Brain Tumor Res Treat.  2018 Oct;6(2):60-67. 10.14791/btrt.2018.6.e14.

Surgical Outcomes of Thalamic Tumors in Children: The Importance of Diffusion Tensor Imaging, Neuro-Navigation and Intraoperative Neurophysiological Monitoring

• Kim JH
• Phi JH
• Lee JY
• Kim KH
• Park SH
• Choi YH
• Cho BK
• Kim SK

• KMID: 2423975
• DOI: http://doi.org/10.14791/btrt.2018.6.e14

Abstract

BACKGROUND
Recently, modern technology such as diffusion tensor imaging (DTI), neuro-navigation and intraoperative neurophysiological monitoring (IOM) have been actively adopted for the treatment of thalamic tumors. We evaluated surgical outcomes and efficacy of the aforementioned technologies for the treatment of pediatric thalamic tumors.
METHODS
We retrospectively reviewed clinical data from 37 children with thalamic tumors between 2004 and 2017. There were 44 operations (27 tumor resections, 17 biopsies). DTI was employed in 17 cases, neuro-navigation in 23 cases and IOM in 14 cases. All diagnoses were revised according to the 2016 World Health Organization Classification of Tumors of the Central Nervous System. Progression-free survival (PFS) and overall survival (OS) rates were calculated, and relevant prognostic factors were analyzed. The median follow-up duration was 19 months.
RESULTS
Fifteen cases were gross total resections (GTR), 6 subtotal resections (STR), and 6 partial resections (PR). Neurological status did not worsen after 22 tumor resections. There were statistically significant differences in terms of the extent of resection between the groups with DTI, neuro-navigation and IOM (n=12, GTR or STR=12) and the group without at least one of the three techniques (n=15, GTR or STR=9, p=0.020). The mean PFS was 87.2±38.0 months, and the mean OS 90.7±36.1 months. The 5-year PFS was 37%, and the 5-year OS 47%. The histological grade (p≤0.001) and adjuvant therapy (done vs. not done, p=0.016) were significantly related to longer PFS. The histological grade (p=0.002) and the extent of removal (GTR/STR vs. PR/biopsy, p=0.047) were significantly related to longer OS.
CONCLUSION
Maximal surgical resection was achieved with acceptable morbidity in children with thalamic tumors by employing DTI, neuro-navigation and IOM. Maximal tumor resection was a relevant clinical factor affecting OS; therefore, it should be considered the initial therapeutic option for pediatric thalamic tumors.

Keyword

Thalamic diseases; Diffusion tensor imaging; Neuronavigation; Intraoperative neurophysiological monitoring; Treatment outcome

MeSH Terms

Central Nervous System
Child*
Classification
Diagnosis
Diffusion Tensor Imaging*
Diffusion*
Disease-Free Survival
Follow-Up Studies
Humans
Intraoperative Neurophysiological Monitoring*
Neuronavigation
Retrospective Studies
Thalamic Diseases
Treatment Outcome
World Health Organization

Figure

• 

  Fig. 1 A heatmap illustrating detailed information on adopting modern technologies (DTI, neuro-navigation and IOM), the extent of tumor resection and postoperative neurological status. DTI, diffusion tensor imaging; IOM, intraoperative neurophysiological monitoring; GTR, gross total resection; STR, subtotal resection; PA, partial resection.

• 

  Fig. 2 Kaplan-Meier plots for PFS and OS of 37 patients according to histological diagnosis (A and D), the extent of tumor resection (B and E), and adjuvant therapy (C and F). PFS, progression-free survival; OS, overall survival; GTR, gross total resection; STR, subtotal resection; PA, partial resection; GBL, glioblastoma, IDH-wildtype; AA, anaplastic astrocytoma, IDH-wildtype; DMG, diffuse midline glioma, H3 K27M-mutant; CNS, central nervous system; PA, pilocytic astrocytoma.

• 

  Fig. 3 Demonstration of planning of surgical approach via preoperative DTI. Coronal MRI (A) and DTI (B) show left thalamic tumor with anteromedially displaced thalamus and laterally deviated PLIC. The transparietal approach was adopted, and gross total resection was performed (C). Coronal MRI (D) and DTI (E) show a right thalamic tumor with anteromedially displaced thalamus and anteromedially deviated PLIC. Tumor was radically removed via a transtemporal approach (F). DTI, diffusion tensor imaging; PLIC, posterior limb of internal capsule.

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