BACKGROUND AND IMPORTANCE: Low-grade insular gliomas remain challenging tumors for aggressive resection because of the numerous functional and vascular structures surrounding them. Because of the potential morbidities associated with open surgical resection, less invasive techniques may confer a more optimal balance between cytoreduction and surgical complications. For this reason, we evaluated the use of laser interstitial thermal therapy (LITT) for resection of a dominant hemisphere oligodendroglioma World Health Organization (WHO) grade II in a 68-yr-old patient by use of multiple staged surgeries for its resection.
CLINICAL PRESENTATION: Patient KK was a 68-yr-old female who was found to have a large, left-sided insular mass that was shown to be an oligodendroglioma WHO grade II, positive for codeletion 1p/19q and IDH1 mutant on biopsy. Over the course of 3 mo, KK underwent 2 stages of LITT, targeting different areas of the 5-cm tumor. The 60-d magnetic resonance imaging (MRI) demonstrated a reduction in size of the tumor from 5.2 × 3.3 × 2.4 cm to 3.6 × 1.9 × 1.4 cm. She returned for a second stage targeting the anterior portion of the tumor. KK did well postoperatively and went on to postsurgical chemoradiation. At the 2-yr follow-up, the lesion showed near resolution on MRI.
CONCLUSION: This case report demonstrates successful use of LITT for staged surgeries to treat a left hemisphere-dominant insular lesion. This establishes the use of LITT as a viable, minimally invasive option to treat tumors that are difficult to access or pose concerns for increased morbidity through an open surgery

Hafez, Daniel M

Leuthardt, Eric C

Liekweg, Caroline

English

Digital Commons@Becker

Washington University School of Medicine Digital Commons@Becker 2020-Current year OA Pubs Open Access Publications 3-1-2020 Staged laser interstitial thermal therapy (LITT) treatments to left Insular low-grade glioma Daniel M. Hafez Caroline Liekweg Eric C. Leuthardt Follow this and additional works at: https://digitalcommons.wustl.edu/oa_4  Part of the Medicine and Health Sciences Commons CASE REPORTStaged Laser Interstitial Thermal Therapy (LITT)Treatments to Left Insular Low-Grade GliomaDaniel M. Hafez, MD, PhD ∗Caroline Liekweg∗Eric C. Leuthardt, MD‡§¶∗Department of Neurosurgery, Barnes-Jewish Hospital, Washington UniversitySchool of Medicine, St. Louis, Missouri;‡Department of Neurological Surgery,Washington University School ofMedicine, St. Louis, Missouri; §Centerfor Innovation in Neuroscience andTechnology, Washington UniversitySchool of Medicine, St. Louis, Missouri;¶Brain Laser Center, WashingtonUniversity School of Medicine, St. Louis,MissouriCorrespondence:Daniel M. Hafez, MD, PhD,Department of Neurosurgery,Barnes-Jewish Hospital,Washington University School ofMedicine,660 S. Euclid Ave., PO Box 8057,St. Louis, MO 63110.Email: hafezd@wustl.eduReceived, July 18, 2018.Accepted,March 18, 2019.Published Online,May 6, 2019.C© Congress of Neurological Surgeons2019.This is an Open Access article distributedunder the terms of the CreativeCommons Attribution-NonCommercial-NoDerivs licence(http://creativecommons.org/licenses/by-nc-nd/4.0/), which permitsnon-commercial reproduction anddistribution of the work, in any medium,provided the original work is not alteredor transformed in any way, and that thework is properly cited. For commercialre-use, please contactjournals.permissions@oup.comBACKGROUND AND IMPORTANCE: Low-grade insular gliomas remain challengingtumors for aggressive resection because of the numerous functional and vascular struc-tures surrounding them. Because of the potential morbidities associated with opensurgical resection, less invasive techniques may confer a more optimal balance betweencytoreduction and surgical complications. For this reason, we evaluated the use of laserinterstitial thermal therapy (LITT) for resection of a dominant hemisphere oligoden-droglioma World Health Organization (WHO) grade II in a 68-yr-old patient by use ofmultiple staged surgeries for its resection.CLINICAL PRESENTATION: Patient KK was a 68-yr-old female who was found to have alarge, left-sided insular mass that was shown to be an oligodendroglioma WHO grade II,positive for codeletion 1p/19q and IDH1 mutant on biopsy. Over the course of 3 mo, KKunderwent 2 stages of LITT, targeting different areas of the 5-cm tumor. The 60-dmagneticresonance imaging (MRI) demonstrated a reduction in size of the tumor from 5.2 × 3.3 ×2.4 cm to 3.6× 1.9× 1.4 cm. She returned for a second stage targeting the anterior portionof the tumor. KK did well postoperatively and went on to postsurgical chemoradiation. Atthe 2-yr follow-up, the lesion showed near resolution on MRI.CONCLUSION: This case report demonstrates successful use of LITT for staged surgeries totreat a left hemisphere-dominant insular lesion. This establishes the use of LITT as a viable,minimally invasive option to treat tumors that are difficult to access or pose concerns forincreased morbidity through an open surgery.KEYWORDS: LITT, Laser, Insular tumor, Craniotomy, Minimally invasive, OligodendrogliomaNeurosurgery 86:E337–E342, 2020 DOI:10.1093/neuros/nyz120 www.neurosurgery-online.comL ow-grade insular gliomas remainchallenging tumors for aggressive resectionbecause of the numerous functional andvascular structures surrounding them.1 Forthis reason, the Berger-Sanai insular gliomaclassification system was designed to helpclassify tumor types that may benefit frommore aggressive surgery, depending on theirlocation and size.2 More aggressive open surgicalresection, however, may increase the risk fordeficits in language, cognition, memory, affect,and sensation, such as olfaction/taste.1-4 Becauseof the potential morbidities associated withopen surgical resection, less invasive techniquesABBREVIATIONS: FLAIR, fluid-attenuated inversionrecovery; LITT, laser interstitial thermal therapy;MRI, magnetic resonance imaging; RSN, resting-state network;WHO,World Health Organizationmay confer a more optimal balance betweencytoreduction and surgical complications.Specifically, laser interstitial thermal therapy(LITT) using the NeuroBlate system (MonterisMedical) provides minimally invasive access,thus sparing surrounding healthy tissue, whileperforming focused and precise ablation of thetargeted pathology. The NeuroBlate systememploys a 3-mm diameter, CO2-cooled laserthat can treat 1 to 2 cm of tissue surroundingthe probe. This has been used successfully forthe treatment of high-grade gliomas, metastaticlesions, and epilepsy in difficult-to-access areas ofthe brain.5-9 Typically, these lesions are treated ina single operation. Lesion volume with diametersof 3 cm or greater may require multiple trajec-tories to treat the entire target. These largevolumes, however, are associated with higherrisk of surgical complications (eg, symptomaticedema and seizures).9 Given the slow growingNEUROSURGERY VOLUME 86 | NUMBER 3 | MARCH 2020 | E337HAFEZ ET ALFIGURE 1. Language localization surrounding left oligodendroglioma in coronal A and axial B plane.nature of low-grade gliomas and the minimally invasive natureof LITT, we have employed a novel staged approach to treata select patient with large, low-grade insular glioma. Thus,the patient trades off a single, higher-risk surgery for multiple,lower-risk procedures. This case report, with consent from thepatient, describes the use of multiple staged LITT therapies totreat a left-sided insular oligodendroglioma with no permanentclinical deficit and near resolution of the tumor on postoperativemagnetic resonance imaging (MRI).CLINICAL PRESENTATIONThe patient is a 68-yr-old female (KK) who initially presentedto her primary doctor with an episode of right hand twitchingand eventually progressing to altered mental status. An MRIperformed demonstrated left-sided insular mass, approximately5 cm in maximal dimension, nestled within language regionsdemonstrated on functional MRI imaging (Figure 1). She subse-quently underwent a biopsy at an outside hospital, and pathologywas an oligodendroglioma World Health Organization grade II,positive for codeletion 1p/19q and IDH1mutant. Although opensurgery was discussed, she did not feel comfortable and opted fora more minimally invasive treatment. Therefore, she was offeredstaged laser ablation of the insular mass.To identify the language network, an advanced brain MRIwas obtained as described in Mitchell et al, 2013 and Leuthardtet al, 2018.10-12 Briefly, the topography of resting-state networks(RSNs) in individual patients is defined using a multilayerperceptron that is trained to assign RSN membership (eg, motor,language, and vision) to each brain voxel on the basis of restingstate functional MRI correlations.11 This method is not specificfor stimulation loci that produce speech arrest, but it is highlysensitive, identifying eloquent speech areas that should be avoidedduring surgical planning. Thus, if the tumor is far from the“language” RSN map, the data show that it is extremely unlikelythat awake stimulation mapping would have yielded a positiveresult that would alter the surgical plan.Using StealthStation navigation (Medtronic, Minnesota), thefirst stage of the procedure targeted the posterior half of thetumor. Using intraoperative MRI, the location of the laserprobe was verified prior to each staged treatment (Figure 2).Treatment of the tumor progressed until the thermal dosagethresholds maximally covered the area of interest, while avoidingnonpathologic and functional regions of the brain. Postoper-atively, she tolerated the procedure well and was observed inthe intensive care unit overnight. Having no deficits followingher laser ablation, she was discharged to home on postoperativeday 1.KK followed up in clinic 1 wk after the ablative procedure.At that time, she had mild difficulty with word repetition.She returned for her 60-d MRI prior to her second stageprocedure. At this time, the left insular mass was reduced insize, now 3.6 × 1.9 × 1.4 cm compared to the preoperativesize of 5.23 × .3 × 2.4 cm (Figure 3A-3F). Clinically, shewas back to her neurologic baseline. The amount of vasogenicedema was also reduced. Three months later, KK returned forthe second stage of treatment. The second ablative procedureused a trajectory that encompassed the anterior portion of theinsular glioma and its extension into the anterior temporal lobe,paying special attention to avoid the branches of the middlecerebral artery. Again, the procedure was tolerated well. Shehad mild expressive aphasia postoperatively, which eventuallyresolved after a 2-wk steroid taper. The patient’s fluid-attenuatedinversion recovery (FLAIR) signal continued to reduce at the 60-dpostprocedure MRI (Figure 3G-3I). She then went on to haveconcurrent chemoradiation with temozolomide at 75 mg/m2,followed by 6 cycles of high-dose adjuvant temozolomide. At2 yr follow-up, she had near resolution of the initial FLAIRE338 | VOLUME 86 | NUMBER 3 | MARCH 2020 www.neurosurgery-online.comSTAGED LASER THERAPY TO LEFT INSULAR GLIOMAFIGURE 2. Coronal A and C and sagittal B and D localizer images demonstrating the location of laser probe for stage I A and B andstage II C and D ablation treatments.signal, which neuroradiology believed to be post-treatment effects(Figure 3J-3L). To analyze the treatment volumes, tumor andtreatment models were created using StealthStation software. Thetumor prior to treatment had a volume of 40 cm3, and theinitial treatment trajectory treated a volume of about 10 cm3(Figure 4A-4C). The volume of the tumor at the start of thesecond treatment was about 28 cm3 (Figure 4D-4F). The secondtreatment trajectory had a larger treatment volume than the firsttreatment, treating about 20 cm3. At the 2-yr follow-up, theresidual hyperintensity volume was around 5 cm3 (Figure 4G-4I),which was stable over 3 MRIs spanning 18 mo since the initialfollow-up.DISCUSSIONThis case represents the confluence of a new way of thinkingabout low-grade insular gliomas and about LITT. Typically,insular tumors are considered through the lens of open surgicalresection.2 LITT therapies have historically been performed as asingle procedure for a given pathology.9 This case demonstratesa good clinical outcome can be achieved with a slow growinglarger lesion, which may be less risky than a single, upfrontopen craniotomy or a single laser procedure (with multipletrajectories) treating a large volume. By performing multiple,staged, well-tolerated single trajectory LITT procedures withNEUROSURGERY VOLUME 86 | NUMBER 3 | MARCH 2020 | E339HAFEZ ET ALFIGURE 3. FLAIR, T1 with, and T1 without images demonstrating treatment of left insular oligodendroglioma. Lesion size and FLAIR signal noticeably reduce insize from preoperation A-C, 60 d after stage I ablation D-F, 60 d after stage II ablation G-I, and 2 yr after stage II ablation J-L.more moderate volumes (<3 cm in diameter), the surgeon cantake a modular approach that could be less morbid for thepatients with comparable cytoreduction accomplished with acraniotomy.Insular lesions, particularly in the dominant hemisphere, haveincreased complexity with surgical resection because of thefunctional anatomy in proximity to these lesions. By stagingthe procedures, the patient was allowed time between sessionsto evaluate the treatment effect, as well as modifications to theplan and treatment aggressiveness. Using different trajectories,each staged surgery allowed for a new area to be targeted, aswell as additional treatments to the already-treated areas, thusmaximizing the cytoreduction. Moreover, gliomas necessarilyare diffusely infiltrating and even with optimal resection, willmost likely recur. Therefore, alternatives that provide successfulcytoreduction with limited invasiveness and surgical foot printmay provide benefit for tumors when possibility of a need forretreatment is high.It is important to note, however, although the describedapproach has numerous potential benefits in the treatmentof insular low-grade gliomas, it will be important to furthervalidate this surgical strategy in the form of larger clinicalexperience and outcome assessments. The use of advanced brainimaging identifying neural networks involved in speech hasbeen reliably and successfully used at our institution, allowingfor use of the minimally invasive approach in specific cases.However, depending on the location of the tumor, performing anawake craniotomy may be necessary, and this minimally invasiveapproach would not be a viable option if language mappingwas essential for increasing the safety of the tumor resection.Therefore, LITT therapy should continue to be used in a case-by-case basis.E340 | VOLUME 86 | NUMBER 3 | MARCH 2020 www.neurosurgery-online.comSTAGED LASER THERAPY TO LEFT INSULAR GLIOMAFIGURE 4. Volumetric analysis using StealthStation neuronavigation software. Coronal, axial, and sagittal images demonstrating the initial tumor volume (blueline; ∼40 cm3) and the first staged treatment volume (pink line; ∼10 cm3) A-C. Images D-F demonstrate the tumor volume at the start of the second treatment(green line; ∼28 cm3) and the second stage treatment volume (orange line; ∼20 cm3). The volume of the residual at the 2-yr follow-up was stable over 18 mo (redline; ∼5 cm3) G-I.NEUROSURGERY VOLUME 86 | NUMBER 3 | MARCH 2020 | E341HAFEZ ET ALCONCLUSIONThis case report demonstrates the versatility of LITT therapy totreat a patient with left insular glioma with multiple staged treat-ments. The treatments were well tolerated, and side effects thatwere encountered resolved during the routine follow-up period.Stereotactic laser therapy can be considered as an alternative forinsular tumors in appropriately selected patients.DisclosuresDr Leuthardt is a consultant for Monteris Medical. The other authors haveno personal, financial, or institutional interest in any of the drugs, materials, ordevices described in this article.REFERENCES1. Glenn C, Conner AK, Rahimi M, Briggs RG, Baker C, Sughrue M.Common disconnections in glioma surgery: an anatomic description. Cureus.2017;9(10):e1778.2. Sanai N, Polley MY, Berger MS. Insular glioma resection: assessment of patientmorbidity, survival, and tumor progression. J Neurosurg. 2010;112(1):1-9.3. Aleem Bhatti AU, Jakhrani NK, Parekh MA. Awake craniotomy with noninvasivebrain mapping by 3-Tesla functional magnetic resonance imaging for excision oflow-grade glioma: a case of a young patient from Pakistan. Asian J Neurosurg.2018;13(2):471-474.4. Brown PD, Maurer MJ, Rummans TA, et al. A prospective study of quality oflife in adults with newly diagnosed high-grade gliomas: the impact of the extentof resection on quality of life and survival. Neurosurgery. 2005;57(3):495-504;discussion 495-504.5. Hawasli AH, Bagade S, Shimony JS, Miller-Thomas M, Leuthardt EC. Magneticresonance imaging-guided focused laser interstitial thermal therapy for intracraniallesions. Neurosurgery. 2013;73(6):1007-1017.6. Hawasli AH, Bandt SK, Hogan RE, Werner N, Leuthardt EC. Laser ablation astreatment strategy for medically refractory dominant insular epilepsy: therapeuticand functional considerations. Stereotact Funct Neurosurg. 2014;92(6):397-404.7. Hawasli AH, Kim AH, Dunn GP, Tran DD, Leuthardt EC. Stereotactic laserablation of high-grade gliomas. Neurosurg Focus. 2014;37(6):E1.8. Hawasli AH, Ray WZ, Murphy RK, Dacey RG, Jr, Leuthardt EC. Magneticresonance imaging-guided focused laser interstitial thermal therapy for subinsularmetastatic adenocarcinoma: technical case report. Neurosurgery. 2012;70(2 SupplOperative):332-337; discussion 338.9. Kamath AA, Friedman DD, Hacker CD, et al. MRI-guided interstitial laserablation for intracranial lesions: a large single-institution experience of 133 cases.Stereotact Funct Neurosurg. 2017;95(6):417-428.10. Leuthardt EC, Guzman G, Bandt SK, et al. Integration of resting state functionalMRI into clinical practice - a large single institution experience. PLoS One.2018;13(6):e0198349.11. Hacker CD, Laumann TO, Szrama NP, et al. Resting state network estimation inindividual subjects. Neuroimage. 2013;82:616-633.12. Mitchell TJ, Hacker CD, Breshears JD, et al. A novel data-driven approachto preoperative mapping of functional cortex using resting-state functionalmagnetic resonance imaging. Neurosurgery. 2013;73(6):969-983; discussion982-963.COMMENTL aser ablation is a novel treatmentmodality being usedmore andmorein neuro-oncology as well as epilepsy surgery. As a minimally invasivecytoreductive treatment, it has a big advantage over open craniotomy inthe setting of recurrent and postradiated cases because of its minimalwound healing issues compared with large incisions. In addition, ithas been used as initial treatment for a number of intracranial tumors,including high-grade glioma. However, in most of the cases, its usageis limited to smaller tumors. In the case of large tumors, because ofincreased edema and temporary worsening mass effect, its role is limitedto combined cases with surgery.This is a very well-written paper; it describes successful treatmentof a large insular tumor by laser interstitial thermal therapy. In thiscase report, which is the very first one of its kind, staged laser ablationhas been used to minimize increased mass effect associated with laserablation in the early postoperative period. Especially in such a highlyeloquent area, because open surgery has its own risks and limitations,using a minimally invasive procedure like laser ablation has a potentialadvantage in treatment planning. Several cases of successful laser ablationfor smaller insular lesions had been reported before, and with thistechnique of staged ablation, size would not be a major issue for selectingpatients.Alireza MohammadiCleveland, OhioE342 | VOLUME 86 | NUMBER 3 | MARCH 2020 www.neurosurgery-online.com

Staged laser interstitial thermal therapy (LITT) treatments to left Insular low-grade glioma

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Staged laser interstitial thermal therapy (LITT) treatments to left Insular low-grade glioma

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