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Home , Pinealoma

SURGI(~AL MANAGEMENT OF INTRACRANIAL *

A. LEY, M.D., A. LEY, Ji~., M.D., J. M. GUITART, M.D., AND C. OLIVERAS, M.D. Neurosurgical Service, University of Barcelona Medical School, Barcelona, Spain

(Received for publication October 19, 1961)

EREBRAL gliomas have challenged the TABLE 1 ingenuity and skill of surgeons ever Intracranial tumors C since the beginning of neurological 1940-1960 surgery. While technical progress during the Type No. Per Cent past ~0 years has brought about satisfactory solutions fl)r the surgical management of 1. Gliomas 48"2 40.9 other intracranial tumors, as for instance `2. Sarcomas `27 `2.3 3. Blood-vessel tumors 61 5.`2 acoustic neurinomas, angiomas and eranio- 4. Papillomas (ehoroid plexus) 7 0.6 pharyngiomas, formerly considered impossi- 5. Congenital tumors 48 4.1 ble to treat radically, therapeutic progress in 6. 145 1`2.3 7. Neurinomas 69 5.9 the surgical management of gliomas has been 8. Pituitary adenomas 88 7.5 practically nil. 9. M:ctastatic tumors 116 9.8 In order to evaluate how much we had ac- 10. Granulomas 51 4.3 11. Parasitic cysts 34, `2.9 complished in that field, we made a survey of 1`2. Miscellaneous 50 4.3 all the intracranial tumors seen at the senior writer's service during the past ~1 years Total 1,178 1O0 (1940-1960). gliomas following the classification of Bailey INCIDENCE and Cushing. 5 We are well aware of the in- Of 1,178 verified intracranial expanding consistency of any classification of tumors lesions (Table 1), 48~ (40.9 per cent) were based on morphology, and we know by our classified as gliomas. This proportion is very own experience the difficulties involved in close to the 4~.3 per cent in Cushing's ~ 193~ classifying some of these tumors on that series of ~,0r intraeranial tumors, but basis. However, if we do not take too slightly lower than those reported by Adson literally the histogenetic implications in- and Svien 1 (47 per cent), Olivecrona is (47.9 per cent), Grant 11 (48.5 per eent),Davisl~ TABLE per cent), Bailey 3 (59.1 per cent) and Row- Cerebral gliomas botham et al. 2~ (66.5 per cent). However, if 19]~0-1960 we take into account that a large proportion of the lesions listed in the miscellaneous Histological Variety No. Per Cent group in Table 1 were tumors of the brain 84 17.5 stem (35 cases) and 3rd ventricle (11 eases), Cerebral 87 which though not verified histologically, Cerebellar 47 probably were gliomas in the majority of Ependymal tumors 44 9.1 41 8.5 these cases, the real proportion of that type Pinealoma 6 1. `2 of tumor in our series would rise to over 44 Spongioblastoma polare `24 5.0 per cent. S1 (4.4 `246 51.0 Table 2 shows the distribution of our `2 0.5 Neuroepithelioma 4 0.8 * Read at the Second International Congress of Neurological Surgery, Washington, D. C., October 17, Total 48`2 100 1961. 365 366 A. LEY, A. LEY, JR., J. M. GUITART AND C. OLIVERAS volved, we think, as do Zimmerman 23 and tively low, and also because we may have Ziilch 24 that Bailey and Cushing's classifica- had different criteria of differentiation be- tion still is the most useful and satisfactory tween this type of tumor and primary sar- we have at hand. Besides, in reviewing our coma. 4,s,I5 This would also explain the slight material, we have been able to confirm once difference found in the incidence of cerebellar more that not only does it serve a noso- . The larger incidence of oligo- graphic urge but also that it corresponds to a dendrogliomas in our series (s may be well established biological fact, the different attributable to the fact that our series began varieties possessing well defined topographic, in 1940 and that we may therefore have been clinical and evolutional peculiarities. more conscious of their existence. In fact, as If we compare the incidence of the various far back as 1932 Cushing 9 was already aware types of gliomas in our series with that in the of the possibility that some of the 18 cases larger series of Cushing 9 and of Grant, n all (2.6 per cent) of cerebral based on the same pathological principles, in his series could have been oligodendroglio- we find some striking differences (Table 3). nlas. The main ones are the lower proportion of The incidence of ependymal tumors in our cerebral astrocytomas and the higher per- series was also two-fold compared with the centage of in our series, the others. We do not know of any explanation difference being roughly 20 per cent less and for that fact. 20 per cent plus, respectively. We think the explanation may lie in the pathological cri- HISTOLOGY AND LOCATION teria that guide our classification and proves In order to evaluate the surgical results, a the difficulty stressed by Kernohan 13 and subdivision of each of the histological varie- others as to the differentiation between glio- ties was established, on the bases of the de- blastomas and some malignant forms of gree of differentiation, cellular atypias or astrocytomas. The proportions found by monstrosities, number of mitoses, and so Ztilch u are so different that they cannot be forth. compared with the above-mentioned series. Of the cerebral astrocytomas, 18 were Concerning cerebellar medulloblastomas, what may be considered pure types, the the difference is not so great. This may be majority being of the fibrillary variety; only ascribable partly to the fact that the propor- were cystic. Four showed areas of oligo- tion of infantile cases in our series is rela- dendroglial or ependymal differentiation, and 15 had signs of dedifferentiation or ma- TABLE 3 lignancy. Among them, there were 5 with the Percentage of various types of gliomas characteristics of : 1 cystic and rather malignant. Cushing9 Grant n Present Histological (86~ (1,147 Series In the group of ependymal tumors, ~8 Variety cases) cases) (48~eases) were . Two of them showed astrocytic and 1 spongioblastic differentia- Astrocytoma Cerebral ~6.6 ~4.8 6.8* tion. Only 1 was cystic and presented in- Cerebellar 10.5 14.4 9.7 tensive calcification. There were 15 epen- Glioblastoma 80.0 80.5 51.0 dymoblastomas, 6 of them being cystic. Medulloblastoma (cerebellar) 9.8 9.7 6. There was also a very atypical and undiffer- 8.0 4.7 9.1 entiated ependymal tumor that originated in Oligodendroglioma 8.9 4.1 8.5 the septum pellucidum. As far as their loca- Astroblastoma 4.0 5.4 l. 0 Spongioblastoma 4.6 3.0 5.0 tion is concerned, 24 were supratentorial, Pinealoma 1.6 1.1 1. most of them (17 cases) arising from the walls of the lateral and 8rd ventricle and sep- * Five astroblastomas, which were included with the cerebral astrocytomas in Table ~, have been omitted turn pellucidum. Nineteen were subten- here. torial; of these, 11 developed in the 4th ven-