The Modern Brain Tumor Operating Room: from Standard Essentials to Current State-of-the-Art

Brain Tumor Institute and Department of Neurosurgery, The Taussig Cancer Center, The Cleveland Clinic, Cleveland, OH 44195, USA.
Journal of Neuro-Oncology (Impact Factor: 3.07). 08/2004; 69(1-3):25-33. DOI: 10.1023/B:NEON.0000041869.45136.34
Source: PubMed


It is just over a century since successful brain tumor resection. Since then the diagnosis, imaging, and management of brain tumors have improved, in large part due to technological advances. Similarly, the operating room (OR) for brain tumor surgery has increased in complexity and specificity with multiple forms of equipment now considered necessary as technical adjuncts. It is evident that the theme of minimalism in combination with advanced image-guidance techniques and a cohort of sophisticated technologies (e.g., robotics and nanotechnology) will drive changes in the current OR environment for the foreseeable future. In this report we describe what may be regarded today as standard essentials in an operating room for the surgical management of brain tumors and what we believe to be the current 'state-of-the-art' brain tumor OR. Also, we speculate on the additional capabilities of the brain tumor OR of the near future.

3 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: La chirurgie représente la première étape du traitement des oligodendrogliomes (OLG) supratentoriels de l’adulte. Mais le rôle de l’exérèse chirurgicale sur le pronostic, le meilleur moment de la chirurgie dans l’histoire naturelle des OLG, la meilleure stratégie d’exérèse demeurent débattues et les courbes de survie après exérèse varient beaucoup d’une étude à l’autre. La confusion qui règne encore sur l’identification et la classification des OLG expliquent en partie ces divergences de résultats. Première des techniques chirurgicales, la biopsie –– chirurgicale ou stéréotaxique –– permet de confirmer un diagnostic posé sur l’imagerie, d’examiner l’extension de l’infiltration tumorale par rapport aux limites des anomalies d’imagerie et de réaliser les examens de biologie moléculaire actuels. Elle peut être le seul geste chirurgical chez des patients porteurs d’une tumeur profonde sans effet de masse important, ou en préalable à une exérèse ou lorsqu’une confirmation histologique est demandée avant une surveillance radio-clinique. Dans les autres cas, c’est l’exérèse tumorale qui est indiquée. Mais il n’a pas été montré que son moment dans l’évolution de la tumeur avait une influence sur la survie, en dehors des tumeurs évolutives responsables de signes déficitaires et d’une hypertension intracrânienne qui requièrent une exérèse chirurgicale rapide à défaut d’être large. La surveillance clinique et en imagerie d’une tumeur dont l’aspect est celui d’un OLG de grade A est donc justifiée et l’exérèse peut être décidée à tout moment ultérieur. Au plan technique, la tendance actuelle est celle d’une exérèse maximale possible, dans le respect des zones cérébrales fonctionnelles puisqu’une exérèse complète au plan carcinologique n’est qu’exceptionnellement possible. Toutefois, les résultats contradictoires ne permettent pas d’affirmer qu’une exérèse large ou complète sur l’imagerie soit associée à une survie significativement plus longue. Dans l’optique d’une exérèse maximale possible et de respect des régions cérébrales fonctionnelles, l’utilisation des outils chirurgicaux actuels –– instruments de neuronavigation, imageurs opératoires, techniques de stimulation corticale per-opératoire, est d’une aide précieuse au chirurgien.
    No preview · Article · Sep 2005
  • [Show abstract] [Hide abstract]
    ABSTRACT: Surgical resection is the first step in the treatment of adult supratentorial oligodendrogliomas (OLG). However, the role of resection on prognosis, the most appropriate time for surgery along the natural history of those tumors, and the best operative strategy remain debated. Survival curves after resection vary greatly among reported series, in particular as a result of a persisting confusion in identification and classification of cerebral OLG. Surgical or stereotactic biopsy is the first surgical procedure which enables confirmation of the diagnosis suggested on imaging, assessment of extension of tumor cell infiltration beyond abnormalities limit described an imaging, and currently available molecular biology studies. Biopsies may be the only surgical procedure in patients having a deep-seated tumor with minimal mass effect, or prior to a surgical resection or a "wait and watch" strategy. Surgical resection is indicated for the other patients. However, it has not been demonstrated that time for resection has an influence on survival, excepted in patients with rapidly growing tumors, with mass effect causing increased intracranial pressure. A wait and watch strategy is therefore warranted in patients with a tumor aspect suggestive of a grade A OLG; surgical resection may be indicated later. There is a current trend for maximal safe resection, preserving functional cerebral areas, since truly complete resection of the tumor including infiltration is exceptional. However, from the contradictory results reported to date, one cannot ascertain whether large or complete resection based on imaging is associated with significantly longer survival. Neuronavigation guidance, intraoperative imaging, and cortical stimulation techniques are helpful neurosurgical techniques enabling maximal safe resection with preservation of functional areas.
    No preview · Article · Oct 2005 · Neurochirurgie
  • [Show abstract] [Hide abstract]
    ABSTRACT: Deep brain stimulation (DBS) is a widely accepted therapy for medically refractory Parkinson's disease (PD). Both globus pallidus internus (GPi) and subthalamic nucleus (STN) stimulation are safe and effective in improving the symptoms of PD and reducing dyskinesias. STN DBS is the most commonly performed surgery for PD as compared to GPi DBS. Ventral intermediate nucleus (Vim) DBS is infrequently used as an alternative for tremor predominant PD patients. Patient selection is critical in achieving good outcomes. Differential diagnosis should be emphasized as well as neurological and nonneurological comorbidities. Good response to a levodopa challenge is an important predictor of favorable long-term outcomes. The DBS surgery is typically performed in an awake patient and involves stereotactic frame application, CT/MRI imaging, anatomical targeting, physiological confirmation, and implantation of the DBS lead and pulse generator. Anatomical targeting consists of direct visualization of the target in MR images, formula-derived coordinates based on the anterior and posterior commissures, and reformatted anatomical stereotactic atlases. Physiological verification is achieved most commonly via microelectrode recording followed by implantation of the DBS lead and intraoperative test stimulation to assess benefits and side effects. The various aspects of DBS surgery will be presented. © 2006 Movement Disorder Society
    No preview · Article · Jun 2006 · Movement Disorders
Show more