A patient in his mid twenties presented himself with a PXA (WHO grade 2) confirmed by open biopsy. The position makes surgical excision very difficult considering prevention of stroke. What would you suggest beside radiotherapy and seizure control?
Eventhough PXA is listed as a WHO grade 2 lesion, these are usually not infiltrative. Therefore, they are generally considered to be best addressed surgically. They have a tendancy for local recurrance if incompletely resected.Surgery should still be the first option with perhaps radiosurgery for any residual tumor. These are rare lesions and chemotherapy probably does not play a roll.
That's correct, chemotherapy does not play a role and surgical resection would be the best way to address it. However, the position involves a high risk.
Question 1: Is there anything known from histology, how these tumor cells differ, which could be possibly used to remove them from the vessel?
Question 2: How about a vascular surgery approach like in aortic aneurysms - in order to reach complete resection? Thanks, Andree
Regarding question 1, I don't have a clue. Regarding question two, it depends on where the PXA is relative to the MCA. If it is more proximal along the course of the M1 segment, surgical resection might place the lenticulo striate vessels and other small perforators at high risk. An endo vascular approach here would likely be unsuccessful also. If the location is more M2/M3 then surgical resection may be less dangerous. There are stent devices small enough to be placed in the MCA but no good covered stents like those used with Aortic repairs. There are microvascular approaches to aneurysms that could perhaps bypass the effected portion of the vessel however small perforators might still be a problem.
Yes, the location is M2 and I was indeed thinking of a bypass. Of course, this approach has its risks, too , but this way complete resection of the tumor can be achieved. A sufficient stent like those used in Aortic repairs would be a solution -
provided, the stent doesn't have to be replaced after a certain time. Maybe that's a new challenge for a company to come up with such a stent solution?!
And to follow up the histology path could be worthwhile in cancer research - to find a way to detach cancer cells not only from vessels, but from surrounding tissue and therefore stop invasion - with a focus on histology instead of signaling pathways. Maybe the topic of a new PhD somewhere?!
In the one PXA (in a child) surrounding the MCA I've been involved with the patient did reasonably well in terms of disease control with cytoreductive surgery leaving tumour around the vessel. A high flow bypass would have been required and given the M1 was encased with its perforators the risk of deep nucleii stroke was unacceptably high. Your case sounds more ameanable but is it fair to say most of these lesions do not - in fact- get "complete" resections?
Best
Correct, our case is more amenable since the location is not M1, but M2 - still complete resection indeed seems rather impossible the way the tumor is wrapped around. Your case sounds very interesting - did you follow up on it?
Is this a left or right sided lesion and have you considered resection with an awake craniotomy. As for a "stent" I highly doubt it would work and the patients that recieve "stents" and "pipeline" need to be pretreated with antiplatelet meds like aspirin and plavix prior to placement. This would not made surgical resection easy. I think we need to look at the images. Some PXA's have a nice gliotic plane around them evidenced on T2 imaging.
Yes, stents are not our first choice here, rather an option, if available - and not much of a gliotic plane.
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