristics In this study the specificity of MRI on the supra sellar tumor was 100% and confirmed by histopathology. The high intake of contrast was 93%, the homogenous was 79%, the dural tail was 49,12% and only 7% patients with brain edema. Ratchaneewan 90%; 90,6%; 33,3% and no edema respectively. In conclusion, the specific image of supra sellar tumor on MRI was: decrease signal in T1, equal with grey matter, high intake of contrast, homogenous, dural tail without sella turcica widening. 4.2. The outcome 4.2.1. The surgical pathway There was 7 doctors with 5 pathways, the most common was the frontal-temporal incision 42,1%. The bifrontal incision (3,5%), unifrontal incision (28,07%), and Keyhole (17,54%), right temporal incision (1,75%). Other authors such as Uschick (2005), there were 53 patients selected and only with temporal approach, Seungjoo Lee
17 (2016) reported 100 patients with the supra sellar tumor approached by three
longitudinal fissure (1%), Martin (2015) reported 27 patients with the supra sellar tumor approached by two incisions: frontal-temporal (81,48%), unifrontal (18,52%). Some authors also proposed the prediction possibility of incision with the outcome . For example Liu Yi, Nakaruma showed the most advantage of frontal-temporal approach. 4.2.2. The outcome according to Simpson classification In 1957, Simpson proposed the tumor removal with 5 level. In this study, most of surgeon approved the impossible of Simpson 1 with tumor removal because of the anatomy. Therefore, in this study, it is classified into three level: Level 1: Total tumor removal with or without ablation of dural mater (Simpson 2 and 3). Level 2: Partial tumor removal (Simpson4) and Level 3: Biopsy (Simpson 5) According to the aforementioned classification, this study had 54,38% Level 1, 43,85% Level 2, 1,77% Level 3 The Level 1 in this study was lower than the others, Margant 80%, Ahmed 81%, Naoki (87,5%) 4.2.3. The complication during and after surgery In this study, 2 patients with intra cerebral hemorrhage at frontal lobe, one patient with contusion, three patients with brain edema, one
18 patient with meningitis and one patient with spinal fluid leaking. Most of them were received conservative treatment with good outcome. 4.2.4. The mortality after surgery Only one patient died in this study, the rest was stable and the duration of treatment last 5 days. The cause of death was intra cerebral hematoma even re-performed surgery. 4.2.5. The patient status after discharge According to Karnofsky, 8 patients was graded with 50-70 (assistance requirement), and 48 patients with 80-100 grade, 1 patient death. 4.2.6. The histopathology result According to many researchers, most of the skull base tumor was benign: 96,5% WHO Grade 1, Grade 2 and 3 took 3,5%. In this study, epithelial tumor took the main proportion. 4.2.7. The visual outcome In this study, the average duration of re-examination was 29,5 months. The shortest was 12 months and the longest was 60 months. In 57 patients: 1 patients died after 5 days, one patient death after 4 years because of another disease not relating to the supra sellar tumor, 8 patients loss of contact. There were only 47 patients reexamined: 4 pre-surgery normal vision with stable after surgery. In 43 patients (8 eyes) with visual impairment: 62,68% visual
19 progression; 25,37% no change; 11,95% worse. The same sequence in other studies was: Hischam 53,2%; 29,8%; 17%; Nakurama 68%; 20%; 12%; Bassiouni 65%; 20%; 15%. 4.2.8. The recurrence In 47 patients, there were 3 patients with recurrence and reperformed surgery in Viet Duc hospital. Hischam with 62 patients observation in 6 years had 3,4% recurrence. Xingang Li with 43 patients, and average 5,4 years of re-examination duration, there was 4,6% recurrence. Fifty three patients of Uschick, with 29,9 months of duration, there was 3,7% recurrence. 4.3. The visual recovery 4.3.1. Age and the visual recovery 4.3.2. The duration from blurred vision to admission in the relation with visual recovery The earlier, the better outcome, statistically significant, p=0,009 The re-examination in 43 patients with vision impairment, it could be proposed the distribution of supra sellar tumor: A (from the planum sphenoidale): 1 (2,33%) B (from pituitary tubercle): 12 (27,9%) C (from pituitary diaphragm) - C1 (anterior schism): 2 (4,65%) - C2 (posterior schism): 19 (44,19%)
20 A+B: 2 (4,65%) B+C: 7 (16%) The outcome following the sequence good-no change- worse: A: 100% good outcome B: 66,66%-16,66%-16,66% C1: 50%-50%-0% C2: 73,68%-15,78%-10,54% A+B: 100% good B + C: 71,42% - 28,58% - 0% According to the location of the tumor , the sequence of good visual outcome was: A + B and A, C2 and B+C, B and C1. This result was the same with Liu Y A>C2>B>C1 (106). Chuan wiwang proposed the best location was diaphragm (78,6%), gradually lower planum (75%), tubecle (69%) 4.3.3. The tumor size and visual outcome It was the result: - Tumor < 2cm: good 70% - Tumor 2-3 cm: good 54,5% - Tumor 3-4 cm: good 73,3% - Tumor > 4 cm: good 55,5% Many authors showed the tumor size could affect the outcome. However, the was not in our study, no statistically significant p = 0,39)
21 4.3.4. The surgical incision and visual outcome In 43 re-assessment patients with visual impairment, the surgical incision result was: - The frontal-temporal incision: 20 patients with 64,7% good; 23,52% no change; 11,78% worse. - The unifrontal incision: 13 patients with 72,2% good; 16,66% no change; 11,14% worse - The Keyhole: 9 patients with 61,53% good; 15,38% no change; 23,09% worse - The bifrontal incision: 01 patient and the result was worse This result also met Nakamura, however different with 57 patients of Uschick approached by unique frontal-temporal incision. Chokyu with bifrontal incision had 90,6% visual recovery. In conclusion, the visual outcome did not relate to surgical incision, no statistically significant p = 0,84. 4.3.5. The tumor removal and visual outcome In 43 re-assessment patients, 58,13% with Simpson 2 and 3; 39,53% with Simpson 4; 2,32% with Simpson 5. However the visual recovery archieved 62,68%, the same with Liu Yi 2014 (the total removal 79%, and visual recovery 66%), and higher than Hischam (the total removal 80%, visual recovery 53,2%). It was proposed that the possibility of visual recovery does not depend on the total or partial tumor removal, but significantly relates to which part of tumor
22 removed and the conservation of dural mater, subarachnoid, optic nerve, schism… The level of tumor removal did not relate to visual recovery, p = 0,24 4.3.6. The comparison of visual recovery factors with other authors. Patien