Vikas Naik, Deepak Agrawal, SS Kale,

MS Sharma, BS Sharma, AK MahapatraDepartment of Neurosurgery & Gamma-Knife

surgery,All India Institute of Medical Sciences, New Delhi

Posterior third ventricular

tumors(PTVT)

diverse histology

• Third ventricle,

• Velum interpositum,

• Thalamus,

• Midbrain,

• Tentorium,

• Splenium,

• Quadrigeminal cistern or

• posterior vasculature

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Benign◦ Meningiomas◦ Ependymomas◦ Teratomas ◦ Pinealocytomas

Malignant◦ Germ cell tumors◦ Non-Germ cell tumors◦ Metstasis

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CSF diversion Microneurosurgery Radiation therapy Chemotherapy Radiosurgery

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Microneurosurgery- complex anatomy vasculature,

critical structures limit complete resection

Radiation therapy- cognitive impairment, radiation

toxicity, hormonal imbalances

Chemotherapy associated toxicity

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To evaluate the effectiveness of gamma knife

(GK) surgery in posterior third ventricular

tumors as a primary treatment or in

conjunction with surgery and/or biopsy

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Retrospective Study

July 97-2009

Study conducted at AIIMS

Data collected from hospital records,

patient files.

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Inclusion criteria

Tumors in and around the posterior third

ventricular region who received Gamma-knife

radio-surgery at our institute were included

in the study

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Clinical examination

Biopsy reviewed

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Primary GK◦ GK based on Imaging +/- tumor markers◦ Biopsy +GK

Secondary GK◦ GK following radical surgery

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GK was done on Leksell B system Parameters assessed

◦ Tumor volume◦ Marginal dose

Follow up at 6 monthly interval◦ CEMRI

MRI screening spine + CSF markers (when required)

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Neuroradiologist reviewed any change in size by visual and manual measurement

Tumor control- same or decrease in size as compared to at time of GK

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Total -17 patients

Age range 14-74 years (mean-36.8 years)

M:F 7:10

Follow up 4-75 months (mean-31.23 months)◦ 1 patient lost to follow up.

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Tumor volume - 1-16.8 cm3 (mean-6.06cm3)

Radiation dose - 11-25 Gy (mean-15.35Gy)

Tumor volume coverage - 88%-94% (mean-91%)

3/17 patients underwent radiation or

chemotherapy as adjuvant treatment.

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Diagnosis Histology

proven

MRI based Csf

diversion

Adjuvant

RT

Adjuvant

CT

Meningioma

s (8)

4 4 1 0 0

Pineal

tumors (4)

3 1 3 1 1

Gliomas

(3)

2 1 1 1 0

PNET

(1)

1 0 1 0 1

Metastasis

(1)

0 1 0 0 0

Total (17) 10 7 6 2 2

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Primary GK Beningn - Meningioma (4) - Pinealocytoma (1) - Glioma (1)

Malignant

- Pinealoblastoma (2) - Metastasis (1)

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Seconadry GK Beningn -Meningioma (4) -Glioma (2)

Malignant -Pinealoblastoma (1) -PNET (1)

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Symptom No of patients in Primary

GK

No of patients in Secondary

GK

Percentage

HEADACHE 4 4 47

ASYMPTOMATIC 4 1 29.4

VOMITING 1 2 17.6

HEMIPARESIS 1 2 17.6

DROOPING OF EYELID 1 1 11.76

SEIZURES 1 0 5.8

MEMORY IMPAIRMENT 1 0 5.8

GAIT ATAXIA 1 0 5.8

URINARY INCONTINIENCE 1 0 5.8

DIPLOPIA 1 0 5.8

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SIGNS No of patients of Primary

GK

No of patients of secondary

GK

PERCENTAGE

NO DEFICITS 5 3 47

HEMIPARESIS 1 3 23.5

PAPILLOEDEMA 2 1 17.6

PARINAUDS 1 1 11.76

SEVENTH NERVE 1 1 11.76

THIRD NERVE 1 1 11.76

RECENT MEMORY 1 0 5.8

NYSTAGMUS 0 1 5.8

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PRIMARY GK

Diagnosis Follow up period(months)

Tumor volume(cm3)

Radiation iso dose(Gy)

Tumor control

Worsening

Beningn

Meningiomas 41 9.05 11.8 4/4 -

Pinealocytomas 36 2.2 15 1/1 -

Glioma 9 3.3 12 1/1 -

Malignant

Pinealoblastoma 15.5 2.05 20.75 1/2 1/2

Metastasis 7 44.3 16 - -

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Diagnosis Follow up period(months)

Tumor volume(cm3)

Radiation iso dose(Gy)

Tumor control

Worsening

Beningn

Meningiomas 54 12.5 12.52 4/4 -

Gliomas 4 6.25 16 1/1 -

Malignant

Pinealoblastoma

9 1.4 24 1/1 -

PNET 25 3.2 16 1/1 -

SECONDARY GK

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Pinealocytoma at GK Pinealocytoma post 24 months GK

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Meningioma at GK Meningioma after 75 months GK

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Pinealoblastoma Pre- Operative 12/18/2009NSI-2009

At GK planning

Pinealoblastoma 9 month after GK

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Decrease in size - 7/14(50%) patients

Same size - 6/14 (42.8%) patients

Good tumor control - 13/14(92.8%)

(At an average follow up of 31.23.2

months)

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Primary GK in beningn disease All patients had 100 % tumor control rates at 27

months

Primary GK in malignant tumors Pinealoblastoma patients had good tumor control at

24months and 27 months post GK Metastasis of a carcinoma breast died at 7 months follow

up.

( Pinealoblastomas have mean survival rate of 29 months with surgery and adjuvant chemo/radiotherapy)

.

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Tatsuya Kobayashi et al studied out of 30 patients who were given radiosurgery after conventional treatment and concluded that pineocytomas, germinomas had 100% control rates, malignant germ cell tumors and pineoblastomas had 50% control rates

Stereotactic gamma radiosurgery for pineal and related tumors. Journal of neurooncology 2001; 54:301-309.

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L Manera et al observed effective tumor control in germinomas, pinealoblastomas with recovery of normal CSF pathways in 7 days of surgery.

Pineal region tumors: The role of stereotactic radiosurgery. Stereotactic and functional Neurosurg 1996;66(suppl 1):164-173

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GK surgery valuable and safe alternative as a

Primary treatment for posterior third

ventricular tumors

Negligible morbidity in the medium term

Good local tumor control in even malignant

tumors

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