10.1007/s00381-007-0331-8

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Child's Nervous System

=A9 Springer-Verlag 2007

Original Paper

Peri-operative quality of life = assessment=20 in endoscopically treated patients with pineal region tumours

Wuttipong Tirakotai¹,=20 Thomas Riegel¹, Alex Stiegel¹,=20 Dieter Hellwig¹, Stefan Heinze¹,=20 Helmut Bertalanffy¹ and Ilhan Celik²

(1)	Department of Neurosurgery, Philipps=20 University, Baldingerstrasse, 35033 Marburg,=20 Germany

(2)	Institute of Theoretical Surgery, = Philipps=20 University, Marburg, Germany

= =

Ilhan CelikEmail:=20 celik@mailer.uni-marburg.de
Email:=20 i.celik@online.de

Received:=20 15 September 2006 Published = online:=20 27 March 2007

Abstract

Background Therapeutic modalities for = pineal=20 region tumours are still matter of debate. Endoscopic treatment is a = minimally=20 invasive approach. The aim of this study was to assess the quality of = life of=20 patients with pineal region tumours who underwent endoscopic procedures. =

Materials and=20 methods Eight patients (male:3, female 5) were = included in=20 this study. Post-operative evaluation of surgical outcome in terms of = quality of=20 life (QoL) was performed using the Quality of Life Questionnaire = (QLQ-C30). The=20 patient=92s outcome scores were compared with normative outcome values = of the=20 German population. Pre-operative and post-operative global QoL and = symptoms such=20 as headache, visual disturbance, gait disturbance, cognitive function = and=20 unconsciousness were documented. Descriptive and explorative statistics = were=20 performed.

Results There were no significant = differences=20 between the normal German population and the endoscopically treated = patients in=20 different health domains and measures of QLQ-C30 (physical functioning = 87.5%,=20 emotional functioning 50%, cognitive functioning 50%, social functioning = 62.5%;=20 percentage represents regular functioning). Improved quality of life = could be=20 demonstrated in short-term (3=9612 months, = n =3D 3) and long-term=20 (21=9629 months, n =3D 5) follow-up. Global QoL = improved significantly=20 (p < 0.001; t-test) post-operatively. The = following changes=20 between pre-operative and post-operative clinical symptoms were found = (headache=20 87.5%/62.5%, visual disturbance 50%/25%, gait disturbance 87.5%/25%, = cognitive=20 functioning 75%/37.5%, unconsciousness 25%/=96).

Conclusion Endoscopic treatment of = patients=20 with pineal region tumours produces improved post-operative quality of = life in=20 all health domains. Therefore, the endoscopic approach should be = considered as=20 an alternative treatment in patients with newly diagnosed pineal tumours = and/or=20 related hydrocephalus.

Keywords Brain=20 tumour - Endoscopic=20 neurosurgery - Neuroendoscopy - Post-operative = outcome=20 assessment - Quality of life

Presented at the Third World = Conference of=20 the International Study Group on Neuroendoscopy (ISGNE), Marburg, = Germany, 15=9618=20 June 2005

Introduction

Neuroendoscopic interventions are nowadays considered as = an=20 alternative treatment for a heterogeneous group of intra-cranial tumours = including pineal region pathologies [7,=20 9,=20 11,=20 16,=20 23,=20 27,=20 30];=20 however, there is considerable discussion regarding the optimal = management of=20 pineal region pathologies [3,=20 5,=20 6,=20 10,=20 15,=20 22,=20 24,=20 25,=20 29,=20 31].=20 It is not the aim of this paper to discuss the therapeutic approach for=20 different tumour types in the pineal region. In the past few years, the = concepts=20 of outcome and quality of life (QoL) have become important measurements = in many=20 clinical studies [2,=20 17].=20 Quality of life in the post-operative surgical patients is the result of = a=20 complex inter-play between objective health and psychosocial variables = [4,=20 19,=20 21].=20 Because there are few studies reporting the quality of life in patients = with=20 pineal region tumours [12,=20 13,=20 28],=20 this present study aimed to assess the post-operative outcome in terms = of QoL=20 using the European Organization for Research and Treatment of Cancer = Quality of=20 Life Questionnaire-Core 30 (EORTC QLQ-C30). The QLQ-C30 is composed of = both=20 multi-item scales and six single-item measures including five functional = scales,=20 three symptom scales and a global health status/QoL scale. A high score = in these=20 three multi-scales would represent a healthy level of functioning, high = level of=20 symptomatology (problems) and high QoL, respectively [1].=20

Materials and methods

Patients

Between 1998 and 2003, 8 patients (5 female, 3 male) = with=20 symptomatic newly diagnosed pineal region tumours underwent = neuroendoscopic=20 procedures in our department. The clinical details are shown on = Table 1.=20 Pre-operative and post-operative global quality of life and symptom, = i.e.=20 headache, visual disturbance, gait disturbance, cognitive function and=20 unconsciousness were documented. Post-operative evaluation of surgical = outcome=20 in terms of QoL was performed using the QLQ-C30 questionnaire. The = patient=92s=20 outcome scores were analysed and compared with the German population = normative=20 values.

Table 1 Clinical = characteristic of eight patients who underwent endoscopic intervention = for=20 pineal region tumours

Patient	Age (years)	Sex	TS (diameter in mm)	Diagnosis	Follow-up (years)	Surgical approach	Previous shunt	Radiation therapy	Pre-operative status	Current status
1	70	F	20	Astrocytoma	2	Third ventriculostomy	No	No	Hydrocephalus, gait disturbance, double = vision	Symptom-free, global QoL from 60 to = 100
2	9	F	20	Low grade astrocytoma	4	Third ventriculostomy and tumour biopsy	No	No	Headache, hydrocephalus, loss of = concentration	Return to school, global QoL from 45 to = 95
3	19	M	28	Germinoma	4	Third ventriculostomy and tumour biopsy	No	Yes	Hydrocephalus, double vision, headache	Double vision, mild headache, global QoL from 20 to=20 80
4	68	F	40	Low grade astrocytoma	4	Third ventriculostomy and tumour biopsy	Yes	No	Headache, gait disturbance, loss of = concentration	Improved symptoms, global QoL from 50 to = 80
5	19	F	15	Small lesion at mesencephalon	2	Third ventriculostomy	No	No	Hydrocephalus, gait disturbance, headache	Symptom-free, returned to work, global QoL from 50 = to=20 100
6	42	F	25	Pineoblastoma	2	Third ventriculostomy and tumour biopsy	No	Yes	Hydrocephalus, drop attacks, cognitive = impairment	Symptom-free, global QoL from 20 to 75
7	14	M	20	Astrocytoma	3	Third ventriculostomy	No	No	Headache, hydrocephalus, dizziness, visual = disturbance	Improved symptoms, global QoL from 20 to = 80
8	70	M	10	Pineal region mass	1	Third ventriculostomy	No	No	Drop attacks, headache, gait disturbance, cognitive=20 impairment	Gait disturbance, cognitive disturbance remain, no = drop=20 attack, global QoL from 5 to 25

F: female, M: male, mm: millimetre, = TS: tumour size.

The EORTC QLS-C30 questionnaire is a tumour-specific, = patient-based=20 instrument designed for self-administration. The cross-cultural validity = and=20 psychometric properties are considered appropriate [1,=20 14,=20 26].=20 The questionnaire comprises five functional scales: physical functioning = (five=20 questions), role functioning (two questions), emotional functioning = (four=20 questions), cognitive functioning (two questions) and social functioning = (two=20 questions). There are three symptom scales (fatigue [three questions], = nausea=20 and vomiting [two questions] and pain [two questions]) and six single = items=20 relating to dyspnoea, insomnia, loss of appetite, constipation, = diarrhoea and=20 financial difficulties. It also includes a global health status/QoL = scale (two=20 questions). All scales and single-item scores are transformed into a = score from=20 0 to 100.

Statistical analysis

Descriptive and explorative analyses were performed using = the SPSS=20 Version 11. Differences were analysed using the Student=92s = t-test and=20 chi-square test; p values <0.05 were considered significant.=20

Results

From our questionnaire analysis, there were no = significant=20 differences between the normative values of the German population and = the=20 corresponding values of the endoscopically treated patients in terms of = health=20 domains and measures of the QLQ-C30 (physical functioning 87.5%, = emotional=20 functioning 50%, cognitive functioning 50%, social functioning 62.5%; = percentage=20 represents regular functioning). Improved quality of life could be = demonstrated=20 in short-term (3=9612 months, n =3D 3) and = long-term (21=9629 months,=20 n =3D 5) follow-up. Global QoL improved significantly = (p < 0.001;=20 t-test) post-operatively (Fig. 1).=20 The following pre-operative clinical symptoms were found (headache = 87.5%, visual=20 disturbance 50%, gait disturbance 87.5%, cognitive functioning 75% and=20 unconsciousness 25%). Some of these symptoms remained post-operatively: = headache=20 62.5%, visual disturbance 25%, gait disturbance 25%, cognitive = functioning 37.5%=20 and unconsciousness 0% (Fig. 2).=20

Fig. 1 Global = quality of=20 life improves significantly (p < 0.001; = t-test)=20 post-operatively in patients who underwent endoscopic surgery

Fig. 2 Pre-operative=20 clinical symptoms are shown in black bars and the remaining=20 post-operative symptoms are shown in open bars

Discussion

The best management for patients with pineal region = tumours remains=20 controversial [6,=20 10,=20 15,=20 22,=20 24,=20 29,=20 31].=20 The proponents of micro-surgery, endoscopic intervention and radiation = therapy=20 claim that their respective technique is appropriate and efficient; the=20 information available to compare the different approaches is largely = from=20 individual case series. The outcome assessment are from the doctor=92s = viewpoint=20 (for example survival, complication and recurrence rates) rather than = from the=20 patients=92 perspective. In addition, there are also different initial = therapeutic=20 managements in both eastern and western groups of pineal tumour = patients. The=20 aim of the present study is not to compare the endoscopic approach with = other=20 therapeutic options because the study design to obtain the results of=20 comparative treatments would be difficult and the acquired result may = not be=20 applicable for every group of patients (especially far eastern patients = who=20 often harbour radiosensitive pineal tumours). However, in addition to = the QoL=20 assessment in patients harbouring pineal region tumours who underwent = endoscopic=20 procedures, the authors tried to implement a QoL-oriented tumour therapy = in=20 neurosurgical practice.

Traditionally, quality of life (QoL) research in medicine = has=20 focused on two main issues: the definition of the construct and the = development=20 of standardised assessment instruments [18].=20 The construction of questionnaires has exploited well-established = psychometric=20 methods and translation procedures [8].=20 The results can be seen in numerous questionnaires assessing somatic,=20 psychological and social aspects of patients=92 well-being and = functional=20 capabilities [20].=20 The goal of a QoL-oriented tumour therapy is to increase the patient=92s = well-being. There have been many attempts to introduce the QoL concept = into=20 clinical practice [2,=20 17].=20 Consequently, the concept of QoL is starting to be accepted and = well-understood=20 in the neurosurgical practice. Therefore, neurosurgeons should be = trained to be=20 competent and willing to apply this concept in their clinical practice. =

According to the results of this present study, improved = QoL could=20 be demonstrated in short-term and long-term follow-up. The = post-operative global=20 QoL also improved significantly (p < 0.001; = t-test) and there=20 was no difference in the health domains between the German population = and the=20 patients undergoing an endoscopic procedure. Therefore, neuroendoscopic=20 procedures including tissue biopsy and CSF pathway diversion may be = considered=20 as an alternative and effective treatment for patients diagnosed with = pineal=20 region tumours when there are good indications for neuroendoscopic = intervention.=20

Conclusions

The authors used established patient assessment methods = with the=20 goal of objectively defining the quality of life in patients treated for = pineal=20 region pathologies. Post-operative quality of life assessment in = patients who=20 underwent endoscopic procedures demonstrated improved QoL in all health = domains.=20 Therefore, the endoscopic approach with or without navigation guidance = may be an=20 alternative treatment of undiagnosed pineal region lesions and/or = related=20 hydrocephalus.

Acknowledgements W.T. is a fellow of the Alexander von Humboldt Foundation in = the year=20 2005=962006.

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