Yay, Notes!

Several weeks ago, I requested the notes from my surgery, and they have finally arrived!  Compelling stuff, I’m sure, if you speak Medical. I’m going to spend a chunk of today trying to translate and understand this, but here it is:

1. The pathology report from during the surgery:

Final Diagnosis:

A, B) “Petrous”, sesectopm:

Myxoid cartilaginous neoplasm involving bone, most consistent with CHONDROSARCOMA, grade 2 of 3.

Immunohistochemistry Studies: Source (Original Label): B1, Population: Neoplastic cells

Block: B1

Label: Brachyury

Marker for: Brachyury

Results: negative

Special Pattern or Comments: Cytoplasmic staining

IHC Interpretation:

Brachyury shows non-specific cytoplasmic staining pattern, excluding the diagnosis of chordoma.

Intraoperative Consultation:

AFS/ATP) Myxoid neoplasm favor chondrosarcoma (CPN/BH) (SR/clk)

Clinical Data:

Left temporal petrosal crani for tumor

Gross Description:

A) Received fresh for intraoperative consultation in a container labeled “Nichols, Maria: detrous” are six fragments of tan soft tissue measuring 0.7 x 0.5 x 0.3 cm in aggregate dimension. Cytological touch preparation is prepared. 1/2 of the specimen is submitted for frozen. The frozen section residue is sumitted in block AFS1. The remaining tissue is submitted in block A2. (SR/clk)

B) Received in formalin labeled “Nichols, Maria: petrous” are fragments of mucoid-appearing, friable, translucent soft tissue admixed with blood clot measuring 2 x 2 x 0.2 cm in aggregate dimension, entirely submitted labeled:

B1 – soft tissue

B2 – apparent blood clot

(SR/clk)

Margaret Flanagan MB, ChB,

Resident

05/08/2015

Eleanor Chen MD, PhD

MD/Pathologist

Electronically Signed 05/08/2015

2. The surgeon’s “operative report”:

Preoperative Diagnoses:

1. Left abductens palsy
2. Left cavernous pretroclival giant lesion extending from the left cavernous sinus down to the level of the foramen magnum.
3. Preoperative angiogram to confirm adequate collateral supply.
4. Distortion of the left petrous cavernous carotid artery from the above.

Postoperative Diagnoses:

1. Left abductens palsy
2. Left cavernous pretroclival giant lesion extending from the left cavernous sinus down to the level of the foramen magnum.
3. Preoperative angiogram to confirm adequate collateral supply.
4. Distortion of the left petrous cavernous carotid artery from the above. (Frozen section was consistent with chondrosarcoma, confirmed by Dr. Hoch, of Soft Tissue Pathology)

Operations:

1. Left frontotemporal craniotomy with partial anterior petrosectomy for resection of giant chondrosarcoma.
2. Anterior skull base and middle fossa approaches for resection of tumor (transcavernous sinus, intra and extradural) and left subtemporal petrosectomy for middle fossa and posterior fossa (petroclival down to the level of the foramen magnum) resection of tumor.
3. Drilling of the middle fossa floor anterior petrosectomy and partial resection of the clivus and large tumor.
4. Decompression of the left abductens nerve at the level of the clivus and Dorello’s canal.
5. Temporalis fascia reconstruction of the middle fossa skull base.
6. Duragen reconstruction of the middle fossa floor and middle fossa defect.
7. Complete skeletonization of the left petrous carotid to the level of the cavernous sinus for complete removal of tumor.
8. Zygomatic osteotomy (withouth dissection of the zygomatic piece from the masseteric muscle).
9. Use of operative microscope.
10. Neurophysiological monitoring in the form of motor evoked potentials, sensory evoked potentials, brainstem auditory evoked potentials, and cranial nerve monitoring for cranial nerves V through XII on the left.

Modifier 22 Statement:

This operationn was at least 50% more difficult than the average complex joint skull base chondrosarcoma in that it extended from the level of the cavernous sinus down the formaen magnum via the petroclival region. There was extreme distortion of the carotid artery and entry in to the cavernous sinus.

Surgeons:

1. Manuel Ferreira Jr., M.D., Ph.D., Attending surgeon of record
2. John D. Nerva, M.D., Assistant
3. Ali C. Ravanapay, M.D., Assistant

Anaesthesia:

General Anaesthesia

Indications for Surgery:

The patient is a 42-year-old female who suffered a partial then near complete abductens palsy on the left. Imaging revealed the presence of a large tumor at the level of the skull base from the cavernous sinus distorting the medial left temporal lobe extending through the petrous bone clivus down the level of foramen magnum. I went over the risks and benefits of surgery with the patient and her husband and the differential diagnosis of which I favored chondrosarcoma versus chordoma. They understood that the role for a complete gross total resection in chordoma is quite different if this proved to be a chondrosarcoma. We talked about the possiblity of staging this procedure or leaving the residual and either following this radiographically versus up-front radiation therapy. They understood that my formal recommendation should this prove to be chordoma would be complete gross total resection of that tumor. We prepared for a left subtemporal transcavernous approach and a posterior fossa, posterior petrosal via anterior and posterior petrosectomies respectively. They understood the risks and benefits and opted to proceed.

Description:

Patient brought to the operating room, placed supine on the operating table. General anaesthesia was induced. The patient was intubated. Perioperative antibiotics were given. The patient was pinned in Mayfield pin headrest. She was turned in the lateral position with the right side down, left side up. Her arm was hung off the bed. We placed an axillary roll. We padded all pressure points. We kept the head in neutral and parallel to the floor. We fashioned a question mark incision on the left by parting the hair and braiding it. We T’d this poseriorly in the retroarticular area as well. We sterilely prepped and draped the patient. We gave the patient 1 gram/kg of mannitol, Decadron, Dilantin and proceeded. We came at the skin with a scalpel. We used Raney clips for hemostasis, reflected the flaps in all directions. We reflected the temporalis muscle and fascia laterally. We dissected the superficial portion of the zygomatic root. We now used a reciprocating saw to cut the zygomatic piece. We kept this attached to the masseter muscle. We were able to reflect the temporalis muscle laterally quite nicely by an additional 3 cm to give us access to the middle fossa floor. We placed multiple bur holes. We fashioned a frontotemporal craniotomy. We set this aside after stripping it and using the craniotome to remove it. We now brought in the operative microscope. I used cottonoids to strip the dura from the middle fossa floor.

I turned my attention to the level of the foramen spinosum. I cut the middle meningeal artery after bipolar electrocautery. I cut this sharply. I dissected the temporal dura from the middle fossa floor. I could see the bone. I found the dehiscent bone over the petrous carotid artery. Just medial to this, I identified the geniculate ganglion and the GSPN. I was able to stimulate this quite nicely. I could see the level of the foramen revale and foramen rotundum. I stripped the dura. I used a Beaver blade to split the dural leafs. I now visualized the arcuate eminence. I placed patties across this region. I used the stimulating electrode to locate the motor branch of V and the facial nerve at the level of the geniculate ganglion. We entered the tumor quite nicely. I was able to use the bony Sonopet to perform a partial petrosectomy, which had largely been done. We entered the tumor quite nicely, as it was soft and fleshy. I sent multiple specimens for frozen section, permanent section, and brain tumor bank. We suctioned this out quite nicely. I identified the petrous carotid artery. I was able to skeletonize it quite nicely. I used the Sonopet to further expose this area. I was able to completely skeletonize the petrous carotid. I followed this into the cavernous sinus. I could see it at the lateral cavernous wall. I now used extended and side swishing pituitary ring curettes to furtehr debulk the tumor. I chased this into the cavernous sinus under direct vision, subtemporally and extradurally, and the greater part of the tumor did deliver itself. We now followed the tumor in the subtemporal region to the posterior fossa dura. I could visualize the level of the arcuate eminence and the level of the cochlea by my radiographic imaging. I continued to follow this down the clivus toward the foramen magnum. We resected the tumor by and large. We used Valsalva maneuvers, extended ring curettes, and I was quite satisfied with the surgical resection. At this point, I opened the dura in a C-fashion. I split the proximal sylivan fissure identifying the optic nerve, left carotid artery, posterior communicating artery, the third nerve. I could visualize at the middle fossa floor the lateral cavernous sinus, which was directed completely free and floppy. I opened the lateral cavernous sinus wall once I identified the third, fourth, and fifth cranial nerves with a 90-degree arachnoid knife. As I did so, I was able to see the Gelfoam that I had placed in the subtemporal extradural root. I extended this into the cavernous sinus. I used extended ring curettes to attempt to identify this region and there was a complete removal of the tumor. I was quite pleased with this. We followed the first, second, and third divisions of the trigeminal nerve. I had identified the third and fourth cranial nerves as well and the sixth cranial nerve remained. We re-tacked the dura up. I went back to the extradural and subtemporal root. I was able to now use extended ring curettes and explore the posterior and anterior portion of the tumor. Once again with bony Sonopet, I was able to widen this opening and obtain additional tumor. We thoroughly irrigated. We hemostased and turned our attention to closure as I had predicted approximately 60% to 75% tumor removal including the symptomatic portion. Prior to closure, we did identify the abductens nerve entering Dorello’s canal, which was decompressed quite nicely. We cut a piece of temporalis fascia. I reconstructed the petrosectomy with this. We now cut a 1 x 3 piece of Duragen which I laid on the middle fossa floor. We used fibrin blue to hold the construct in place. We closed the dura with 4-0 nylon sutures in running fashion. We placed multiple packups around the periphery, 4-0 nylon sutures, and then a tack-up stitch to the middle bone flap. This was replated miniplates and screws. We closed the temporalis muscle fascia and galea and the complete dual incision with layered Vicryl sutures. We used running 3-0 nylon suture for the skin in running fashion.

As the attending surgeon of record, I, Manuel Ferreria Jr., M.D., Ph.D., was present. I performed key portions of the procedure. I was immediately available throughout the complete operation. I notified the patient’s family of results of surgery at the conclusion.

3. CT and MRI scans from before and after surgery:

Reviewed in the Post-Surgery Notes post