the first stage surgery of the patient with meningioma extensively invaded skull base

Submitted by FengGuodong on Thu, 06/27/2019 - 14:38

Dear collegues, I am sorry for the wrong uploading of the PDF information of the meningioma patient's first stage surgery last time. I upload the correct one this time.I have completed the first stage of this patient of the meningioma 4 months ago. I will keep you informed about the following treatments.

Guodong Feng

Beijing, China

ZaniniOtavio

Mon, 07/08/2019 - 13:57

Dear Dr. Feng,

Congratulations for the first step of your patients surgical plan. This must have been a dificult and demanding work. Really nice job.

I have special interest in knowing how difficult it was to deal with the tumor around the internal carotid artery. Did you see a plan of clivage beetwen tumor and the adventicia? How was the tumor removal performed?

I also would like to ask about the anterior extension of the tumor. In the surgical images, it seems that the horinzontal portion of the internal carotid artery was free. I suppose that the work around the cavernous sinus would be better than I expected.

On the other hand, there is still demanding job programmed for the next steps, specially considering CPA and retroclival/intravertebral space.

Thank you for sharing this case with us. Keep us informed about the evolution.

Best wishes for you and your team,

Otavio Zanini

Dear Guodong,
Congratulations for the successful first stage operation of your patient. The postoperative MR shows that you were able to remove the complete extradural portion of the tumor and this was not an easy job. Therefore, even if your PDF illustrations are very clear and self-explanatory, it would be helpful if you could give us some surgical details for neurotologists less familiar with this type of surgery.
For example: 
- Fig. TMJ:  have you mobilized temporarily or definitively removed the zygomatic arch for exposure of the TMJ?
- Fig. Eustachian Tube:  had you to cut the Mandibular Division of the Trigeminal Nerve (V3) to expose the ET? How have you closed the Eustachian Tube? 
- Fig. FN: did the Meningioma invade the epi-, peri- and endoneurium of the FN?
- Fig. Tumor invaded Jugular Foramen: how much tumor did you remove and have you covered the resection with temporalis fascia when closing?
- Figs. Tumor and ICA (vertical segment) and The ICA after tumor removal: how difficult was the separation of the tumor from the adventitia of the ICA? In case of damage of the arterial wall were you prepared to ligate the ICA?
- Fig. FN (Vertical segment was resected with the tumor…):  do you mean with “vertical” the
 “mastoid “segment of the FN?  What reconstruction of the FN you expect to do after the third stage of surgery?

I am looking forward to the next steps of your surgery because the meningioma of your patient is unusually extensive. In the past I have operated similarly located but less extensive meningioma. I was removing the extradural extension in a first stage leaving the remaining intradural portion of the tumor to be removed by the neurosurgeon. Form the operation I used as you did a combination of the Infratemporal fossa approaches Type A and B. The surgical steps I have used are illustrated in the Chapter on Infrat. Fossa Approach Type B of the the book  Microsurgery of the Skull Base (Ugo Fisch, Douglas  Mattox - Georg Thieme Verlag Stuttgart-New York 1988: pp 316-329).The pre- and postoperative MRI of a Meningioma in a  similar location and also operated with a combination of Type A and B approaches are shown in pp. 339-340 (Fig. 4-65-ABCD).
Your experience with the meningioma extensively invading the skull base is unique. Thank you for sharing it with us.
Best regards
Ugo
 

FengGuodong

Sun, 08/04/2019 - 15:57

Dear Zanini,

Thank you for your commands and reminder of goodwill. 

The tumor separating from the ICA is really very difficult as the ICA was compressed and deformed by the tumor. However, I did find a plan of clivage between tumor and the adventicia. So we can separated the tumor along it. Of course, we need the special equipment and instruments, for example, the good microscope ( we used Leica OH 4) to help us find the clivage and the gentle teeth microforceps designed by myself( I have showed it during the course) to hold the small piece of tumor on the ICA, and good assistant for the exposure.

The horinzontal portion of the internal carotid artery was indeed free so we can expose the both superior and inferior ends of ICA, which make the surgery safer because we can quick control it in case the tumor rupture the artery and been broken during the separation.

In conclusion, the enough exposure help us to complete the difficult operations, the IFT Type A+B is a prefer option.

It was really nice to meet you in Zurich. I am sorry to answer you so late because I can see your message until now.

Best regards,

Guodong

FengGuodong

Sun, 08/04/2019 - 16:29

Dear Prof. Fisch,

Thank you for you commands and questions. I am certainly very happy to share more surgical details as follows with colleagues.

- Fig. TMJ:  have you mobilized temporarily or definitively removed the zygomatic arch for exposure of the TMJ?

 

I temporarily inferior reflected the zygomatic arch and temporal muscle for exposure of the TMJ with the technique as described in P299-300

 

- Fig. Eustachian Tube:  had you to cut the Mandibular Division of the Trigeminal Nerve (V3) to expose the ET? How have you closed the Eustachian Tube?

 

Yes, I cut the V3 for exposure and closed the ET watertight with 3 sutures.

 

- Fig. FN: did the Meningioma invade the epi-, peri- and endoneurium of the FN?

 

The meningioma invaded the FN, It is impossible to separate the FN from tumor, so I can’t make clear which layer was invaded.

 

- Fig. Tumor invaded Jugular Foramen: how much tumor did you remove and have you covered the resection with temporalis fascia when closing?

 

I removed the tumor extradural, and did not cover the resection with temporalis fascia when closing. What’s the objective of covering the resection with temporalis fascia when closing?

 

- Figs. Tumor and ICA (vertical segment) and The ICA after tumor removal: how difficult was the separation of the tumor from the adventitia of the ICA? In case of damage of the arterial wall were you prepared to ligate the ICA?

 

The tumor separating from the ICA is really very difficult as the ICA was compressed and deformed by the tumor. According to the states quo of our team, we were ready to reconstruct the ICA in case of damage of the ICA, as we have discussed in the other case.

 

- Fig. FN (Vertical segment was resected with the tumor…):  do you mean with “vertical” the

 “mastoid “segment of the FN?  What reconstruction of the FN you expect to do after the third stage of surgery?

 

Yes, the “vertical” is the “mastoid “segment of the FN. The FN will have to waiting for the Cross-face transplantation after the third stage of surgery.

 

Best regards,

Guodong