I think Dr. El-Ezharie. Thank you, Ogur. Very, very nice presentation. Really very appreciable. My two questions. First question is, according to the histology, don't you think that first biopsy in your strategy, in the same strategy, biopsy to know what's that, and if it's a grau blasoma, perhaps you will not be very aggressive. And if it's perhaps benign, you should be very total rejection. And the second question is the last presentation is very nice. It's into the third ventricle. Don't you think that it's feasible by endoscopy? The first question, we know that if it's grau blasoma, if we do better resection, they live longer. It doesn't matter it's in thalamus or not. So I know that my grau blasoma tumors cases, we are going to publish our series this year, they live much longer than just only radiated and chemotherapy patients. So I know it's big, very difficult surgery, and I gained a little. I know. But I know that I do correct. I know that this is what we have to try. And I operate grau blasoma, thalamic grau blasoma. I know that they are living longer. And then I don't like stereotoxic procedure also. It is not easy in thalamus. Also, in thalamus, you can get one part. Even in grau blasoma, you may have a low-grade tumor sample. This is also another story. In MRI, you can tell. If it's adult patient, and if MRI clear, they are 100% grau blasoma in this series. The second question was that I know endoscopy. I didn't involve the discussion with cholecyst. But I use endoscopy last 14 years. Every day, I am touching. I am playing. And my learning curve is not like this. My learning curve is this. I couldn't manipulate. I couldn't manipulate. Some people are very expert to manipulate under the endoscope. They say they can do very well. They say they can open the choroidal fissure. Opening choroidal fissure is, or dissecting the tumor, sometimes much more difficult than to put a 10-0 suture. So I ask them. They should do bypass in endoscope. And then they can show me the bypass results, and I can trust. At least myself, I cannot manipulate with the endoscope. I think Dr. Omer Hodges has a question. Professor Turek, thank you. Beautiful lecture. I already answered that, but just comment. Just continue with that. From my experience and what I learned from pathologists, when we see on MR, there is no so well enhancement of the glioma and thalamus. And we can, thinking that it's low grade. And even during the surgery, if we send the sample, they will say maybe grade 2, even 3. But experienced pathologists usually say if it's in thalamus, you should counting that it's grade 4 probably, because they are very aggressive. They are Y-type IDH negative. They have mostly 1P, 19Q mutations, so and so. So even if we don't thinking on MR before the surgery that it's high grade, we should counting on that. And I learned that it's mostly high grade glioma. Yeah, that's correct. That's correct. Thank you. Dr. Chaglar. Just for the enhancement, you've got adult and children. Yeah, children is another story. They enhance beautifully because they are the pathologists. Astrocytoma. Yeah, children is another story, yeah. Phallocytic astrocytoma, the most benign it has so intensely. Yeah. Thank you for a wonderful presentation. A comment and a question. The comment is you did mention that low grade gliomas look the same when you look under the microscope. The feel is very important, I think. It's very different. So that's the main thing. That's the comment. And the question is, do you use the modified Torkenshin shunt? That is the tube that we put from the third ventricle to the cisterna magna when you go supracerebellar? No. Has it worked with you? It hasn't worked with us too well. Yeah, I never need it. I never use it. So I try to use, you know, if I do anterior transcallosal, I perform third ventricles to me. If I go posterior interemispheric, I open the lamina terminalis, believe it or not. And in one case, Professor Yashagil was there. I am not lying. I opened the tuber cinerium in one case because my angle was okay and her brain was okay. So I opened that also. So any case, you have to always think that aqueduct can be obstructed someday. So we have to be careful and try to open as much as possible. And maybe someday I have to think about that shunt. But all the problems, postoperative problems, came from the CSF problem. For example, the surgery was excellent, patient was excellent. Three months later, the patient may have CSF problems. After radiotherapy, another story. It's a headache. It's a headache. But it's worth it. I want to entertain you all of what make me cry every day. Karen, can you put that meningioma case? It will take only five minutes, but you will see. You saw the earlier meningioma by the sagittal sinus. They did a beautiful operation, right? A post-op, there was a small, tiny residual. Who will do that? Who will not touch the sinus and will leave the small residual for safety? Who does? I bet you 90% of the practices is that out there, right? Who would bypass the sinus? Is there anybody who would bypass it? This doesn't need bypass. This was all included. But if it was one wall or two walls, who will pursue that case and repair the wall of the sinus? Very few. Now, let's say they are elected for safety, like the 90% of the people. That's what's happening out there. To leave that small piece on the sinus, where is it? Where is it? Yeah, the immediate post-op. Who will give radiosurgery for this case? Next week, next month, whatever. I expected a lot more because the practice I see, this is automatically almost went for radiosurgery. So who will? I mean, don't hesitate. I'm not going to eat anybody. I'm just going to scream. Actually, this is a very common practice that this is automatically giving post-op radiation driven by some findings that if you give the radiation immediately after, the control was better than if you wait until they grow. Now, one second. We did not get in there. Now, can you listen just for a second? Now, hold on. Let me just, one second. We didn't give radiation to this guy. This is recurrence without radiation. Between here and here, there is no radiation. No, no, no, but I'm entertaining here. I know, I know. I'm not criticizing of what you did. Now, after it got the radiosurgery, is the complication of radiosurgery in the parasagittal area higher than the complication of radiosurgery in other places? Who says yes? You all need to know that. The parasagittal area complication of radiosurgery, edema, seizures, necrosis, was higher. And symptomatically, even, it's also higher. Now, a patient finally happy without complication, and three years later, after the radiosurgery, or two years later, came back. So put his picture. Okay. But don't make it hypothetical. Put his picture. We have a scenario. It's obviously that human grown, and let's have a nice word to say that it got out of control. It really never controlled anything, but let's say it got out of control of radiosurgery right now. And that's what your tumor, what do you do? That's the patient I see every day. What do you do? Who will operate again? Okay, who will just give him a stereotoxic fractionated radiation or proton beam? Nobody. We operate it again. You know what's going to happen after we operate it again? Even if you had gross total removal, remember gross total removal is not total removal in meningioma. Gross total removal is in grade three. But let's say we got that. You know what's going to happen? And now, not in three years, in one and a half year. Do you have a picture to what happened after one and a half year? You will imagine with me that tumor just grown much bigger and much faster. And now expand on the fox anteriorly and expand down posteriorly. And now occluding more segment posterior of the sinus. So what do you do? These are the patient I'm seeing every day. These are more than 60% of my practice. A year and a half after this good resection of this, it came back everywhere. You operate. Right? And now it is a frank grade two with the KI 67 of 70%. What do you do? You had the gross total removal. What do you do? What they're doing? You got now aggressive tumor rate as grade two, 70% KI 67. The fourth recurrence or the third recurrence, it's giving radiation. Now what do you think is going to happen? Only in one year time, that tumor, after the radiation, it came back everywhere. What do you do? What do you do? They're probably having another operation, but you know your operation is not good. You already did four of them. And now many of those people going to protocols of trying medical treatment or anti-angiogenesis treatment. Or now we have also the immunotherapy treatment. They fail. They're all fail. And now in nine months, the clinical deterioration happening. You already did four operation. The tumor is growing out of his ear and hair and head and everywhere. What do you do? You either says you raise the hat and you give up or things. There has been one other, because this patient and this family, especially if the patient is not too old, they want whatever it is, they're already been seven, eight years in and out the hospital because they want to treat the patient. In those desperate situation, after removing a gross total removal, you try to tell them enough is enough, but the patient still want to fight it. I've been putting brachytherapy. And I am very surprised. Don't hear me. I hate radiation. I know what horrible radiation is doing to meningiomas. But in those in the game, a brachytherapy of those has been really give me a much longer control. I know they're going to fail. But I got a few, two rhabdoid meningiomas after long story of surgery and radiation and giving up totally. It's now past six years after a brachytherapy of something I thought that they will pass six months. So that's one things we need to think of. But the one things we need to stop for sure, not to think, but to stop, is radiating those meningiomas. Because that's the course after radiation. It's breaking the DNA. It's making the chromosome unstable. It's going from grade one to grade two to grade three. Yes, sir. Last question. Hi, Dr. Al-Mufti. Just wondering, do we know what happens if we don't irradiate those difficult meningioma? Do we have history of what happened? Can they recur and recur and recur even without radiotherapy? I sure will agree with you that there is cases that one cannot achieve symptoms on a grade one. And I sure agree with you that there is cases that there is a residual tumor despite your best effort. Okay? So I agree right there. But I'm saying those cases could be a lot less than today. And I'm saying those cases should not be deliberately we force them that way. That we in advance, before we operate on the guy, operate on, this is going out there now, operate that we're going to take a half of it out and radiosurgery the other half. And it's called fancy name is hybrid management of meningioma. Now, let's go back to your question. Now, let's go back to your question. I give them my best chance to take it out and I have the residual. The choice is here now then either to observe or to give radiosurgery automatically. They're saying if you observe and he's going to say those are the one less responsive to radiosurgery. Well, they're less responsive to radiosurgery because the one which you observe might go for a long, long time without radiosurgery. And I know that very well without to need anything to control them. So, it's the opposite. Now, we about 10 years ago probably now took a 150 patient who had a residual and had radiosurgery. And took up equal number 170 which we just observed. Okay. And we analyzed them. The one who had a radiosurgery after, immediately after, they got better control within the first eight years. The one who did not have it, their Kaplan-Meier came down. The two line met together about 10 years time or between eight and 10 if I remember. So, all what radiosurgery if you give it immediately, all what it does it maybe shift the time of the recurrence in term of years. So, I will wait and wait and wait. And many of them do not need anything. And I will show you one tumor after another, after another. That's there been 10, 15, 20 years without any growth. And you expect that in benign meningioma. And you expected more after surgery a skull base. If you did a skull base surgery. Because we really devascularizing the tumor even if we left a little bit. And there at least the late Dr. Steiner thought that the effect of radiosurgery on those basal meningioma was just to knock out the blood supply. So, I would not give radiation. I will try to avoid radiation on meningioma in every possible mean. There is a people at some time they're going to need it. And there is a selective cases. But this is automatic sending everybody meningioma to radiation. I think we just creating all of these cases. Thank you very much. The meeting is over. I appreciate everybody attending it. Have a nice evening.

glioblastoma

meningioma

histology

resection

endoscopy

radiation