Transcript
So, we're gonna start this afternoon session. My name is Javier Fandino. I am a neurosurgeon working in Aarau, in Switzerland. It's a pleasure for me to present all the distinguished speakers. So we'll talk on benign brain tumors and radiosurgery applications. The first announcement I have to, I was asked to do, is that after the session is gonna be a group picture here. So, prior to the break, we should stand here and be ready for a group picture. So be awake.
On behalf of all the speakers, I would like to thank the company for this great opportunity to talk from a neurosurgical and radiological point of view about benign brain tumors. My topic is gonna be more than an introduction, and then I will just make some comments on meningiomas, which are very common nowadays. And we are neurosurgeons and radiosurgeons are very confronted every day with these diagnoses. And we have to decide for the patient. Most of them are asymptomatic. They don't have deficits and they need an explanation for treatment.
I don't have any disclosures related to this issue or to this talk. And as I said, incidental meningioma is a very often diagnosed nowadays. And we found in about 1.85 per 100,000. In the U.S., nowadays more in women than men. And the relative annual growth rate ranged between 0.48% and 2.8%. The tumor doubling time range between 1.2 and 143 years. So we have a lot of range of growing in these benign lesions. And the question is always, should we treat or not? Should we operate or should we go for a radiosurgery?
There are many groups of patients operated or treated or not, which are collecting information. So we have to be prepared and include all therapeutic options during the explanation of this diagnosis. There are big tumors, big meningiomas that there's no question that has to be treated. Like, this a huge planum sphenoidale meningioma, which has to be operated in order to relieve the patient from the mass effect, and try to gain a better cognitive function.
And also there are small meningiomas in patients that are asymptomatic or have very few or mild deficits. So, for example, in this young patient that we treated, a couple of weeks ago in my hospital, we were confronted with a different therapy options to observe and follow up to do just a biopsy, for example, in order to get the histology to know if it is Grade II or III, to do a biopsy and the radiosurgery, to do just as radiosurgery, or just to go for surgical removal.
And I show this case because as a neurosurgeon I have to remember you. Most of you are radiosurgeon that a microsurgical resection is still an option. As you can see here, this patient was treated microsurgically, and we could got an excellent result with a total removal of the lesion. Not always is like this. Many patients are different, and they cannot be resected totally.
Another case, also the tentorial meningioma with an excellent result. These two patients did not have any complication and are recovering pretty well from surgery. So, why change the challenge from in pathology? The introduction of CT/MRI is a reason. In the first world, the amount of MRIs that are done in the normal population is increasing. For example, in Switzerland, we have the highest density of MRI in the world. And the safety of intraoperative techniques also allow us to operate more early these cases with a less surgical risk.
Aging population. Life expectancy is also a reason to have an increase of the incidence of this pathology. But also histologic grading. Twenty years ago we did not, or we were not aware that many patients, around 20%, were at Grade II and Grade III. They grow faster, and they have to be treated earlier. There are a lot of epidemiological studies published and, of course, we have the advances in nonsurgical techniques like radiosurgery, which allows us to treat these cases.
The most important thing I think, when we are confronted to incidental meningiomas, is histology nowadays, or the awareness of histology. We know, based on different studies, that incidentally found growing meningiomas are more malignant or more Grade II and III than incidental found or symptomatic meningiomas. So we have to always aware, should we get a histology prior to the treatment or not? Is this meningioma growing up faster or not? Because the chance to have a Grade II or III, which is related or associated with a poor outcome, regardless of the treatment, has to be considered.
We know, for example, from this study from Kasuya et al that the incidental-growing found meningiomas have a higher proliferation index compared to asymptomatic or compared to just to incidental without any documented growing. So we have to be aware of that. And we also know, we also have many patients like this one, for example, who was follow-up 10 years, and all of a sudden, the meningioma start to grow. For example, we see the MRIs from 2006, and 10 years later we just realized that the tumor was growing. So, this case has to be treated in order to avoid neurological deficits.
The annual growth rate cannot be denied. All studies show that. And we know that, as I said, relative annual growth range between 0.48% and 2.8% a year. So there are facts in literature regarding growth rate. And many people try in the last year to do like treatment algorithm to write about that. For example, this a patient on a review paper by Caldwell.
And as you'd see, many people try to divide the treatment between the two age groups, less than 65 or older than 65, but actually there is no consensus. And in patient less than 65, you can do whatever you want as a physician or as a neurosurgeon try to talk to the patient. There is actually no consensus based on the size of the tumor, based on the location, or the risk of the radiosurgical treatment, or the surgical treatment.
So then the idea of Leksell, that time in the 50s, was actually to bring the radiosurgery to a surgical vision. And I think that is the most important thing that he did. And we are very, very grateful with the new softwares developed and new vision, for example, from this company, in order to bring this vision to help us to think in radiosurgery during the surgery. And we will hear more about that here with the next speakers.
So this concept, to bring surgery and radiosurgery, help for the surgeon to be aware that he or she has to think about radiosurgery during the resection of the tumor. So, the limits of the surgeries are more important for the surgeon having these kind of technical tools. So there's no place for egos, for surgeons nowadays. We have to think about neurological deficits, about life expectancy, about the possibility to treat the patient with radiosurgery after the microsurgical treatment. So, for me, as a neurosurgeon, it change a lot the way I had to understand and to proceed the aggressivity during the surgery.
So this software, like the adaptive hybrid surgery, help us to have a workflow, which start before the surgery with a planning, and during the surgery, or during the debulking, help us to limit or to stop the resection in order to plan the radiosurgery right during the search or to talk to radiosurgeons during the surgical treatment.
And this is, for example, OR and the surgeon and the radiosurgeon is sitting next to the head of the patient discussing. Based on this software, if the tumor has to be resected more extensively of we can start a risk more or not. So this new vision, this new understanding of the limit of the surgery, surgical treatment, is for me one of the most important thing, and I hope that the company will support the further development of these tools for neurosurgeons, which actually will support the radiosurgery treatment in the future.
So the workflow is divided in three steps. The preop, the intraop, and the postop as you can see here. And during the surgery, based on navigation and so-called intraoperative structure up, we can...or the surgeon can know exactly the volume resected in order to stop the surgery, to stop the resection, or to go further for more in tumor resection. We can also have updates of this analysis during the surgery based on the identification of the limits of the tumor resected.
So I'm gonna show just a couple of cases in order to introduce my colleagues, my...the other speakers, which are a couple of cases of how it works. And there's a lot of work to do. And again I hope that the company will support the further development of these software. This, for example, is a 51-year-patient was operated on these huge meningioma, sphenoid wing meningioma. We planned a residual tumor prior to the surgery with/or a rediosurgeons. And he's in red for example. So we go for surgery, and we know exactly how to do, what to do, and what to resect in order to be able to do radiosurgery in a safe way.
So, this is a planned residual tumor in green. I'm gonna skip all these slides very fast. This is craniotomy plan that we did with the navigation. These are the intraop finding showing the nerve and the eloquent structures of the [inaudible 00:11:40]. And here is a tumor at the beginning of the surgery with 100% of the volume. And during the surgery, during the resection, we could document the volume, for example, of these step of surgery 65% of resection. So we go further. We calculate based on intraop structure updates the possibility and the way how to do radiosurgery. This is the way we can identify the tumor remnant, which also is not perfect yet. But I hope we will have a better tool for these aims.
So at that point of the surgery, the tumor was resected in 58%. Later at 41% as you can see here. And then we also could, at this moment, know if the patient is a single dose or hyperfractionated to therapy after surgery without forcing the resection. And there's a consensus during the surgery, which allow the interaction between radiosurgeons and surgeons. This the only moment, actually, I think that neurosurgeons and radiosurgeons have their chance to talk nowadays. Because with this software are getting faster and nobody talk to each other. You know, these elements and all these softwares are so fast that you don't even meet the planning room, you know that, and very seldom.
So, for example, this case is a remnant tumor that was achieved. And remnant tumor was radiated. Was treated with radiosurgery.
The second case, for example, is also a 59-year-old patient with this huge tumor and was also planned. Was actually a tentorial notch meningioma. We planned the residual tumor in red, showing this slide, prior to taking the patient to OR. And we know exactly that, with the residual tumor, we will not able to treat the patient with a single dose. But it was fine, and the patient knew that. And the surgeon was not forced to resect more.
This is a setup and team during this surgery. And we start, based on navigation, the tumor resection. We achieved here in green 82% of resection then go further with a 74%, 47%, and so on. So the whole surgery is a communication between the surgeon, the radiosurgeons, and in order to define what the limits are.
And these are the last pictures based on CT, for example, this case, and these are the final postop MRI findings, which were treated after the surgery. The last case very fast is a older patient, 78-year-old, also with a huge meningioma compressing the brain stem and with a volume of 20.8 CC. That's the only thing that the surgeon talk off and on about volume. We surgeon never do that before. We talk about volume, we talk about possibility of radiosurgeon. So it's the communication change, and the vision, from a surgical point of view, change with this software.
The residual tumor was in green as we can see with 8 CCs. So we defined that and then went for resection and see all the cases. The resection will start with 89% and then 78% based on volumetry 38%. And then the end, we could decide to stop the surgery with this volume of 6.5 CC and go for a radiosurgery after the surgical treatment. We can see here the remnant tumor.
So there are limitations and shortcomings, and the development is pretty slow. I don't really feel that the company is doing...probably they are thinking in the back office, but I hope that they will be faster in this development. The anatomic mapping is an issue. For example, the precision due to brainshift has to be optimized. Shaper is not optimal. The intraoperative volume-updates are also not a reliable nowadays. I hope that we can do that without any pointer. With a light tool or something like that, in order to get or to reach this deep part of the resection and so on.
And there are a future improvement that are needed. As I said, anatomical mapping, automatic mapping of tumor, volume, and organs at risk. Better tool for intraop scanning of remnant tumors, for example, with MRI, and integration of DTI data in the planning software. So, saying that, I will introduce the next speaker Dr. Orin Bloch from Chicago.
On behalf of all the speakers, I would like to thank the company for this great opportunity to talk from a neurosurgical and radiological point of view about benign brain tumors. My topic is gonna be more than an introduction, and then I will just make some comments on meningiomas, which are very common nowadays. And we are neurosurgeons and radiosurgeons are very confronted every day with these diagnoses. And we have to decide for the patient. Most of them are asymptomatic. They don't have deficits and they need an explanation for treatment.
I don't have any disclosures related to this issue or to this talk. And as I said, incidental meningioma is a very often diagnosed nowadays. And we found in about 1.85 per 100,000. In the U.S., nowadays more in women than men. And the relative annual growth rate ranged between 0.48% and 2.8%. The tumor doubling time range between 1.2 and 143 years. So we have a lot of range of growing in these benign lesions. And the question is always, should we treat or not? Should we operate or should we go for a radiosurgery?
There are many groups of patients operated or treated or not, which are collecting information. So we have to be prepared and include all therapeutic options during the explanation of this diagnosis. There are big tumors, big meningiomas that there's no question that has to be treated. Like, this a huge planum sphenoidale meningioma, which has to be operated in order to relieve the patient from the mass effect, and try to gain a better cognitive function.
And also there are small meningiomas in patients that are asymptomatic or have very few or mild deficits. So, for example, in this young patient that we treated, a couple of weeks ago in my hospital, we were confronted with a different therapy options to observe and follow up to do just a biopsy, for example, in order to get the histology to know if it is Grade II or III, to do a biopsy and the radiosurgery, to do just as radiosurgery, or just to go for surgical removal.
And I show this case because as a neurosurgeon I have to remember you. Most of you are radiosurgeon that a microsurgical resection is still an option. As you can see here, this patient was treated microsurgically, and we could got an excellent result with a total removal of the lesion. Not always is like this. Many patients are different, and they cannot be resected totally.
Another case, also the tentorial meningioma with an excellent result. These two patients did not have any complication and are recovering pretty well from surgery. So, why change the challenge from in pathology? The introduction of CT/MRI is a reason. In the first world, the amount of MRIs that are done in the normal population is increasing. For example, in Switzerland, we have the highest density of MRI in the world. And the safety of intraoperative techniques also allow us to operate more early these cases with a less surgical risk.
Aging population. Life expectancy is also a reason to have an increase of the incidence of this pathology. But also histologic grading. Twenty years ago we did not, or we were not aware that many patients, around 20%, were at Grade II and Grade III. They grow faster, and they have to be treated earlier. There are a lot of epidemiological studies published and, of course, we have the advances in nonsurgical techniques like radiosurgery, which allows us to treat these cases.
The most important thing I think, when we are confronted to incidental meningiomas, is histology nowadays, or the awareness of histology. We know, based on different studies, that incidentally found growing meningiomas are more malignant or more Grade II and III than incidental found or symptomatic meningiomas. So we have to always aware, should we get a histology prior to the treatment or not? Is this meningioma growing up faster or not? Because the chance to have a Grade II or III, which is related or associated with a poor outcome, regardless of the treatment, has to be considered.
We know, for example, from this study from Kasuya et al that the incidental-growing found meningiomas have a higher proliferation index compared to asymptomatic or compared to just to incidental without any documented growing. So we have to be aware of that. And we also know, we also have many patients like this one, for example, who was follow-up 10 years, and all of a sudden, the meningioma start to grow. For example, we see the MRIs from 2006, and 10 years later we just realized that the tumor was growing. So, this case has to be treated in order to avoid neurological deficits.
The annual growth rate cannot be denied. All studies show that. And we know that, as I said, relative annual growth range between 0.48% and 2.8% a year. So there are facts in literature regarding growth rate. And many people try in the last year to do like treatment algorithm to write about that. For example, this a patient on a review paper by Caldwell.
And as you'd see, many people try to divide the treatment between the two age groups, less than 65 or older than 65, but actually there is no consensus. And in patient less than 65, you can do whatever you want as a physician or as a neurosurgeon try to talk to the patient. There is actually no consensus based on the size of the tumor, based on the location, or the risk of the radiosurgical treatment, or the surgical treatment.
So then the idea of Leksell, that time in the 50s, was actually to bring the radiosurgery to a surgical vision. And I think that is the most important thing that he did. And we are very, very grateful with the new softwares developed and new vision, for example, from this company, in order to bring this vision to help us to think in radiosurgery during the surgery. And we will hear more about that here with the next speakers.
So this concept, to bring surgery and radiosurgery, help for the surgeon to be aware that he or she has to think about radiosurgery during the resection of the tumor. So, the limits of the surgeries are more important for the surgeon having these kind of technical tools. So there's no place for egos, for surgeons nowadays. We have to think about neurological deficits, about life expectancy, about the possibility to treat the patient with radiosurgery after the microsurgical treatment. So, for me, as a neurosurgeon, it change a lot the way I had to understand and to proceed the aggressivity during the surgery.
So this software, like the adaptive hybrid surgery, help us to have a workflow, which start before the surgery with a planning, and during the surgery, or during the debulking, help us to limit or to stop the resection in order to plan the radiosurgery right during the search or to talk to radiosurgeons during the surgical treatment.
And this is, for example, OR and the surgeon and the radiosurgeon is sitting next to the head of the patient discussing. Based on this software, if the tumor has to be resected more extensively of we can start a risk more or not. So this new vision, this new understanding of the limit of the surgery, surgical treatment, is for me one of the most important thing, and I hope that the company will support the further development of these tools for neurosurgeons, which actually will support the radiosurgery treatment in the future.
So the workflow is divided in three steps. The preop, the intraop, and the postop as you can see here. And during the surgery, based on navigation and so-called intraoperative structure up, we can...or the surgeon can know exactly the volume resected in order to stop the surgery, to stop the resection, or to go further for more in tumor resection. We can also have updates of this analysis during the surgery based on the identification of the limits of the tumor resected.
So I'm gonna show just a couple of cases in order to introduce my colleagues, my...the other speakers, which are a couple of cases of how it works. And there's a lot of work to do. And again I hope that the company will support the further development of these software. This, for example, is a 51-year-patient was operated on these huge meningioma, sphenoid wing meningioma. We planned a residual tumor prior to the surgery with/or a rediosurgeons. And he's in red for example. So we go for surgery, and we know exactly how to do, what to do, and what to resect in order to be able to do radiosurgery in a safe way.
So, this is a planned residual tumor in green. I'm gonna skip all these slides very fast. This is craniotomy plan that we did with the navigation. These are the intraop finding showing the nerve and the eloquent structures of the [inaudible 00:11:40]. And here is a tumor at the beginning of the surgery with 100% of the volume. And during the surgery, during the resection, we could document the volume, for example, of these step of surgery 65% of resection. So we go further. We calculate based on intraop structure updates the possibility and the way how to do radiosurgery. This is the way we can identify the tumor remnant, which also is not perfect yet. But I hope we will have a better tool for these aims.
So at that point of the surgery, the tumor was resected in 58%. Later at 41% as you can see here. And then we also could, at this moment, know if the patient is a single dose or hyperfractionated to therapy after surgery without forcing the resection. And there's a consensus during the surgery, which allow the interaction between radiosurgeons and surgeons. This the only moment, actually, I think that neurosurgeons and radiosurgeons have their chance to talk nowadays. Because with this software are getting faster and nobody talk to each other. You know, these elements and all these softwares are so fast that you don't even meet the planning room, you know that, and very seldom.
So, for example, this case is a remnant tumor that was achieved. And remnant tumor was radiated. Was treated with radiosurgery.
The second case, for example, is also a 59-year-old patient with this huge tumor and was also planned. Was actually a tentorial notch meningioma. We planned the residual tumor in red, showing this slide, prior to taking the patient to OR. And we know exactly that, with the residual tumor, we will not able to treat the patient with a single dose. But it was fine, and the patient knew that. And the surgeon was not forced to resect more.
This is a setup and team during this surgery. And we start, based on navigation, the tumor resection. We achieved here in green 82% of resection then go further with a 74%, 47%, and so on. So the whole surgery is a communication between the surgeon, the radiosurgeons, and in order to define what the limits are.
And these are the last pictures based on CT, for example, this case, and these are the final postop MRI findings, which were treated after the surgery. The last case very fast is a older patient, 78-year-old, also with a huge meningioma compressing the brain stem and with a volume of 20.8 CC. That's the only thing that the surgeon talk off and on about volume. We surgeon never do that before. We talk about volume, we talk about possibility of radiosurgeon. So it's the communication change, and the vision, from a surgical point of view, change with this software.
The residual tumor was in green as we can see with 8 CCs. So we defined that and then went for resection and see all the cases. The resection will start with 89% and then 78% based on volumetry 38%. And then the end, we could decide to stop the surgery with this volume of 6.5 CC and go for a radiosurgery after the surgical treatment. We can see here the remnant tumor.
So there are limitations and shortcomings, and the development is pretty slow. I don't really feel that the company is doing...probably they are thinking in the back office, but I hope that they will be faster in this development. The anatomic mapping is an issue. For example, the precision due to brainshift has to be optimized. Shaper is not optimal. The intraoperative volume-updates are also not a reliable nowadays. I hope that we can do that without any pointer. With a light tool or something like that, in order to get or to reach this deep part of the resection and so on.
And there are a future improvement that are needed. As I said, anatomical mapping, automatic mapping of tumor, volume, and organs at risk. Better tool for intraop scanning of remnant tumors, for example, with MRI, and integration of DTI data in the planning software. So, saying that, I will introduce the next speaker Dr. Orin Bloch from Chicago.