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SNI Digital, Innovations and Learning, an association with the Hose Neurosurgery Lab and Baghdad Iraq are pleased to present. The 22nd SNI and SNI Digital Baghdad Neurosurgery Online Meeting held
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on March 23, 2024,
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the meeting originator and coordinator of Sammer Hose of the Universities of Baghdad and Cincinnati.
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The subject of this meeting is Pediatric Neurosurgery, Global Pediatric Neurosurgery Experience and Cases from Argentina, Iraq and Nicaragua. The meeting organizer and moderator is Jorge Lazarus,
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Emeritus Professor Pediatric Neurosurgery at the UCLA Medical Center in Los Angeles, California
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This presentation will be on the subject of pediatric brainstem tumor biopsy. How we do it and why? By Lucilla, Domica, Laplace, Fidel Sosa, and Andre Servio of the Department of Neurosurgery at
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Feliney Hospital and Medical Center in Buenos Aires, Argentina. So my name is Lucida de la McLaplace I'm a fifth year neurosurgical resident
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at Feliney in Buenos Aires, Argentina. And together with Dr. Fidel Sosa, who is the chief of the PTHR at New Social Department here in Feliney, and his whole team of pediatric neurosurgeons, we
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wanted to present to you our cases of the sub-temporal approach for the biopsy of diffuse brainstem high-creatic leomas.
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So as an introduction, We all know tumors of the brainstem constitute a very heterogeneous group, ranging from what are the low grade primaries and from nervous systems tumors, such as the
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pylocytic astrocytoma among others, to what are the high grade tumors. Since the hook classification from 2021, they constitute mostly the H3K27M mutant, diffuse midline gliomas, as well as other
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H3 wild type tumors
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So brainstem-diffused tumors represent approximately 10 of all pediatric central nervous system tumors. Among them, the H3K27M mutant, diffuse midline gliomas are very rare childhood central
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nervous system tumors that carry a dismal prognosis, as we all know with a mean survival time of 12 to 24 months, sometimes even less. So tumor biopsies not only helpful for addressing a correct
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diagnosis, but it's also a very important strategy nowadays for the continuous study of further therapeutic options and specific molecular targets in order to find a treatment for this pathology.
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Given their complex location and the lack of effective current treatments, even though there's surgical options that we have cannot guarantee a macroscopic or a gross total or even an ear total sub
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total section of these tumors, they do offer the possibility of biopsy in these lesions with the aim of their understanding their behavior and the hope of finding some molecular targets on some
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additional treatment.
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So there are multiple surgical approaches described. One of the most commonly used are both stereotactic biopsy or either neuro-navigation guided surgery but however what we wanted to present is our
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experience with open biopsy also to be safe and accessible route to properly address pathology.
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So what we like to do is to use the sub-temporal approach. The sub-temporal approach provides an easy and safe approach. It gives a good bleeding control with no need of additional technologies,
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such as are the stereotactic of the new navigation surgeries It also gives the opportunity to obtain big and the morphological samples, which we all know are extremely important in order to obtain
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all the molecular biologists that the patient needs. So these are today's section views. We would like to thank the left one to Dr. Maximilian Unius, who kind of lent it to us for this
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presentation. It shows the lateral view of the right sub-temporal approach and the second one shows the syphallic view, which shows the great corridor that the sub-temporal approach provides.
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accessing the bonds. So our our idea now was to present two patients that we had at our service and that we operated using this this approach as an example of how we do it. So this is the first
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patient that this patient was a 13 year old male. He presented with a right third cranial nerve six and seven cranial nerve palsy as well as some gate disturbance. So he went to an neurologist, the
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orders and an MRI and what they found was this very expansive lesion. It was approximately five centimeters in diameter. This
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this sequence is a flare sequence. It was hyperintense inflammatory tube and
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it generated all
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this comprising of the fourth ventricle as well as the adjacent structures.
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So we talked this patient over with our neuro oncologist or pediatric neuro oncologist team and we decided to perform a biopsy. So we did it via the sub temporal approach. We had good samples, the
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patient had no per separated complications. And the result was an
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H3K27M altered diffuse dioma. These are some of the pictures of the anatomopathological results This is the H3 staining, and this is the HNE result. The patient, these are his postoperative MRI.
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This is a three month postoperative MRI when he started the radiation therapy. It's the eight month postoperative MRI. The patient had no complications due to a surgery or the treatment either, but
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he died a year after the surgery, due unfortunately to oncological progression of the disease So this is the second patient. It's a very similar patient. It's a 12 year old female patient that
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presented with a bright facial palsy and
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left brachochuropulsive, comfortable with a Miller-Gobler syndrome. So it was very similar. We talked it over with the neuro-oncological team and we decided to form a biopsy and the result was same.
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It was an H3K27M, if you use midline glioma. This is the H3 staining and this is the
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metoxilineusin result. Even though the patient had no
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necrosis or mitrovascular proliferation, the H3 positivity result correlated with the
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H3K27M, midline diffuse glioma result. So this is his eight month was operative MRI. The arrow shows the biopsy site. The patient had no complications currently undergoing oncological treatment,
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but she's on the second line of treatment now due to the prognosis of this pathology. So in conclusion, the diffuse midline gliomas are rare child groups and from nervous systems. They carry a very
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decimal prognosis unfortunately. Historically biopsy for these tumors was only used when the diagnosis was not clear They used to be treated only by the image, but nowadays with the forthcoming of
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different surgical techniques and mostly with the development of new subtypes of molecular targets, the biopsy seems to be a fundamental step nowadays. So we wanted to present an alternative to
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what's usually used, such as the stereotactic or the new navigation on surgeries, which is the sub temporal approach, a classic approach to the brainstem, but which is an excellent alternative to
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buy-ups in the pathology and with no need of additional technology.
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So, well, this is the bibliography, and that's all, I wanted to thank everyone for the opportunity to be talking with you right now and to be on the part of these presentations. So, thank you
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very much. Thank you, Dr. Lometra, La Blas, thank you. Quite challenging, no? Because
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as everybody in the audience know, the brainstem tumors are a no-go area, you know? Yes And there is
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one important aspect of this that
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I didn't have this experience. I never use this approach sometimes for the biopsy of intrinsic tumors. We all went posteriorly, not through the very miserable retraction. And this is a much
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smarter approach independently of the way because your patients have fun, unfortunately, sometimes outcome, right?
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We always, and with this, I know that I may get into some problem for saying this, we did sometimes by doing surgery, by doing a safe surgical procedure, by we are showing to the family and to
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the patient that is, although the prognosis can be this small, although the outcome is not guaranteed, although the child may not survive, we still say, Okay, we are going to do the best that we
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can. And that is allowable in itself, you know. So, alterations in itself. And that's the spirit, also, of a pediatric neurosurgeon. And I'm sure on all the others, but I am biased for
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pediatricians, is that you go and you do the extra step. I mean, yes, don't worry. is a fatal disease, but we here will do the best. We will put ourselves on the test to improve the health of
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your child. Summer holds as they, summer, do you have to say something? Yeah,
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thank you Dr. Laplace for this nice presentation. I really appreciate
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the initiative for the pushing for alternatives
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depending on the cases and the ignorance and to be individualized according to patient. Speaking on the bias, Professor Lazarov, I'm biased to the vascular. So my question to Dr. Laplace will be
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more on the doing September for biopsy. I can imagine it will be less invasive than the usual September we use for skull base But is
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there's any need to - to consider the Vinafla Bay as an obstacle of planning, maybe it will affect the site of approach or just to consider why the section. So what's your thoughts on that? Yes,
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it's an excellent question. So we will, first of all, we see if the patient, well, if it has the age enough to see if he's left or right handed, and we always use the non-dominant side, but
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besides that, yes, the Vinafla Bay, it's crucial for this approach. So we evaluate it with the pre-operative MRI if we are going to have the enough corridor for use for use of this approach. And
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if Vinafla Bay is quite in the middle of it, if it's not possible, we don't do it. I don't know if Delcrefidels also wants to say something else. He's the main surgeon and the one with the most
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expertise.
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Unfortunately, we have no problems with La Verbein Yeah.
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Always come and come, we do the biopsy.
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Yes, we haven't encountered any problems with it, but yes, it's a very important thing to consider when using a sub-temporal approach.
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Yeah, thank you. Well done. Of course. Could you go back to the images you had in your presentation and share screen? Yes.
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And where you had A, not patient B, but patient A. Yes, of course.
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Fidel, you're approaching this, that was very good. You're, there are many ways to approach this. The traditional way was to approach this posteriorly, I guess, and somewhat separately. You
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chose the sub-temporal way because it was easier for the patient, easier surgery, can you talk about that?
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Yes, it's very, it's an easy surgery for us. We are, realize a lot of ones, and we prefer this socially because the better, we have a
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better breathing control, and we can take larger amount of our artificial ensembles. And in this, less technology, because in our kind of business, sometimes it's difficult to get some
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technologies as a node, a node, a node, a brigade, or a state attack, this, a biopsy.
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Fidel, let's say the tumor was located in the, on the floor of the fourth ventricle, in other words, superiorly and not laterally, this is diffuse,
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that would make it a longer route to get to that, wouldn't
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it? is that human is in the floor of the, in the fourth boundary of the way.
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we approach the tumor with a telovellar approach. With a telovellar approach. Yes. So you do it posteriorly. So it depends upon the location of the tumor as to what approach you're doing and so
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forth. And then on case B,
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Lucia. Yes,
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of course, here. It was obviously located more to one side So how do you choose what area? There's some that have eye contrast or hyperdense area. There's some that are lower dense. How do you
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make
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a choice on which area to choose?
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Fidel, could you answer that or? We'll show the areas with the, there are more cellularity. Also in
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MRI, we can know which is the, the shown that is most cellularity. This is the
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exactly place to the biopsy. So, if you look at the image, so that would be the image would be where you, where you have the most contrast material. So anywhere, anywhere in that image, or
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would it be in a more, in the more cystic area, where you could get at least some decompression? How do you deal with that?
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Sometimes these tumors not take very contrast, contrast. There are, without contrast,
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a bit really, we treat to take a large, large amount of pathological samples. And we have no problems with the patient, with
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the patient doing well in a few days. And oncologist's scan to, to begin with the complementary treatment.
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And so,
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so how do the people do? What are the complications? How do they do after your surgery?
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We have no complications Maybe,
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and
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in Madoma, sometimes, but it's not frequent.
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And no complications. You have any cranial policies or any sensory deficit or motor deficit or are they transient or they get over it quickly?
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I don't
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understand the question, please If they have a deficit, a neurologic deficit, Is it just brief or is it not at all for any of them? No, we have known the relational, we've known the
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relational deficit.
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How many biopsies do you take of the brain stem? Do you take multiple or do you take one? No, we take multiple, multiple biopsies
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Sorry, we also do some, we do some frozen biopsy at the time, we have the pathology team waiting for the biopsy so that they can certify that what we have sent is enough, and that we are at target
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for the place of the tumor So we always do it with the pathological team in place for us to be okay with the amount that we are sending. I'm sorry, I interrupted Of
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course, Fidel, sorry, I'm not sure I am. I'm speaking very loud, but if you did remember that we have also a band in the pathological section to not to put some samples of all of our tumors, not
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for frozen section to preserve in a frozen condition samples of the tumors for the future. Maybe for ventilation, maybe for a foundation one, whatever the patient or the family decide So we have to
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need more than one biopsy, they'll perform as we are in the other population. We took a lot of biopsy, if it's possible. In those cases, you know, the human is big enough to take out more than
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one biopsy
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Thank you, Andre. Sure, there's some people who want to know what kind of
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an instrument you used to biopsy at So, I said, do
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you use a little biopsy for a sense of where? What did you use a little needle and do some aspiration? How do you do this? Because other people may want to try this and because of your approach.
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What do you do? You use biopsy, four steps. A biopsy, four steps, are you? Yes, yes. Okay. And do you do anything special with the bleeding that you get after you take the sample? Or how
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deep, how do you know how deep to go and so forth? So maybe one centimeter, and we have no bleeding. And we can, we should this approach, we can control the bleeding.
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Okay, so no deficits and no bleeding. You go about a centimeter in. Yes.
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Okay. Oh, okay. Now, I assume you're, as Andrea said, you're collecting all these, you have a tumor bank. And there's some papers appearing in the literature the genetic changes, and some of
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them are, at least one of them I know I've read, as sensitive to some chemotherapeutic agent. Are you doing anything in this line? Yes, of course. This is the reason why we change our policy. I
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will speak about adult population. I performed surgeries in the adult population. Fidel is the chief of the
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Peliatrix area unit. But the point is it's more or less the same until maybe six years ago, six, five years ago, the policy of our neuroemphological department was completely different in the
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adult population. Brenistem tumors, like the first case Lucila showed, maybe our oncologist said go to the, to treat the patient with radiotherapy now because of the advancement in methylations.
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Our oncologist wants the biopsy and is mandatory to perform biopsy to do methylations. We are involved with the Heideberg group. we are trying to do the methylation in the same way that they are
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doing. And that the reason why they try to obtain it very clear the most important histopathological diagnosis, in order to know which way to treat chemotherapy, immunotherapy, you know. In our
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case, we have our ball tumor, neurosurgeon performed the surgeries, but then our oncologist, which are very jellows, who had took up the patients and decided the treatment, but they need biopsy.
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Since the last five years, we changed our policy. Fiddle maybe, she's doing the same approach because, you know, it's more frequent in the pediatric population.
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Dr. Alwash here asked what about intraoperative neurophysiology monitoring? Do you do any monitoring? Yes, yes. We'll use You use a monetary always. Yes.
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What do you monitor?
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You know, we're the eighth nerve or the seventh nerve. What do you monitor, what do you
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want? Yes, we have electromyography of the fifth, six, seven, lower tranial nerves, and then long, long tracts in motor evoke in potential and some of the sensitive motorboat potentials. And
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we also have the possibility to
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have, we are using a specific cannula of aspiration with the isolated the team in order to perform stimulation, monopolar stimulation if you want, in the middle of the brainstem. So when we are
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trying to check out the biopsy with the forces as a field search after doing that, sometimes we put this cannula in order to change. It's not subcortical, but it's intra-brainstem, in order to
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know how. how near from the nuclear tranial nerves we are. Excellent, and that's it. So you said immediately elevates the procedure to something that should be in centers, like yours that have
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all that extra monitoring equipment and so forth, is that correct?
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Yes. No, okay. So
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the next patient that will come to your service, you will do this approach. So the next child with high grade leoma, diffuse segment, brain strength leoma, will have the sub-temporal approach and
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you will be collecting data of that, okay? Wonderful, I think that. Hopefully. Yeah, how many cases do you see? How many cases do you see, buddy? How many cases a year do you see?
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Your referrals after how many come a year with Bringsham Tumors.
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How many cases? Yeah, how many do you think, Fidel, that you operate a year? We are using this technique for a lot of years ago. We prefer this technique that done the
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reproductive biopsies or no renovation biopsies. I
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think we are using this technique almost 20 years. And we use now, we like this approach.
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So I had a question there. How many of these tumors do you see? You're under a, how many do you see? You're brainstem tumors? Maybe two, no, two,
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go ahead. Just finish. Is there a reply first in the pediatric population, please? Yes. Yes. Yes. Maybe two or three tumors are near. Okay, so it's
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not common anymore in the world and when you're a major center, and you get two or three a year or so, it's not something somebody's inexperience should do. Is that correct? Oh, yes. No, but
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also in the moment, there is this popular belief even here in the United States that if the patient has a brainstem glioma, the neurologist usually send this directly to the neuro oncologist, they
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bypass the neurosurgeon. I feel that if you expand or you present cases you are at the casuistic in publications and in conferences more and more that the number, that the culture of avoiding
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surgery for brainstem gliomas can naturally change. I would like to, because otherwise this is the fascinating subject, but we have one or two more at least, or three or four more fascinating
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subjects. I would like you to, yes, don't ask me, I say something. No, no, no, it's fine, I don't want it to. I mean, I think the answer is a very important questions. Everybody needs to
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know. I compliment them on trying to get tissue in these tumors. Otherwise, we don't know what we're treating. I think you've done a great job. Absolutely. And I have to make a brief note. I am
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extremely happy to see Dr. Sosa in the command of this. I remember when he was a resident. Anyway, so sorry for that, I mean, don't at all. Dr.
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Huandong Sal is then one. Remember you are ready to share your. Yes, yes, Professor. Yes, Dr. Laplace with your case A, number A. Ah. Yes. It's already - So extensive. I think the biopsy
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was a bit late. Patients must have presented with lots of geological problems The patient, yes, he had a. a three-week history of
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his neuroilogable deficit. And he went to the neurologist and the neurologist ordered the MRI and due to the MRI, he was not from Buenos Aires. He was from a province that's quite far from here.
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So the medical attention there, it all takes a lot more time. So when they performed the MRI, the patient was then referred to Flany. And when the patient came here, the deficit was quite severe
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But that happens a lot here in Argentina because we have a lot of centralized medicine. So in Buenos Aires, we usually do have, fortunately, quite fast treatment and evaluation of patients. But
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when you go outside of Buenos Aires and mostly to other provinces, it takes a lot of time for patients to be referred to big centers. Yeah, thank you. Very nice, sorry, Lucilla. Thank you so
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much for the
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presentation.
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