Eso Masterclass In Neuro-Oncology: Multidisciplinary Management Of Adult Brain Tumour

September 20 — September 22

Milan, Italy

Programme

The European School of Oncology was founded by Umberto Veronesi and Laudomia Del Drago in 1982, with the aim of contributing to the reduction of deaths from cancer due to late diagnosis and/or inadequate treatment. By improving the skills of all health professionals dealing with cancer patients, ESO helps shorten the time needed to transfer knowledge from research centres to daily practice, combining advanced technology with humanism in care.

ESO’s mission is reflected in its motto “Learning to Care”, which emphasises the importance of the learning process, and the goal of caring for the patient in a holistic sense, in contrast to focusing purely on treating the disease.

Due to its financial independence, ESO has the rare privilege of being able to set its own priorities. It therefore pays particular attention to developing the transfer of knowledge in areas that are least supported by industry, such as surgery and in rare pathologies (including childhood tumours), and in countries and regions with limited economic resources.

Spinal Schwannoma Classification

Spinal Schwannoma Classification

Preoperative planning remains crucial for successful Spinal Schwannoma treatment and relies to a great extent on proper tumor classification. The literature includes multiple classification systems for spinal schwannomas, each of which is associated with both positive and negative ramifications for preoperative planning 1) 2) 3)4).

Consequently, there is a lack of consensus concerning the optimal system of classification for schwannomas 5).

The literature includes numerous schwannoma classification systems. Jinnai and Koyama 6) classified schwannomas into five groups based on the relationship between the tumor and the dura mater and/or intervertebral foramen. This classification system is useful, as it takes into consideration tumor localization relative to the dura, but it does not take into account volume, which is important for preoperative surgical planning.

Sridhar classification

Sridhar 7) was the first, in 2001, to suggest a classification system of benign spinal schwannoma including giant and invasive spinal schwannomas (type I to V).

Park et al. 8) reported the use of a new classification system, and Type VI and Type VII were added. But the classification system as defined by Park et al. were inadequate because both the figures and the tumors were not clearly described in their manuscript.

A case could not be classified based on Sridhar’s spinal schwannoma classification system. Thus, as shown in a case, of Kotil type VIII must be added to the modified Sridhar classification (Kotil classification) system of benign spinal schwannomas 9).

Sun and Pamir however, think classification of seven distinct types of schwannomas using Sridhar et al.’s system is not practical because the characteristics of seven tumors types are difficult to remember. Another drawback of their system is that tumor volume is only considered for dumbbell-shaped tumors, and craniocaudal dimension is not a consideration, which limit the diagnostic value and consistency of the classification system 10).

Asazuma Classification

Asazuma et al. 11) devised a schwannoma classification system for cervical dumbbell- shaped tumors that consisted of nine categories. An important drawback of their classification system is that it cannot be used for thoracic or lumbar schwannomas, which are as common as cervical schwannomas.

Asazuma et al. classification system for dumbbell spinal schwannoma:

Type 1 intradural extradural restricted to the spinal canal. The constriction occurs at the dura.

Type II are all extradural, and are subclassified as:

IIa do not expand beyond the neural foramen.

IIb inside spinal canal + paravertebral.

IIc foraminal + paravertebral.

Type IIIa are intradural and extradural foraminal, IIIb are intradural and extradural paravertebral.

Type IV are extradural and intravertebral.

Type V are extradural and extralaminar with laminar invasion.

Type VI show multidirectional bone erosion.

Craniocaudal spread: IF & TF designate the number of intervertebral foramina and transverse foramina involved, respectively (e.g. IF stage 2 = 2 foramens).

Schwannomas involving C1 & C2: May involve vertebral arteries and require additional caution.

Sun and Pamir Classification

It is based on consideration of tumor volume and localization relative to the dura and spinal canal. For approximate calculation of tumor volume, spinal schwannomas were considered ellipsoid bodies, and tumor volume was calculated using the following formula:

Tumor volume = 4 / 3 π × (craniocaudal length / 2) × (transverse diameter / 2)2 .

Tumors were then assigned to 1–3 volume groups (group A, B, and C) and designated as 1 of 4 types (type I, II, III, and IV) accord- ing to localization (i.e., group B type II tumor). Tumor volume <2 cm3 was considered group A, 2–4 cm3 group B, and >4 cm3 group C. Tumor typing was as follows: localized exclusively intra- durally: type I; intradural localization with extradural extension to the nerve root foramina, but restricted to the spinal canal: type II; intradural dumbbell-shaped tumor in the spinal canal extending to the extraforaminal region: type III; and localized completely outside the root foramina: type IV


Sridhar et al.’s 12) classification system is arguably the most similar of the previously reported systems to the novel classification system described by Sun and Pamir however, they think classification of seven distinct types of schwannomas using Sridhar et al.’s system is not practical because the characteristics of seven tumors types are difficult to remember. Another drawback of their system is that tumor volume is only considered for dumbbell-shaped tumors, and craniocaudal dimension is not a consideration, which limit the diagnostic value and consistency of the classification system 13).


Based on the findings, Sun and Pamir think that all schwannomas should be classified according to localization and volume, so as to achieve the desired benefit of classification—ease and reliability of preoperative decision making and preparation. In addition, this classification system makes tumor localization easier to understand, as compared to other systems, and is suitable for all schwannoma types.

It is a simple and effective tool that shows extremely helpful for avoiding unnecessary surgical approaches and complications. Due to the system’s simplicity of having only three tumor groups and its reliability—indicated by the associated low postoperative side effect rate, use of this novel classification system should be considered by any surgical department that seeks a standardized schwannoma surgery protocol. 14).


Dumbbell spinal schwannoma

Giant spinal schwannoma

Cervical spinal schwannoma

Thoracic spinal schwannoma

Lumbar spinal schwannoma

References

1)

Chowdhury FH, Haque MR, Sarker MH. High cervical spinal schwannoma; microneurosurgical management: an experience of 15 cases. Acta Neurol Taiwan (2013) 22:59–66.
2)

Fernandes RL, Lynch JC, Welling L, Gonçalevs M, Tragante R, Temponi V, et al. Complete removal of the spinal nerve sheath tumors. Surgical techniques and results from a series of 30 patients. Arq Neuropsiquiatr (2014) 72:312–7. doi:10.1590/0004-282×20140008
3)

Iwasaki Y, Hida K, Koyanagi I, Yoshimoto T, Abe H. Anterior approach for dumbbell type cervical neurinoma. Neurol Med Chir (1999) 39:835–9. doi:10.2176/nmc.39.835
4)

Kim P, Ebersold MJ, Onofrio BM, Quast LM. Surgery of spinal nerve schwannoma. Risk of neurological deficit after resection of involved root. J Neurosurg (1989) 71:810–4. doi:10.3171/jns.1989.71.6.0810
5)

Sun I, Pamir MN. Non-Syndromic Spinal Schwannomas: A Novel Classification. Front Neurol. 2017 Jul 17;8:318. doi: 10.3389/fneur.2017.00318. eCollection 2017. PubMed PMID: 28769861; PubMed Central PMCID: PMC5511849.
6)

Jinnai T, Koyama T. Clinical characteristics of spinal nerve sheath tumors: analysis of 149 cases. Neurosurgery (2005) 56:510–5. doi:10.1227/01. NEU.0000153752.59565.BB
7) , 12)

Sridhar K, Ramamurthi R, Vasudevan MC, Ramamurthi B. Giant invasive spinal schwannomas: definition and surgical management. J Neurosurg (2001) 94:210–5.
8)

Park SC, Chung SK, Choe G, Kim HJ. Spinal intraosseous schwannoma : a case report and review. J Korean Neurosurg Soc. 2009 Oct;46(4):403-8. doi: 10.3340/jkns.2009.46.4.403. Epub 2009 Oct 31. PubMed PMID: 19893734; PubMed Central PMCID: PMC2773402.
9)

Kotil K. An extremely giant lumbar schwannoma: new classification (kotil) and mini-open microsurgical resection. Asian Spine J. 2014 Aug;8(4):506-11. doi: 10.4184/asj.2014.8.4.506. Epub 2014 Aug 19. PubMed PMID: 25187870; PubMed Central PMCID: PMC4149996.
10) , 13) , 14)

Sun I, Pamir MN. Non-Syndromic Spinal Schwannomas: A Novel Classification. Front Neurol. 2017 Jul 17;8:318. doi: 10.3389/fneur.2017.00318. eCollection 2017. PubMed PMID: 28769861; PubMed Central PMCID: PMC5511849.
11)

Asazuma T, Toyama Y, Maruiwa H, Fujimura Y, Hirabayashi K. Surgical strategy for cervical dumbbell tumors based on a three-dimensional classification. Spine (2004) 29:E10–4. doi:10.1097/01.BRS.0000103662. 13689.76

EUROSPINE 2018

Date:
19-21 September 2018
Location:
Barcelona, Spain
Venue:
CCIB – Barcelona International Convention Centre

Pre-day Courses on Tuesday, 18 September

Pre-day Course I 
13:00-17:45
Anterior Approaches to the Thoracic and Lumbar Spine
Chairs: Pedro Berjano, Milan, Italy and Hossein Mehdian, London, UK
Room 112

The anterior approach to the spine has been around for the last 50 years. Originally, the surgery involved a large abdominal incision in which the surgeon would cut through the abdominal muscles and the peritoneal cavity to gain access to the spine. Today, however, anterior approaches to the spine can be done with a minimally invasive approach. As with all surgical procedures, the anterior approach to spine carries with it a few risks and potential complications that are unique to this surgical approach.

Educational goals:

  • To provide participants with an opportunity to interact with experts in the clinical use of anterior approaches to the spine
  • To provide information with clinical significance that goes more in depth than classical textbooks
  • To gain a comprehension of the variety of anterior approaches to the spine in every anatomical region.
Pre-day Course II
13:00-17:00
Emerging Technologies in Spine Surgery
Chairs: Doniel Drazin and J. Patrick Johnson, USA
Room 111

This course will explore the new advances in the field of emerging technologies in spine surgery and will provide the current state of the art in the use of technology for treating spinal pathology. Topics include and are not limited to intraoperative imaging, navigation, robotics, next generation microscopes and surgical instruments, combinatorial technologies, augmented reality and surgical simulators.

Course Objectives:

  • Develop an understanding of the role of emerging technologies in improving the care of neurosurgical and orthopaedic patients with spinal disorders.
  • Identify the indications to use and the expected outcomes of utilising navigation and emerging technologies in the treatment of spinal disorders.
  • Develop a strategy to implement new technologies providing beneficial spinal care for patients with spinal disorders.

Sections include: Navigation, emerging technologies, and hands-on

Pre-day Course III 
13:00-17:00
Spine Tango Users Meeting (STUM)
Chairs: Anne Mannion and Emin Aghayev, Zurich, Switzerland
Room 118/119

Spine Registry

CME-Accreditation of Pre-day Courses
The EUROSPINE 2018 pre-day courses were granted the following CME credits (ECMEC®s) by the European Accreditation Council for Continuing Medical Education (EACCME®):

Pre-day Course I, Anterior Approaches to the Thoracic and Lumbar Spine: 4 ECMEC
Pre-day Course II, Emerging Technologies in Spine Surgery: 3 ECMEC
Pre-day Course III, Spine Tango User Meeting (STUM): 3 ECMEC

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