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P H Roche

Publications and source records attributed to P H Roche.

At least 19 recordsLinked to original sources
PubMed2003

Relative indications for radiosurgery and microsurgery for acoustic schwannoma.

The physical and biological principles underlying the use of radiosurgery for the treatment of vestibular schwannomas of up to 2.5 cm in diameter are reviewed together with the historical controversies that have surrounded its introduction. The results in terms of mortality, quality of life, preservation of facial movement and hearing, incidence of shunt-dependent hydrocephalus, cancer neogenesis and brain stem damage are compared in the Marseilles series of 600 microsurgical procedures and 830 Gamma knife procedures and with the peer-reviewed literature. The key principles of a steep profile to radiation exposure at the tumour margin, careful topographical planning of the radiation against the tumour shape to minimise the radiation dose to the cranial nerves and brain stem, early tumour swelling, tumour texture and national history of the tumour are analysed. Protocols for the management of unilateral schwannoma, Type II neurofibromatosis (both the Wishart and the Gardner types) and residual/recurrent tumours are presented. In summary, the growth of nearly 97% of vestibular schwannomas (up to 2.5 cm) is arrested by the Gamma knife, the facial nerve is preserved in almost all cases and hearing may be preserved at its pre-operative level in nearly 70% of cases without the complications of microsurgery.

Humans↗
PubMed2001

Surgical anatomy of the infratemporal fossa using the transmaxillary approach.

In this study we evaluated the ability of the transmaxillary route to expose the elements of the infratemporal fossa (ITF). Five adult cadaver heads were dissected on both sides, after making a paralateronasal incision. The maxillary branch of the trigeminal nerve served as a superior landmark to progress into the retroantral space and pterygopalatine fossa. The maxillary artery, lateral pterygoid muscle, pterygoid venous plexus, foramen rotundum and foramen ovale were identified. Distances between those elements and angle of approaches of the foramen ovale and foramen rotundum were measured in the horizontal plane. In all cases, the anterior loop of the maxillary artery and the sphenopalatine artery were located in the proximal retroantral fatty space and could be ligated without optic magnification. The maxillary nerve could be followed up to the foramen rotundum at a 44 mm mean distance from the opening. The mean angle of vision to the foramen rotundum was 31 degrees. Under the greater sphenoid wing and lateral to the pterygoid process, desinsertion and partial resection of the lateral pterygoid muscle were required to identify the pterygoid venous plexus and foramen ovale. The pterygoid venous plexus was organized as a compact network of channels between and superior to the muscle fibers; it was in close relation with the foramen ovale. Access to the foramen ovale was deep (mean 56 mm) and narrow (20 degrees). Our results indicate that the transmaxillary approach is a minimally invasive procedure that gives an appropriate window to the structures of the retroantral space and to the pterygomaxillary fissure and pterygopalatine fossa. Monitoring of the retropterygoid portion of the infratemporal fossa by this route is inadequate.

Adult↗
PubMed2001

Long-term outcome after gamma knife surgery for secondary trigeminal neuralgia.

OBJECT: This study was directed to evaluate the potential role of gamma knife surgery (GKS) in the treatment of secondary trigeminal neuralgia (TN). The authors have identified three anatomicoclinical types of secondary TN requiring different radiosurgical approaches. METHODS: Pain control was retrospectively analyzed in a population of patients harboring tumors of the middle or posterior fossa that involved the trigeminal nerve pathway. This series included 53 patients (39 women and 14 men) treated using GKS between July 1992 and June 1997. The median follow-up period was 55 months. Treatment strategies differed according to lesion type, topography, and size, as well as visibility of the fifth cranial nerve in the prepontine cistern. Three different treatment groups were established. When the primary goal was treatment of the lesion (Group IV, 46 patients) we obtained pain cessation in 79.5% of cases. In some patients in whom GKS was not indicated for treatment of the lesion, TN was treated by targeting the fifth nerve directly in the prepontine cistern if visible (Group II, three patients) or in the part of the lesion including this nerve if the nerve root could not be identified (Group III, four patients). No deaths and no radiosurgically induced adverse effects were observed, but in two cases there was slight hypesthesia (Group IV). The neuropathic component of the facial pain appeared to be poorly sensitive to radiosurgery. At the last follow-up examination, six patients (13.3%) exhibited recurrent pain, which was complete in four cases (8.8%) and partial in two (4.4%). CONCLUSIONS: The results of GKS regarding facial pain control are very similar to those achieved by microsurgery according to series published in the literature. Nevertheless, the low rate of morbidity and the greater comfort afforded the patient render GKS safer and thus more attractive.

Adolescent↗
PubMed2001

[Recurrent acoustic neurinoma after complete surgical resection].

BACKGROUND: Mortality of acoustic neurinoma surgery is currently very low, well below the figures reported by the first surgeons. Morbidity has also declined with attempts at preserving the facial function and more recently hearing function. Long-term follow-up has demonstrated the well-known risk of recurrence after partial resection, but also evidenced a risk after complete resection. PATIENTS AND METHODS: We reviewed two series of patients, the first including 40 patients treated and followed at the Timone Hospital since 1975 and the second including 97 operated patients who were followed by the ENT Federation over 8 to 16 years. We studied recurrence after partial and complete resection. RESULTS: Recurrence rate was 20% after partial resection and 9.2% after complete resection. DISCUSSION: The 20% recurrence rate after partial resection was similar to that reported in the literature. After total extirpation, our 9.2% recurrence rate appears well above the 1% reported by others. Although our series could have a bias due to the large number of patients lost to follow-up, the large population size and the fact that we had a majority of large tumors would suggest that recurrence rate is generally underestimated. An 8 to 10% rate appears to be closer to reality. Most recurrences were late, with a peak around 8 years. We did however observe recurrences as early as 1 year and as late as 20 years. Delay appears to be shorter after partial removal. A wide range of localizations were observed but two areas predominated: the internal auditory canal and the components of the acousticofacial pedicle, and to a lesser degree the brain stem. Most patients were asymptomatic. The principal manifestations were balance disorders or trigeminal nerve lesions, more rarely facial palsy. But these clinical signs came late and generally signaled a bulky tumor measuring more than 3 cm. CONCLUSION: These findings lead us to insist on the need for radiological monitoring of all operated neurinomas irrespective of the initial surgery. MRI appears to be more accurate than computed tomography. Images must be interpreted carefully due to possible postoperative remodeling. For us, these observations point to the need for prolonged follow-up of at least 8 years, longer for young subjects, for all patients undergoing surgical resection of an acoustic neurinoma.

Adolescent↗
PubMed2000

Gamma knife radiosurgery as a primary treatment for prolactinomas.

OBJECT: The purpose of this study was to estimate the efficacy of gamma knife radiosurgery (GKS) in controlling tumor growth and endocrinopathy associated with prolactinomas. METHODS: Between 1993 and 1997, 164 of 469 patients with pituitary adenomas treated by GKS harbored prolactinomas. The dose to the tumor margin ranged from 9 to 35 Gy (mean 31.2 Gy), and the visual pathways were exposed to a dose of less than 10 Gy. The mean tumor diameter was 13.4 mm. The mean follow-up time for 128 cases was 33.2 months (range 6-72 months). Tumor control was observed in all but two patients who underwent surgery 18 and 36 months, respectively, after GKS. Clinical cure was achieved in 67 cases. Clinical improvement was noted with a decrease in the hyperprolactinemia after GKS. Nonetheless, in 31 (29%) of 108 patients who were followed for more than 2 years no improvement in serum prolactin levels was demonstrated, although this could be normalized by bromocriptine administration after treatment. Nine infertile women became pregnant 2 to 13 months after GKS and all gave birth to normal children. There was no visual deterioration related to GKS. Five women experienced premature menopause. In these patients there was subtotal disappearance of the tumor and an empty sella developed. CONCLUSIONS: Gamma knife radiosurgery as a primary treatment for prolactinomas can be safe and effective both for controlling tumor growth and for normalization of prolactin hypersecretion. A higher margin dose (> or = 30 Gy) seemed to be associated with a better clinical outcome. Gamma knife radiosurgery may make prolactinomas more sensitive to the bromocriptine.

Humans↗
PubMed2000

[Neurofibromatosis type 2. Preliminary results of gamma knife radiosurgery of vestibular schwannomas].

BACKGROUND AND PURPOSE: The aim of this study was to assess tolerance and efficacy of gamma knife radiosurgery on vestibular schwannomas for patients affected with neurofibromatosis type 2. METHODS: Between July 1992 and December 1997, a gamma knife procedure was performed on 35 vestibular schwannomas affecting 27 patients (12 females and 15 males, mean age=27 years-old, range: 14-65). Fifteen of the patients were included in the Wishart subtype (severe form) and 12 patients in the Gardner subtype (mild form). This group of 27 patients represented 8,2% of the total group of vestibular schwannomas radiosurgically treated by our team. The mean tumor volume was 4,000 mm(3) (range: 400-14,400 mm(3)) and staging according to Koos classification was 9 stage 2 tumors (extension in the cerebellopontine angle), 19 stage 3 tumors (in contact with the brain stem or cerebellum) and 7 stage 4 tumors (compression of axial structures). The delivered mean marginal dose (50% isodose) was 13 Gy (range: 10-18 Gy). After the treatment, the mean clinical and radiological follow-up was 32 months (range: 6-70). RESULTS: Twenty six (74%) of the treated tumors were controlled by the treatment (15 stabilizations and 11 regressions of the tumor volume) at last follow-up. One microsurgical removal was required in a growing stage 4 tumor and in 2 cases of growing stage 3 tumors. Three post-radiosurgical facial nerve deficits (9%) were observed, 2 of them were transient. According to the Gardner and Robertson classification, classes I (good) and II (serviceable) hearing were preserved at last follow-up in 57% of the patients having the same hearing level prior to the gamma knife. CONCLUSIONS: Our experience confirms that tolerance of gamma knife radiosurgery compares favorably with microsurgery of bilateral vestibular schwannomas. This treatment should be restricted to small and medium growing tumors. Treatment strategy of neurofibromatosis type 2 patients should be planned by multidisciplinary experienced teams disposing of the whole armamentarium. A longer follow-up study is required to confirm the current results regarding the tumor control rate.

Adolescent↗
PubMed2000

[Endolymphatic sac tumors].

Tumors of the endolymphatic sac are rare and can be found in patients with Von Hippel Lindau disease. They most often develop within the intrapetrosal part of the sac but can sometimes be located in the distal part. Their growth is slow and they spread in two directions: laterally toward the external and middle ear and in the direction of the jugular foramen and medially into the ponto-cerebellar angle. The symptoms are usually auditive, with a constant neurosensorial deafness of sudden onset in 50 % of cases and sometimes associated with a tinnitus and dizziness. The varieties with medial extension result in a cerebellopontine angle syndrome. Diagnosis is made by imaging (CT scan and MRI) that reveals a heterogeneous tumor between the lateral sinus and the internal auditory meatus, hypervascularized showing contrast, with cystic zones and associated with bone lysis. Histological examination of a papillary cystadenoma is performed and the differential diagnosis is essentially made with a papillary of the choroïd plexus. They require total surgical excision in order to avoid possible recurrence and can be performed by retrosigmoïd approach, or more ideally, by transpetrosal approach.

Adult↗
PubMed1999

[Lumbar canal stenosis caused by amyloidosis of the yellow ligament].

Symptomatic lumbar canal stenosis without bony stenosis has previously been described. We describe the pathological modifications of ligamentum flavum among such operated patients. Ten patients were prospectively included in this study. Their mean age was 74, ranges: from 52-90. Clinical manifestation was a radicular claudication (sciatic or crural). Neuroradiology confirmed in all cases the ligamentum flavum thickness as the main cause of the symptomatology. This feature was also confirmed operatively and complete resection of the ligamentum flavum was performed. Resolution of the radicular pain was obtained in all cases at last follow-up. Pathological examination of the ligamentum flavum displayed characteristic features of degenerative modifications and elastic fibers fragmentation caused by numerous amorphous deposits. The deposits were studied using red Congo staining, polarized light and immunostaining methods. Such technique showed evidence of amyloid origin of the deposits. Immunodetection was positive for the P component in the amyloid deposits and for beta-2-microglobulin in one case (chronic renal failure and hemodialysis). The deposits did not express antitransthyretin antibodies. In parallel, control ligamentum flavum were obtained from 10 operated patients affected by bony lumbar stenosis. Moderate degenerative features were observed but small amounts of amyloid deposits were found in only 3 of those cases, without thickening of the ligamentous structure. This study correlates the presence of thickened ligamentum flavum caused by amyloid deposition, with symptomatic non-osseous lumbar canal stenosis. Association with degenerative modifications of the spine in the studied cases is suggestive of a microtraumatic origin.

Aged↗
PubMed1999

[Dural metastases mimicking meningioma. Report of a case].

We report a case of dural metastasis, detailing the neuroradiologic and therapeutic aspects. The clinical presentation was limited to a progressive left hemiparesis. Post-contrast CT scan revealed a heterogeneous high-density mass of the right fronto-parietal convexity. MRI demonstrated dural involvement mimicking meningioma. Chest X-ray showed a right lung opacity, suggesting the diagnosis of dural metastasis. Surgical resection was performed. Histology confirmed the diagnosis of dural metastasis from a poorly differentiated carcinoma. Treatment was completed with radiotherapy and chemotherapy. Dural metastases are rarely reported. A review of the literature revealed principally 2 radiological aspects: hemorrhagic effusion and tumor mass. The pathophysiology of dural metastases is still a subject of debate. Two mechanisms have been put forward involving venous and arterial dissemination. As radiological aspects are confusing, the diagnosis of dural metastasis should be evoked in patients with spontaneous hemorrhagic subdural effusion or a tumor mass involving the dura mater.

Diagnosis, Differential↗
PubMed1999

[Epidermoid cyst of the lateral ventricles].

A case of epidermoid cyst of the lateral ventricles is reported. The patient presented with a weakness of the left lower limb and neuropsychological disorders. The diagnosis was assessed by CT scan and MRI, and confirmed at the operation. The lesion has been largely removed through a transcallosal approach though incompletely. However the long term follow-up was uneventful. Twenty-nine cases of the literature have been reviewed.

Adult↗
PubMed1998

Anterior lumbosacral dislocation: case report and review of the literature.

BACKGROUND: Anterior lumbosacral dislocation is a rare traumatic anterior spondylolisthesis. METHODS: We report a new case surgically treated and review the eight cases previously reported. RESULTS: The mechanism of injury is hyperflexion-distraction. Neurological signs are inconsistent. Indirect radiological signs such as bilateral multiple transverse process fractures are strongly suggestive of the diagnosis. This complete soft tissue injury induces a definitive instability and requires an open reduction with posterior fixation. CONCLUSIONS: Suspicion of lumbosacral dislocation requires a computed tomography scan exploration with multiplanar reconstructions. Early reduction is associated with neurologic recovery. However, prognosis is correlated with the initial neurologic status and the severity of other associated injuries.

Adult↗
PubMed1998

Endolymphatic sac tumors: report of three cases.

OBJECTIVE AND IMPORTANCE: We present three cases of endolymphatic sac tumors and review the previously published cases. Despite frequent extension to the cerebellopontine angle, these rare tumors have only recently been recognized by neurosurgeons. CLINICAL PRESENTATION: A 26-year-old man developed a progressive hearing loss, revealing an intrapetrous retrolabyrinthine tumor on the right side. A 28-year-old woman experienced a left cerebellopontine angle syndrome, with a lytic intrapetrous mass extending into the cerebellopontine angle. A 38-year-old woman presented with an intracranial hypertension syndrome caused by a tumor of the jugular foramen. INTERVENTION: For the first and second patients, the tumors originated from the operculum of the endolymphatic sac. Total removal was achieved, via a transpetrosal approach, in these two cases. No recurrence was detected after a 20-month follow-up period. For the third patient, the tumor originated from the distal part of the sac. Recurrence was observed 8 years after subtotal removal via a retrosigmoid route. Histological analysis revealed a papillary-cystic adenocarcinomatous pattern in all cases, without features of aggressiveness. CONCLUSION: Endolymphatic sac tumors are locally invasive neoplasms characterized by bipolar intrapetrous and posterior fossa involvement. The anatomic complexity of the endolymphatic sac may explain the distinct patterns of extension of these tumors. Early radical surgery is related to good outcomes.

Adenocarcinoma, Papillary↗
PubMed1997

Expression of cell adhesion molecules in normal nerves, chronic axonal neuropathies and Schwann cell tumors.

Cell adhesion molecules (CAMs) play a role in the normal development and regeneration of tissues as well as in the biological behaviour of tumors. We studied the immunohistochemical expression of various CAMs, such as neural cell adhesion molecule (NCAM), its polysialylated isoform (PSA-NCAM), epithelial (E-) cadherin, and beta1 integrins (alpha2beta1, alpha5beta1, alpha6beta1) in a series of frozen specimens of 10 normal nerves, 5 axonal neuropathies, 26 benign Schwannomas and 2 malignant peripheral nerve sheath tumors (MNST). NCAM was expressed by non-myelinating Schwann cells from normal nerves and overexpressed by Schwann cells from patients with chronic axonal neuropathies and Schwannomas. The expression was lower in MNST. Expression of PSA-NCAM was heterogeneously displayed by Schwann cells from the various tissues studied. Anti E-cadherin immunoreactivity was present in myelin sheath in normal nerves and axonopathies. It was expressed in some Schwannomas especially in vestibular Schwannomas. Integrins VLA alpha2 and VLA alpha6 were widely expressed by Schwann cells from normal nerves, axonal neuropathies and Schwannomas but their expression was low in MNST. VLA alpha5 was not expressed by Schwann cells from normal nerve and Schwannomas but present in chronic axonal neuropathies and MNST. In addition VLA alpha6 was strongly expressed by perineurial cells. These data show that CAMs have a characteristic pattern of expression in normal nerve. Also, some CAMs are always expressed by Schwann cells but the expression of others differs in normal nerves versus axonopathies or tumors, suggesting a role of the microcellular environment in the regulation of CAM expression. Schwannomas have different pattern of expression than MNST.

Axons↗
PubMed1997

Cell-adhesion molecules in human meningiomas: correlation with clinical and morphological data.

Integrins form a family of cell adhesion molecules. CD44 glycoproteins are found in a wide variety of isoforms; the most common, CD44s (standard) is widely distributed, and functions as an adhesion molecule. In this study, we have investigated immunohistochemically the distribution of some VLA integrins (alpha2, alpha5 and alpha6 chains of beta1 integrins) and CD44s in 44 meningioma specimens and normal arachnoid villi. Meningiomas were of meningothelial (16), transitional (13) and fibroblastic (15) subtypes. There were 13 grade I, 19 grade II and 12 grade III (27%). Immunoprecipitates were quantified by image analysis and correlated with clinical (age, sex, location) and morphological data (histological subtypes and grades). VLA alpha5 chain was expressed by normal arachnoid villi (mainly cap cells) and by 42 out of 44 meningioma specimens. Expression was lower in fibroblastic meningiomas (P=0.02). VLA alpha2 and alpha6 chains were not observed in normal arachnoid villi. VLA alpha2 was expressed by 15 meningiomas, VLA alpha6 by 10. Interestingly, meningiomas expressing either VLA alpha2 or alpha6 were usually of grade III (P< or =(0.05). CD44s was found on various parts of arachnoid villi and in all meningiomas although expression was higher in meningothelial and transitional than in fibroblastic (P< or =0.001). These results show that VLA alpha5 and CD44s are widely expressed by arachnoid villi and meningiomas, in contrast to VLA alpha2 and VLA alpha6. It was noted that high grade meningiomas (III) express VLA alpha2 and alpha6 suggesting that changes in integrin pattern expression are a feature of these meningiomas. Moreover, strong CD44s expression characterizes meningothelial and transitional meningiomas. Previous studies have shown that high NCAM expression is a feature of fibroblastic meningiomas whereas meningothelial and transitional meningiomas expressed mainly E-Cadherin, and that polysialylated NCAM expression was restricted to high grade meningiomas. Taken together these features suggest that each cell adhesion molecule has a characteristic pattern of expression according to meningioma subtype and grade. No correlation was seen between integrins and CD44s expression and clinical data.

Adolescent↗
PubMed1997

[Primary spinal osteosarcomas].

The rarity of primary osteosarcoma of the spine led us to index the 66 reported cases published in literature. From this analysis a difference was found between spinal osteosarcoma and osteosarcoma of the extremities. Tumors of the spine appear to be two times more frequent in the male population in their thirties. The average period between the beginning of the symptoms and the first consultation is seven months. Back pain is permanent and localized to the affected vertebra. In 80 percent of the cases, neurological symptoms already exist at the stage of the diagnosis. Magnetic resonance imaging (MRI), computed tomography and standard X-ray remain complementary in the morphological analysis of this tumor. All the aspects from the lytic to sclerotic forms are noted, although the lytic form is common. Among spinal osteosarcoma, the lumbar vertebrae are the most frequently affected. Diagnosis can only be established by pathology, even though this may also lead to some errors. In all the reported cases surgery is used, but carcinological methodology is not possible and a complete removal of affected tissue is difficult, with this being achieved in only a quarter of the cases. Radiation therapy, when used, requires doses of 70 Gy to 80 Gy without any certitude of controlling the tumour and with high risks of post-radiation complications. Chemotherapy on its own, despite the use of high-dose methotrexate, only has a temporary effect due to partial action on the primary center. Twenty years ago, only twenty percent of all patients suffering from osteosarcoma lived beyond two years, with worse prognosis for spinal osteogenic sarcoma. Today, the therapeutic approach for spinal tumors uses techniques developed in the treatment of osteosarcoma of the extremities, which can now expect more than seventy percent of all patients to live beyond five years. Present day methods recommend a rapid confirmation of the diagnosis, and then a neoadjuvant chemotherapy followed by surgery to remove all the affected area. This strategy allows an evaluation of the tumor chemosensitivity and to adapt the treatment in consequence. The latest results of this treatment on spinal osteosarcoma appear to be encouraging.

Humans↗
PubMed1997

[Primary spinal osteosarcoma. Apropos of a case].

We report a case of primary osteogenic sarcoma of the third lumbar vertebra, detailing the neuroradiologic and therapeutic aspects. The clinical presentation was limited to low back pain which radiated to the left thigh for 5 months. Lumbosacral spine roentgenograms revealed a sclerotic lesion of the left part of the body of the third lumbar vertebra. Treatment consisted of total vertebrectomy, chemotherapy completed with radiotherapy. Fourteen months after a complex combined treatment no recurrence was observed. A review of the literature highlighted the rarity of this tumor. Usually, patients with vertebral osteogenic sarcoma do poorly. Today, the therapeutic approach for these spinal tumors should use techniques developed in the treatment of osteosarcoma of the extremities because of their encouraging results.

Adult↗
PubMed1997

[Acoustico-facial cavernomas. Apropos of 2 surgically treated cases].

BACKGROUND: Acousticofacial cavernomas are rare lesions. Only 4 cases with a cerebellopontine extension have been reported previously whereas intrapetrous facial nerve cavernomas are well described in the otologic literature. In this paper, we describe two additional cases of acousticofacial cavernomas. METHOD AND RESULTS: The two patients were operated via a translabyrinthine route with a preoperative diagnosis of vestibular schwannoma. In the first case, the lesion was confined in the internal auditory canal whereas the cavernoma extended into the cerebellopontine angle in the latter. CONCLUSIONS: Diagnosis is suspected when facial nerve deficit strikingly reveals a small cerebellopontine angle lesion. MRI examination is not specific enough when the lesion is confined to the internal auditory canal. Treatment is based upon surgical removal although facial nerve impairment is often described as the main cause of postoperative morbidity.

Adult↗