NEUROSURGICAL ONCOLOGY

UNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of tumor-related diseases of the cranium. Demonstrate the ability to formulate and implement a diagnostic and treatment plan for tumor-related diseases of the cranium that are amenable to surgical intervention.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

1. Summarize the epidemiology, incidence, and risk factors for intracranial neoplasms.
2. Summarize the tenets of tumor biology including genetic factors and biochemical processes associated with invasion. Describe the natural history of intracranial neoplasms.
3. List a differential diagnosis of lesions requiring biopsy and describe their pathophysiology.
4. List the various types of bone tumors involving the calvarium.
5. Describe and differentiate:
   1. astrocytomas, including the accepted World Health Organization (WHO) grading scheme
   2. gliomas other than astrocytomas
   3. metastatic tumors, including location and common origins
   4. infectious, granulomatous, and cystic lesions that may present in a tumor-like manner
6. Define the cell or origin of meningioma, its common intracranial locations, and the expected presentation for each location.
7. Define the embryological origin of arachnoid cysts and their natural history; list the etiologies of other cystic lesions of the brain, including tumoral and infectious.
8. Describe the anatomic location, cell of origin, clinical presentation, age at presentation, and natural history of common intrinsic posterior fossa neoplasms, including cerebellar astrocytoma, medulloblastoma, and ependymoma.
9. Describe the anatomy of the posterior fossa and the relation of the cranial nerves to the brain stem and skull.
10. Illustrate the relationship of the facial, vestibular, and cochlear components of the acoustic nerve at the internal auditory meatus.
11. Describe the various tumors that may arise in the cerebellopontine angle (CPA).
12. Describe the management of a patient with a brain abscess, including the role of stereotactic drainage or open drainage.
13. Explain the medical workup of a patient with a diagnosed brain abscess.
14. Specify the follow-up and evaluation of the patient with a brain abscess following surgical treatment.
15. Describe the embryological origin of craniopharyngioma. List the common locations of the tumor.
16. Describe the common presentations of pituitary tumors, the cell of origin, and endocrinopathies associated with:
    1. null cell adenomas
    2. somatotrophic adenomas
    3. prolactinomas
    4. corticotrophic secreting adenomas
    5. thyrotrophic-secreting adenoma
17. Define the medical management of the secreting pituitary tumors. Explain the role of surgery in each of the tumors above.
18. Describe the etiology of fibrous dysplasia, its presentation and general management. List the indications for surgery for benign tumors of bone at the base of the skull, and potential adjuvant therapy.
19. List the tumors that may be routinely approached through a transtemporal route.
20. Describe the indications for use of lumbar spinal drainage in skull base surgery, and its implementation. List all complications associated with continuous lumbar spinal drainage.
21. Illustrate the general principles of stereotaxis and the underlying localization techniques used in the presently used frame-based and frameless systems.

Middle Level:

1. Describe appropriate postoperative management with drainage of brain abscess or cyst.
2. Describe the appropriate surgical management and postoperative treatment of bony skull lesions.
3. Describe the role of surgery in arachnoid cysts, infectious cysts, and tumor-related cystic lesions. Describe the adjuvant treatment of parasitic cysts.
4. Explain the rationale and indications for various skull base approaches to the anterior, middle and posterior cranial fossae. Identify the important anatomical landmarks for each approach. Illustrate the general principles used in prophylaxis of CSF leaks employed in skull base surgery.
5. Describe the neurosurgical management for the following tumors involving the anterior cranial fossa:
   1. meningioma
   2. fibrous dysplasia
   3. esthesioneuroblastoma
   4. osteoma of the frontal sinus
   5. chondroma, chordoma
   6. mucocele
   7. bony metastasis
6. Explain the use of the balloon occlusion test of the carotid artery, its indication for use in skull base tumor surgery, how it is performed, and how the information gained influences surgical management.
7. Explain the surgical advantage of transposing the facial nerve during a transtemporal skull base approach.
8. Describe the transcondylar approach, the relationship of the lower cranial nerves, and the exposure gained over a routine suboccipital craniectomy.
9. llustrate the transpetrosal approach and the relationship of the transverse and sigmoid sinuses with skull bony landmarks such as the asterion, mastoid and inion.
10. Describe the intradural course of the trochlear nerve, trigeminal nerve through Meckel's cave and the abducens nerve and Dorello's canal.
11. Describe the surgical management of the frontal sinus which has been exposed during craniotomy for anterior skull base surgery. Illustrate the development and use of a frontal vascularized pericranial flap and explain its indication. Similarly, illustrate the use of a myocutaneous flap of the temporalis muscle and list the locations for application.
12. Describe the general methods employed for embolization of tumors of the head and neck, and the indications for such procedures.
13. Compare and contrast the methods for stereotactic radiation, including particle beam, gamma ray or linear accelerator, and the indications for each technique.

Senior Level:

1. Describe the indications for transcranial orbitotomy and list the lesions which require this approach.
2. Discuss the surgical management and postoperative treatment of astrocytomas, gliomas other than astrocytomas, metastatic brain tumors, infectious granulomas, and cystic lesions presenting in a tumor-like manner. Review the role of radiotherapy, chemotherapy, and other adjunctive treatments of these neoplasms.
3. Describe the role of surgery for intracranial meningioma, and the relation between the surgical option and location of tumor. Discuss adjuvant treatments of meningioma and their efficacy.
4. Discuss the surgical treatment of common intrinsic posterior fossa neoplasms, including cerebellar astrocytoma, medulloblastoma, and ependymoma including the role of ventricular drainage, and surveillance imaging. Present adjuvant treatment options and outcomes for the various posterior fossa intrinsic tumors.
5. Address the surgical goals of treatment, complications of surgical treatment, and adjuvant therapy for posterior fossa meningioma.
6. List and illustrate the various approaches for removal of a vestibular schwannoma, and the rationale and indication for each approach.
7. Describe the role of stereotactic radiosurgery and microsurgery in the management of vestibular schwannoma.
8. List the various approaches to the midline clivus and review the indications for each approach. Outline the surgical and medical management of tumors of the clivus and midline skull base.
9. Explain the management goal for a patient with craniopharyngioma, and the risks of surgical treatment and conservative treatment. Describe the various surgical approaches used to resect craniopharyngiomas and the options for adjuvant treatment, including radiotherapy and chemotherapy (systemic and local).
10. Illustrate the transnasal-transphenoidal approach and its indications. Define the options for treatment of recurrent pituitary tumors of all types (including medical management). Describe the risks of the approach and the management of the complication of CSF leak.
11. Illustrate the various skull base approaches to the anterior, middle and posterior cranial fossae in detail, explaining the key anatomical landmarks and strict indications for the approach.   List the complications relevant to each approach and the management of each complication.
12. List a differential diagnosis of orbital tumors, their usual location within the orbit, medical and surgical management of the tumor and the approach used to remove the tumor if indicated.
13. List the various tumors and their location in which an orbitocranial approach may be indicated for their removal.
14. Compare and contrast the exposure offered by the pre-and postauricular infratemporal approach, and the indications for each approach.
15. Illustrate transposition of the facial nerve during a transtemporal skull base approach.
16. Describe the location of meningiomas intracranially which are amenable to preoperative embolization.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

1. Perform a complete history and physical examination on patients with intracranial neoplasms.
2. Review appropriate radiographic studies with a radiologist and formulate a differential diagnosis for patients with intracranial neoplasms.
3. Prepare patients for cranial tumor surgery.
4. Understand the positioning of patients for craniotomy and craniectomy.
5. Assist in the opening and closing of craniotomies and craniectomies for neoplasms.
6. Place lumbar drains.
7. Demonstrate the ability to open and close scalp incisions.
8. Perform ventriculostomies.
9. Demonstrate proper postoperative wound care.

Middle Level:

1. Independently determine a differential diagnosis based on the patient's history, physical examination, and radiographic studies.
2. Position patients for craniotomy and craniectomy.
3. Perform the opening and closing of craniotomies and craniectomies.
4. Assist in the resection of intracranial neoplasms.
5. Resect skull lesions.
6. Operatively treat supra- and infratentorial brain abscess.
7. Demonstrate the ability to manage postoperative complications including but not limited to:
   1. brain edema
   2. meningitis
   3. cranial flap infection
   4. postoperative seizures
8. Assess the need for appropriate pre-, intra-, and postoperative monitoring.
9. Obtain proper nonneurosurgical consultation in tumor patients.
10. Identify patients requiring rehabilitation services.
11. Utilize appropriate support agencies and groups for patients with intracranial neoplasms.

Senior Level:

1. Demonstrate the capability to function independently in all phases of management of patients with intracranial neoplasms.
2. Perform resection of supra- and infratentorial intra-axial and extra-axial neoplasms.
3. Perform resection of pituitary lesions.
4. Perform or serve as first assistant for skull base procedures.
5. Oversee the pre- and postoperative management of patients with intracranial neoplasms.
6. Assume teaching responsibilities for junior residents as assigned.
7. Assume responsibility for managing the pyschosocial aspects of intracranial neoplasms.