Thalamus tumors - case report and review the literature.pdf

Thalamus tumors case review

1. THALAMIC TUMORS
BSNT: Trịnh Nguyên Khoa

2. Nội dung trình bày
Bệnh án
tham khảo
Tổng quan u
vùng hạ đồi Thảoluận

3. Bệnh án tham khảo
I.Hành chính:
-Họ và tên: Nguyễn Phương V.
-Giới tính: Nữ
-Sinh năm: 2020 -> 4 tuổi
-Nhập viện: 08/02/2024

4. II. Lí do nhập viện
Yếu ½ người phải

5. III. Bệnhsử
Khoảng1 thángnay, emyếukèmtêtăngdần½
người(P), trongđóchân(P) > tay(P), điđứng
loạngchoạng
Tìnhtrạngbệnhngàydiễntiến, emđikhámđược
chụpphimCT scan sọchẩnđoántheodõiu não
báncầu(T), sauchuyểnbệnhviệnNhiĐồng2

6. IV. Tiền căn
-Chưa ghi nhận bất thường

7. V. Khám
-Em tỉnh, tiếp xúc tốt, thực hiện được y lệnh
-Sinh hiệu ổn lúc khám
-Môi hồng, chi ấm, mạch rõ, CRT <2s
-Đồng tử 2 bên 3mm, pxas (+)
-Yếu 1/2 người phải, sức cơ tay (P) 3/5, sức cơ chân
(P) 2/5
-Babinski đáp ứng gập 2 bên, phản xạ gân cơ (++)

8. MRI sọ não (tại BV Nhi Đồng 2)

9. MRI sọ não (BV Nhi Đồng 2)

10. VI. Điều trị
Phẫu thuật lấy u vi phẫu + giải phẫu bệnh lý

11. Kết quả giải phẫu bệnh

12. THALAMICTUMORS
-Greek word: θάλαμος(thalamos)
-Thalamus = ” No man’s land” region:
+ Deep and central location
+ Its intricate intrinsic circuitry and
connections to eloquent adjactent structure
=> Seems to be a surgically inaccesible
structure

13. Epidemiology
-Limited research
-Pediatrics : 2% - 5% brain tumor population
-Adults : 1% brain tumor population
-According to a specific study of Steinbok et al. :
-No age and sex predominance
-Mean age :
-Unilateral: 8.9 years (0.4-17.9 yrs)
-Bilateral: 6.6 years (1.5 - 14.7 yrs)

14. Surgical anatomy

18. Subdivisions:
•Anterior part
•Medial part
•Lateral part:
•Dorsal tier
•Ventral tier

19. Functioning of the thalamus
•Thalamus has been implicated in a wide diversity of functions:
oMemory
oEmotions
oSleep-wake cycles
oExecutive decision making
oAlerting responses
oSensorimotor processing and control
oCognition

20. Aterial supply
Mainly: PCA + PcomA

21. Growth patterns of thalamic tumors
•80% unilateral, 20% bilateral oUnilateral tumors -> neurological symptoms:
•Confined by thalamus
=> distorting adjacent structures through mass effect.
Ex: pilocytic astrocytomas (PA)
•Grow beyond the boundaries into surrounding white
matter, spreading under ventrical ependyma
=> Diffuse tumors, ex: Fibrillary or infiltrating gliomas

22. Clinical presentation:
•Relating to:
•Site (nuclear group, effect on CSF pathways)
•Size (Mass effect on adjacent structures and ventricles)
•Rate of growth (rapidity of symptom evolution)

23. Clinical presentation
•Headache (evidence of increased ICP)
•Motor weakness
•Sensory changes
•Seizures
•Cognitive deterioiration
•Personality changes
•Less common: various movement disorders and classic
thalamic syndrome: tremor, dystonia, chorea, myoclonus,….

24. Radiographic presentation
•Diverse radiographic appearance due to broad range of
histologies
•According to Puget et al:
•75% thalamic tumors: contrast enhancemant
•22% had calcifications on CT
•37% had cystic component
•32% extended down to the brainstem

28. Pathological diagnosis obsered in some reported series

29. Histopathology
•Gliomas: Most common
•Low grade tumors: pilocytic astrocytomas, pilomyxoid astrocytomas,
diffused astrocytomas, nonspecific low-grade astrocytomas
•High grade tumors: anaplastic astrocytomas, GBMs,…
•Other rare tumors: ependymomas, PNETs, gangliogliomas,….

30. Treatment
•Clinical presentation
•Goals of the patient and family
•MRI characteristics
•Tumor border definition
=> Deciding whether biopsy or resection is indicated

34. Open resection:
•Depending on:
•The location of tumor
•The advoidance of critical
anatomic structure
*Rangel-Castilla L, Spetzler RF. The 6 thalamic regions: surgical approaches to thalamic cavernous malformations,
operative results, and clinical outcomes. J Neurosurg. 2015;123(3):676–685.

35. Anterioinferior thalamus Medial thalamus

36. Lateral thalamus Posterosuperior thalamus

37. Lateral posteroinferior thalamus Medial posterioinferior thalamus

38. A.Anterior interhemispheric
transcallosal approach
B.Posterior interhemispheric
transcallosal approach
C.Transcortical parietoocipital
approach
D.Supracerebellar infratentorial
approach

39. Total/subtotal or partial resection
According to: Puget S, Crimmins DW, Garnett MR, et al. Thalamic tumors in children: a reappraisal. J
Neurosurg. 2007;106(suppl 5):354–362.

40. Adjuvant treatment
•WHO grade I and II lesion -> close MRI follow-up
Ex: Low-grade gliomas after biopsy -> MRI at: 3 months, 6
months, 1 year, yearly for next 3 years and then every 2
years.
•WHO grade III and IV -> follow by radiotherapy +/-
chemotherapy based on molecular studies

41. Outcome
•Long-term survival of low-grade gliomas in children is excellent with 5-year OS reaching 87% (*)
•Unilateral thalamic low-grade tumors had a 5-year OS rate of 84% ± 17% compared to 6.9% ± 13.2% of high-grade tumors (**)
(*):Fisher PG, Tihan T, Goldthwaite PT, et al. Outcome analysis of childhood low-grade astrocytomas. Pediatric Blood Cancer.
2008;51(2):245–250.
(**) Steinbok P, Gopalakrishnan CV, Hengel AR, et al. Pediatric thalamic tumors in the MRI era: a Canadian perspective. Childs
Nervous Syst. 2016;32(2):269–280.

42. Outcome

45. Prognosis
•Bilateral tumors have poorer outcomes, survival of just over 1
year
•Age at presentation: key factor affecting survival
•Histopathology

46. Summarize
•Thalamic tumors are most commonly gliomas.
•The decision to resect thalamic tumors is complex and is dependent
on the location within the thalamus, surgical accessibility via non-
eloquent structures, whether it is well-defined or infiltrative, and the
goals of the patient and family.
•Although all surgical procedures carry inherent risk,
a stereotactic biopsy is a relatively low-risk procedure that can
provide invaluable information into the tumor’s biology, the patient’s
prognosis, and recommended adjuvant therapies.
•Recent molecular insights have the potential to develop novel, more
personalized, therapeutics.

47. Preferences
•Puget S, Crimmins DW, Garnett MR, et al. Thalamic tumors in children: a reappraisal. J
Neurosurg. 2007;106(suppl 5):354–362.
•Steinbok P, Gopalakrishnan CV, Hengel AR, et al. Pediatric thalamic tumors in the MRI
era: a Canadian perspective. Child’s Nerv Syst. 2016;32(2):269–280.
•Youmann and Winn Neurological surgery 8th edition, volume 2, chapter 234: Thalamic
Tumors, 1770-1776
•Schmidek and Sweet (Vol 1) Operative Neurosurgical Techniques 7th Editio.pdf
•Rangel-Castilla L, Spetzler RF. The 6 thalamic regions: surgical approaches to thalamic
cavernous malformations, operative results, and clinical outcomes. J Neurosurg.
2015;123(3):676–685.
•Bernstein M, Hoffman HJ, Halliday WC, Hendrick EB, Humphreys RP. Thalamic tumors in
children. Long-term follow-up and treat- ment guidelines. J Neurosurg. 1984;61(4):649–
656.
•Snell’s clinical neurosurgery chapter 12: Thalamus, 312-320.

48. Thảo luận
•Vai trò phân biệt giữa u đồi thị nguyên phát và thứ phát ? Chiến lược
quản lý có khác nhau không ?