Wednesday, November 30, 2011

Novel cell lines established from pediatric brain tumors

Abstract  
The paucity of cell culture models for childhood brain tumors prompted us to establish pediatric cell lines for use in biological experiments and preclinical developmental therapeutic studies. Three cell lines were established, CHLA-200 (GBM), CHLA-259 (anaplastic medulloblastoma) and CHLA-266 (atypical teratoid rhabdoid tumor, AT/RT). Consistent with an AT/RT origin, CHLA-266 lacked INI1 expression and had monosomy 22. All lines had unique DNA short tandem repeat "fingerprints" matching that of the patient's tumor tissue and were adherent on tissue culture plastic, but differed in morphology and doubling times. CHLA-200 had a silent mutation in TP53. CHLA-259 and CHLA-266 had wild-type TP53. All three lines were relatively resistant to multiple drugs when compared to the DAOY medulloblastoma cell line, using the DIMSCAN fluorescence digital image microscopy cytotoxicity assay. RNA expression of MYC and MYCN were quantified using RT-PCR (Taqman). CHLA-200 expressed MYC, DAOY and CHLA-259 expressed MYCN, and CHLA-266 expressed both MYCN and MYC. CHLA-200 was only tumorigenic subcutaneously, but CHLA-259 and CHLA-266 were tumorigenic both subcutaneously and in brains of NOD/SCID mice. Immunohistochemistry of the xenografts revealed GFAP staining in CHLA-200 and PGP 9.5 staining in CHLA-259 and CHLA-266 tumors. As expected, INI1 expression was lacking in CHLA-266 (AT/RT). These three new cell lines will provide useful models for research of pediatric brain tumors.

  • Content Type Journal Article
  • Category Laboratory Investigation - Human/Animal Tissue
  • Pages 1-12
  • DOI 10.1007/s11060-011-0756-5
  • Authors
    • Jingying Xu, Developmental Therapeutics Program, Division of Hematology-Oncology, USC-CHLA Institute for Pediatric Clinical Research, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
    • Anat Erdreich-Epstein, Department of Pediatrics and Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA
    • Ignacio Gonzalez-Gomez, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
    • Elizabeth Y. Melendez, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
    • Goar Smbatyan, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
    • Rex A. Moats, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
    • Michael Rosol, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
    • Jaclyn A. Biegel, Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
    • C. Patrick Reynolds, Developmental Therapeutics Program, Division of Hematology-Oncology, USC-CHLA Institute for Pediatric Clinical Research, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA





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Successful endovascular treatment of a growing megadolichoectasic vertebrobasilar artery aneurysm by

Publication year: 2011
Source: Journal of Clinical Neuroscience, Available online 29 November 2011
José E. Cohen, John M. Gomori, Samuel Moscovici, Eyal Itshayek
Giant dolichoectatic and fusiform aneurysms of the vertebrobasilar artery are among the most difficult and dangerous aneurysms to treat. Conservative management may be reasonable in asymptomatic elderly patients. Nevertheless, due to the frequent presence of mass effect on the brainstem and the risks of thromboembolic events and rupture, these aneurysms often demand treatment rather than observation. With the advancement of endovascular techniques some of these lesions have become treatable without the high morbidity and mortality rates associated with open surgical treatment. When dealing with giant, progressively enlarging symptomatic aneurysms, more limited therapeutic alternatives are available. The authors present a case of a growing megadolichoectatic vertebrobasilar artery aneurysm causing major disability due to increasing mass effect in a 51-year-old man. The aneurysm was treated with flow diversion by placing multiple telescoped stents and diverters ("diverter-in-stent" technique), achieving thrombosis of the aneurysm and reduction of the mass effect on the brainstem, with neurological improvement. The successful clinical and angiographic results observed in our case of giant dolichoectasic vertebrobasilar aneurysm contribute to the literature on giant aneurysms treated by means of flow diversion.





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Tuesday, November 29, 2011

Second Cancer Often Same Type As the First

Risk varies depending on original disease, Danish researchers report

HealthDay news image

Source: HealthDay





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Research on outcomes is essential

Research on outcomes in independent sector treatment centres (ISTCs) is welcome, indeed essential. Chard and colleagues' paper shows that some routine elective operations performed by cherry picked...





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Think it possible you may be mistaken

Few experiences are worse than a missed cancer diagnosis, but being missed by doctors who persistently refused to consider it possible is one. Doctors do not diagnose what they have not thought of....





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Sunday, November 27, 2011

Scientists Discover New Approach For Cancer Medication

As the "recycling plant" of the cell, the proteasome regulates vitally important functions. When it is inhibited, the cell chokes on its own waste. Cancer cells, in particular, are very sensitive because they need the proteasome for their uncontrolled growth...





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Thursday, November 24, 2011

Stereotactic Body Radiotherapy Reirradiation for Recurrent Epidural Spinal Metastases

Purpose: When patients show progression after conventional fractionated radiation for spine metastasis, further radiation and surgery may not be options. Stereotactic body radiotherapy (SBRT) has been successfully used in treatment of the spine and may be applicable in these cases. We report the use of SBRT for 60 consecutive patients (81 lesions) who had radiological progressive spine metastasis with epidural involvement after previous radiation for spine metastasis.Methods and Materials: SBRT was used with fiducial and vertebral anatomy-based targeting. The radiation dose was prescribed based on the extent of spinal canal involvement; the dose was 8 Gy × 3 = 24 Gy when the tumor did not touch the spinal cord and 5 to 6 Gy x 5 = 25 to 30 Gy when the tumor abutted the cord. The cord surface received up to the prescription dose with no hot spots in the cord.Results: The median overall survival was 11 months, and the median progression-free survival was 9 months. Overall, 93% of patients had stable or improved disease while 7% of patients showed disease progression; 65% of patients had pain relief. There was no significant toxicity other than fatigue.Conclusions: SBRT is feasible and appears to be an effective treatment modality for reirradiation after conventional palliative radiation fails for spine metastasis patients.





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Descriptive epidemiology of CNS tumors in France: results from the Gironde Registry for the period 2

An increase in the incidence of CNS tumors has been observed in many countries in the last decades. The reality of this trend has been much debated, as it has happened during a period when computer-assisted tomography and MRI have dramatically improved the detection of these tumors. The Gironde CNS Tumor Registry provides here the first data on CNS tumor incidence and trends in France for all histological types, including benign and malignant tumors, for the period 2000–2007. Incidence rates were calculated globally and for each histological subtype. For trends, a piecewise log-linear model was used. The overall annual incidence rate was found to be 17.6/100 000. Of this rate, 7.9/100 000 were neuroepithelial tumors and 6.0/100 000 were meningiomas. An overall increase in CNS tumor incidence was observed from 2000 to 2007, with an annual percent change (APC) of +2.33%, which was explained mainly by an increase in the incidence of meningiomas over the 8-year period (APC = +5.4%), and also more recently by an increase in neuroepithelial tumors (APC = +7.45% from 2003). The overall increase was more pronounced in women and in the elderly, with an APC peaking at +24.65% in subjects 85 and over. The increase in the incidence rates we observed may have several explanations: not only improvements in registration, diagnosis, and clinical practice, but also changes in potential risk factors.






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"Pulsatile" high-dose weekly erlotinib for CNS metastases from EGFR mutant non-small cell lung cance

Erlotinib is effective for epidermal growth factor receptor (EGFR) mutant lung cancer, but CNS penetration at standard daily dosing is limited. We previously reported that intermittent "pulsatile" administration of high-dose (1500 mg) erlotinib once weekly was tolerable and achieved concentrations in cerebrospinal fluid exceeding the half maximal inhibitory concentration for EGFR mutant lung cancer cells in a patient with leptomeningeal metastases; we now expand this paradigm to a series of 9 patients. We retrospectively identified patients with EGFR mutant lung cancer treated with pulsatile erlotinib for CNS metastases (brain and/or leptomeningeal) that occurred despite conventional daily erlotinib or other EGFR tyrosine kinase inhibitors. Mutations in available lung and CNS tissue were correlated with efficacy. Erlotinib was administered as monotherapy at a median dose of 1500 mg weekly. Best CNS radiographic response was partial in 67% (6/9, including 2 with isolated leptomeningeal metastases), stable disease in 11% (1/9), and progressive disease in 22% (2/9). Median time to CNS progression was 2.7 months (range, 0.8–14.5 months) and median overall survival was 12 months (range, 2.5 months–not reached). Treatment was well tolerated. No acquired resistance mutations in EGFR were identified in the CNS metastases of 4 patients, including 1 harboring T790M outside the CNS. Pulsatile erlotinib can control CNS metastases from EGFR mutant lung cancer after failure of standard daily dosing. CNS disease may not harbor acquired resistance mutations that develop systemically. A prospective trial is planned.






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Correlation of the extent of tumor volume resection and patient survival in surgery of glioblastoma

Extent of resection (EOR) still remains controversial in therapy of glioblastoma multiforme (GBM). However, an increasing number of studies favor maximum EOR as being associated with longer patient survival. One hundred thirty-five GBM patients underwent tumor resection aided by 1.5T intraoperative MRI (iMRI) and integrated multimodal navigation. Tumor volume was quantified by manual segmentation. The influences of EOR, patient age, recurrent tumor, tumor localization, and gender on survival time were examined. Intraoperative MRI detected residual tumor volume in 88 patients. In 19 patients surgery was continued; further resection resulted in final gross total resection (GTR) for 9 patients (GTR increased from 47 [34.80%] to 56 [41.49%] patients). Tumor volumes were significantly reduced from 34.25 ± 23.68% (first iMRI) to 1.22 ± 16.24% (final iMRI). According to Kaplan–Meier estimates, median survival was 14 months (95% confidence interval [CI]: 11.7–16.2) for EOR ≥98% and 9 months (95% CI: 7.4–10.5) for EOR <98% (P< .0001); it was 9 months (95% CI: 7.3–10.7) for patients ≥65 years and 12 months (95% CI: 8.4–15.6) for patients <65 years (P < .05). Multivariate analysis showed a hazard ratio of 0.39 (95% CI: 0.24–0.63; P = .001) for EOR ≥98% and 0.61 (95% CI: 0.38–0.97; P < .05) for patient age <65 years. To our knowledge, this is the largest study including correlation of iMRI, tumor volumetry, and survival time. We demonstrate that navigation guidance and iMRI significantly contribute to optimal EOR with low postoperative morbidity, where EOR ≥98% and patient age <65 years are associated with significant survival advantages. Thus, maximum EOR should be the surgical goal in GBM surgery while preserving neurological function.






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Pituicytomas, a Perspective

Publication year: 2011
Source: World Neurosurgery, Available online 23 November 2011
Ivan Ciric
Pituicytomas are rare sellar-suprasellar tumors, largely benign, that are of glial origin. They usually present with symptoms related to their location: headaches, visual changes and mostly anterior pituitary dysfunction. Imaging diagnosis reveals a sellar-suprasellar lesion occupying the position of the stalk. The characteristic histological features are spindle cell tumors arranged in storiform pattern. The immunohistochemical analysis of the tissue is characterized by strong immunopositivity for glial fibrilary acidic protein (GFAP) signifying their glial origin and for nuclear staining with thyroid transcription factor-1 (TTF-1) signifying their origin from pituicytomas.The preferred treatment is gross total surgical removal since there is no evidence that adjuvant therapy is effective. Incomplete resections lead to recurrences.





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Wednesday, November 23, 2011

Primary Central Nervous System Tumors: Pathogenesis and Therapy

Remarkable advances in the understanding of central nervous system (CNS) tumor initiation, progression, and molecular features continue to shape the field of neurooncology and are beginning to yield the first real advancements in patient care in many years. Improved understanding of tumor pathogenesis directly affects current therapy for many CNS tumors, and that clinical translation is appropriately reflected in both the title and text of this new book in the Current Clinical Oncology series. This concise text, divided into three parts, expertly covers CNS tumors in 22 chapters with the contribution of 58 chapter authors. Although nearly half of the authors are affiliated with Harvard, a reasonable number of major academic institutions in the United States and a few international centers are also represented.





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Surgery Followed by Radiotherapy Versus Radiotherapy Alone for Metastatic Spinal Cord Compression Fr

Purpose: Despite a previously published randomized trial, controversy exists regarding the benefit of adding surgery to radiotherapy for metastatic spinal cord compression (MSCC). It is thought that patients with MSCC from relatively radioresistant tumors or tumors associated with poor functional outcome after radiotherapy alone may benefit from surgery. This study focuses on these tumors.Methods and Materials: Data from 67 patients receiving surgery plus radiotherapy (S+RT) were matched to 134 patients (1:2) receiving radiotherapy alone (RT). Groups were matched for 10 factors and compared for motor function, ambulatory status, local control, and survival. Additional separate matched-pair analyses were performed for patients receiving direct decompressive surgery plus stabilization of involved vertebrae (DDSS) and patients receiving laminectomy (LE).Results: Improvement of motor function occurred in 22% of patients after S+RT and 16% after RT (p = 0.25). Posttreatment ambulatory rates were 67% and 61%, respectively (p = 0.68). Of nonambulatory patients, 29% and 19% (p = 0.53) regained ambulatory status. One-year local control rates were 85% and 89% (p = 0.87). One-year survival rates were 38% and 24% (p = 0.20). The matched-pair analysis of patients receiving LE showed no significant differences between both therapies. In the matched-pair analysis of patients receiving DDSS, improvement of motor function occurred more often after DDSS+RT than RT (28% vs. 19%, p = 0.024). Posttreatment ambulatory rates were 86% and 67% (p = 0.30); 45% and 18% of patients regained ambulatory status (p = 0.29).Conclusions: Patients with MSCC from an unfavorable primary tumor appeared to benefit from DDSS but not LE when added to radiotherapy in terms of improved functional outcome.





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Irradiation of Spinal Metastases: Should We Continue to Include One Uninvolved Vertebral Body Above

Purpose: Historically, the appropriate target volume to be irradiated for spinal metastases is 1–2 vertebral bodies above and below the level of involvement for three reasons: (1) to avoid missing the correct level in the absence of simulation or (2) to account for the possibility of spread of disease to the adjacent level, and (3) to account for beam penumbra. In this study, we hypothesized that isolated failures occurring in the level adjacent to level treated with stereotactic body radiosurgery (SBRS) were infrequent and that with improved localization techniques with image-guided radiation therapy, treatment of only the involved level of spinal metastases may be more appropriate.Methods and Materials: Patients who had received SBRS treatments to only the involved level of the spine as part of a prospective trial for spinal metastases comprised the study population. Follow-up imaging with spine MRI was performed at 3-month intervals following initial treatment. Failures in the adjacent (V±1, V±2) and distant spine were identified and classified accordingly.Results: Fifty-eight patients met inclusion criteria for this study and harbored 65 distinct spinal metastases. At 18-month median follow-up, seven (10.7%) patients failed simultaneously at adjacent levels V±1 and at multiple sites throughout the spine. Only two (3%) patients experienced isolated, solitary adjacent failures at 9 and 11 months, respectively.Conclusion: Isolated local failures of the unirradiated adjacent vertebral bodies may occur in <5% of patients with isolated spinal metastasis. On the basis of the data, the current practice of irradiating one vertebral body above and below seems unnecessary and could be revised to irradiate only the involved level(s) of the spine metastasis.





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Tuesday, November 22, 2011

Avastin No Longer Approved for Breast Cancer, FDA Says

"Patients must have confidence that the drugs they take are both safe and effective for their intended use," says FDA Commissioner Margaret Hamburg, MD.
News Alerts





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Complete regression of papillary tumor of the pineal region after radiation therapy: case report and

Abstract  
Papillary tumor of the pineal region (PTPR) is a rare neuroepithelial tumor that arises in the pineal region. The optimal treatment for PTPR remains controversial, as no definitive treatment strategy exists for this lesion. It is not clear whether aggressive surgical removal is superior to biopsy followed by radiotherapy. The majority of cases in the literature have undergone attempted gross total resection with a supracerebellar-infratentorial or a transcallosal-transventricular approach. In this report, we describe a case of PTPR in a 23 year-old male that presented as a third ventricular mass causing obstructive hydrocephalus. An endoscopic third ventriculostomy was performed followed by an endoscopic biopsy. Postoperative radiotherapy resulted in complete regression of the tumor with no evidence of tumor recurrence at 25 months. This case highlights a minimally invasive strategy for a rare neoplasm that resulted in a favorable response to radiation therapy, thereby avoiding the risks of aggressive surgical removal. We also review the radiographic and histopathologic features of PTPR and discuss various options of treatment reported in the literature.

  • Content Type Journal Article
  • Category Case Report
  • Pages 1-8
  • DOI 10.1007/s11060-011-0764-5
  • Authors
    • Smruti K. Patel, Department of Neurological Surgery, Neurological Institute of New Jersey, UMDNJ-New Jersey Medical School, 90 Bergen Street Suite 8100, Newark, NJ 07101, USA
    • Krystal L. Tomei, Department of Neurological Surgery, Neurological Institute of New Jersey, UMDNJ-New Jersey Medical School, 90 Bergen Street Suite 8100, Newark, NJ 07101, USA
    • Lana D. Christiano, Department of Neurological Surgery, Neurological Institute of New Jersey, UMDNJ-New Jersey Medical School, 90 Bergen Street Suite 8100, Newark, NJ 07101, USA
    • Ada Baisre, Department of Pathology, Neurological Institute of New Jersey, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ, USA
    • James K. Liu, Department of Neurological Surgery, Neurological Institute of New Jersey, UMDNJ-New Jersey Medical School, 90 Bergen Street Suite 8100, Newark, NJ 07101, USA





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Brain Cancer Vaccine Shows Positive Results

Celldex Therapeutics, Inc. (NASDAQ: CLDX) announced today that its immunotherapeutic vaccine called Rindopepimut showed positive results in prolonging survival in patients with newly diagnosed EGFRvIII-positive glioblastoma (GB), one of the most aggressive forms of brain cancer...





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Monday, November 21, 2011

Percutaneous biopsy of lesions in the cavernous sinus region through the foramen ovale: diagnostic a

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-9, Ahead of Print.
Object The cavernous sinus and surrounding regions—specifically the Meckel cave, posterior sector of the cavernous sinus itself, and the upper part of the petroclival region—are the location of a large variety of lesions that require individual consideration regarding treatment strategy. These regions may be reached for biopsy by a percutaneous needle inserted through the foramen ovale. The aim of this retrospective study was to evaluate the diagnostic accuracy of percutaneous biopsy in a consecutive series of 50 patients referred for surgery between 1991 and 2010. Methods Seven biopsies (14%) were unproductive and 43 (86%) were productive, among which 28 lesions subsequently underwent histopathological examination during a second (open) surgery. To evaluate the diagnostic accuracy of the procedure, results from surgery were compared with those from the biopsy. Results Sensitivity of the percutaneous biopsy was 0.83 (95% CI 0.52–0.98), specificity was 1 (95% CI 0.79–1), and κ coefficient was 0.81. Conclusions Because of its valuable diagnostic accuracy, percutaneous biopsy of the cavernous sinus and surrounding regions should be performed in patients with parasellar masses when neuroimaging does not provide sufficient information of a histopathological nature. This procedure would enable patients to obtain the most appropriate therapy, such as resective surgery, corticosteroids, chemotherapy, radiotherapy, or radiosurgery.





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Sunday, November 20, 2011

Pathological laughter and crying in patients with pontine lesions

Journal of Neurosurgery: Pediatrics, Volume 8, Issue 6, Page 544-547, December 2011.
Pathological laughter and crying (PLC) has been widely documented in the medical literature in association with various pathological processes in the brainstem, particularly infarction. However, it remains poorly understood. The authors present a case report and analyze all the cases in the literature to try to localize a putative faciorespiratory center. This 13-year-old girl developed a pontine abscess subsequent to sphenoid sinusitis. This increased in size despite antibiotic treatment, and she developed PLC. The abscess was then stereotactically aspirated, with resolution of the symptoms. A PubMed search of the term "pathological laughter and crying" was performed. From these papers all reported cases of PLC were identified. Cases without neuroimaging were excluded. The remaining cases were categorized as small lesions permitting accurate localization within the pons, or large nonlocalizing lesions. All images of localizing lesions were magnified to the same size and placed on a grid. From this an area of maximal overlap was identified. The authors identified 7 cases of small localizing lesions with adequate imaging. The area of maximal overlap was in the region of the anterior paramedian pons. All the lesions involved this region of the pons. There were 28 further reports of large lesions that either resulted in gross compressive distortion of the pons or diffusely infiltrated it, and thus, although implicating involvement of a pontine center, did not allow for localization of a specific region of the pons. The authors report a case of PLC caused by a pontine abscess. Symptoms were reversible with stereotactically assisted aspiration and antibiotic administration. Analysis of the lesions reported in the literature showed a pattern toward a regulatory center in the pons. The most consistently involved region was in the anterior paramedian pons, and this may be the site of a faciorespiratory center.





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Correlation among magnetic resonance imaging findings, prognostic factors for survival, and histolog

Journal of Neurosurgery: Pediatrics, Volume 8, Issue 6, Page 539-543, December 2011.
Object The aim of this study was to compare MR imaging characteristics with histopathological findings of intrinsic brainstem lesions and also to show the prognostic factors in patients with diffuse brainstem glioma. Methods Between February 1988 and August 2007, 44 brainstem biopsies were performed at the Roger Salengro Hospital in Lille, France, in children with intrinsic brainstem lesions not amenable to excision. Twenty-six were female and 18 male, and the mean age was 6 years. Results Histological evaluation revealed diffuse brainstem glioma in all patients with diffuse nonenhancing brainstem lesions. Diffuse brainstem glioma was found in 18 patients (90%) with diffuse enhancing brainstem lesions. Pathological entities different from diffuse glioma were verified in 2 patients (10%)—1 with ependymoma and 1 with ganglioglioma. In 4 of 5 patients with a focal nonenhancing brainstem lesion, the histopathological diagnosis was diffuse low-grade glioma. In 6 of 10 patients with focal enhancing brainstem lesion, the diagnosis was diffuse brainstem glioma, and pathological entities different from diffuse brainstem glioma were verified in 2 (20%), both with pilocytic astrocytoma. The mean 1-year actuarial survival rates for patients classified with low-grade and high-grade glioma were 80.4% ± 0.08% and 48.6% ± 0.14%, respectively. Conclusions The impact of stereotactic biopsy on intrinsic brainstem lesions was greater in patients with MR imaging–documented enhancing lesions in whom the diagnosis of diffuse glioma was less frequent. Patients with low-grade glioma seem to have longer survival than those with high-grade glioma.





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Supracerebellar infratentorial endoscopically controlled resection of pineal lesions: case series an

Journal of Neurosurgery: Pediatrics, Volume 8, Issue 6, Page 554-564, December 2011.
Object The heterogeneous clinical manifestations and operative characteristics of pathological entities in the pineal region represent a significant challenge in terms of patient selection and surgical approach. Traditional surgical options have included endoscopic transventricular resection; open supratentorial microsurgical approaches through the midline, choroidal fissure, lateral ventricle, and tentorium; and supracerebellar infratentorial (SCIT) approaches through the posterior fossa. The object of the current study was to review the preoperative characteristics and outcomes for a cohort of patients treated purely via the novel endoscopically controlled SCIT approach. Methods A single-institution series of 9 consecutive patients (4 male and 5 female patients [10 total cases]; mean age 21 years, range 6–37 years) treated via the endoscopically controlled SCIT approach for a pathological entity in the pineal region was retrospectively reviewed. The mean follow-up time was 13.2 months. Results The endoscopically controlled SCIT approach was successfully used to approach a variety of pineal lesions, including pineal cysts (6 patients), epidermoid tumor, WHO Grade II astrocytoma (initial biopsy and recurrence), and malignant mixed germ cell tumor (1 patient each). Gross-total resection and/or adequate cyst fenestration was achieved in 8 cases. Biopsy with conservative debulking was performed for the single case of low-grade astrocytoma and again at the time of recurrence. The mean preoperative tumor and cyst volumes were 9.9 ± 4.4 and 3.7 ± 3.2 cm3, respectively. The mean operating times were 212 ± 71 minutes for tumor cases and 177 ± 72 minutes for cysts. Estimated blood loss was less than 150 ml for all cases. A single case (pineal cyst) was converted to an open microsurgical approach to enhance visualization. There were no operative complications, as well as no documented CSF leaks, additional CSF diversion procedures, or air emboli. Seven patients underwent concomitant third ventriculostomy into the quadrigeminal cistern. At the time of the last follow-up evaluation, all patients had a stable or improved modified Rankin Scale score. Conclusions The endoscopically controlled SCIT approach may be used for the biopsy and resection of appropriately selected solid tumors of the pineal region, in addition to the fenestration and/or resection of pineal cysts. Preoperative considerations include patient presentation, anticipated disease and vascularity, degree of local venous anatomical distortion, and selection of optimal paramedian trajectory.





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Old Drugs Find New Target For Treating Brain Tumor

Scientists at the University of California, San Diego School of Medicine and UC San Diego Moores Cancer Center, in collaboration with colleagues in Boston and South Korea, say they have identified a novel gene mutation that causes at least one form of glioblastoma (GBM), the most common type of malignant brain tumor...





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Slack brain in meningioma surgery through lateral supraorbital approach

Rossana Romani, Marja Silvasti-Lundell, Aki Laakso, Hanna Tuominen, Juha Hernesniemi, Tomi Niemi

Surgical Neurology International 2011 2(1):167-167

Background : Surgery of skull base meningiomas by the lateral supraorbital (LSO) approach requires relaxed brain. Therefore, we assessed combined effects of the elements of neuroanesthesia on neurosurgical conditions during craniotomy. Methods : The anesthesiological and surgical charts of 66 olfactory groove, 73 anterior clinoidal, and 52 tuberculum sellae meningioma patients operated on by the senior author (J.H.) at the Department of Neurosurgery of Helsinki University Central Hospital, Helsinki, Finland, between September 1997 and August 2010, were retrospectively analyzed. Results : One-hundred fifty-four (82%) patients had good surgical conditions, and this was achieved by (1) elevating the head 20 cm above the cardiac level in all patients with only slightly lateral turn or neck flexion, (2) administering mannitol preoperatively in medium or large meningiomas (n = 60), (3) maintaining anesthesia with propofol infusion (n = 46) or volatile anesthetics (n = 107) also in patients with large tumors (n = 37), and (4) controlling intraoperative hemodynamics. Brain relaxation was satisfactory in 18 (10%) and poor in 15 (8%) patients. The median intraoperative blood loss was 200 (range, 0-2000) ml. Only 9% of patients received red blood cell transfusion. The median time to extubation was 18 (range, 8-105) min after surgery. Extubation time correlated with the patients' preoperative clinical status and the size of tumor but not with the modality of anesthesia. Conclusions : Slack brain during the LSO approach is achieved by correct patient positioning, preoperative mannitol, either by propofol or in small tumors inhaled anesthetics, and optimizing cerebral perfusion pressure. Under these circumstances, intraoperative brain swelling is prevented, bleeding is minimal, and no blood transfusions are needed.





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Friday, November 18, 2011

Clinical presentation and outcome of patients with intradural spinal cord tumours

Publication year: 2011
Source: Journal of Clinical Neuroscience, Available online 17 November 2011
Mithun Nambiar, Bhadrakant Kavar
We aimed to retrospectively investigate the clinical presentation and outcome of surgical intervention of patients with intradural spinal cord tumours (IDSCT), and to assess the predictors of surgical outcome. A total of 109 patients with IDSCT (57 males and 52 females) (130 admissions; mean age, 45.9 years; range, 14–89 years) underwent surgery between 1 January 1994 and 30 June 2009 at The Royal Melbourne Hospital. Ninety per cent of tumours were classified as low grade. Pain was the most common symptom at presentation (60%) and the mean duration of symptoms was 37.8 weeks (0–4 years). Total resection was achieved in 72.3% of patients with IDSCT. An extramedullary location was the strongest predictor of greater extent of tumour resection (odds ratio [OR] = 4.367, 95% confidence interval [CI] = 1.876–10.204,p = 0.001), whereas a rostral location was also a significant predictor of greater resection (OR = 1.393, 95% CI = 1.014–1.908,p = 0.040). The surgical mortality rate was 0.92%. A good pre-operative clinical grade was the strongest predictor of a positive post-operative neurological status at discharge for IDSCT (OR = 7.382, 95% CI = 4.575–11.912,p < 0.001). The mean follow-up was 37.9 months (16 days–165 months). A good post-operative clinical grade was the most significant predictor of a positive neurological outcome at short-term follow-up (OR = 9.953, 95% CI = 4.941–20.051,p < 0.001), while a good pre-morbid clinical grade was the most significant predictor of a positive outcome at long-term follow-up (OR = 9.498, 95% CI = 2.780–32.451,p < 0.001). We concluded that surgical outcome was influenced by pre-morbid, pre-operative and post-operative clinical grades, the extent of resection, tumour grade and tumour location with respect to the spinal parenchyma. Surgical intervention has a high success rate for tumour control and we recommend total resection where possible.





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Glioblastoma multiforme and cerebral cavernous malformations: intersection of pathophysiologic pathw

Publication year: 2011
Source: Journal of Clinical Neuroscience, Available online 17 November 2011
Matthew K. Mian, Brian V. Nahed, Brian P. Walcott, Christopher S. Ogilvy, William T. Curry
Cerebral cavernous malformations (CCM) are known to occur in both sporadic and familial forms. To date, there has been no identified association of CCM with glioblastoma multiforme. We present a 69-year-old woman with a 14 year history of multiple CCM who developed progressive aphasia. She had no radiation exposure and had only undergone a single computed tomography scan in her entire life. MRI demonstrated irregular gadolinium enhancement in the area of a prior stable CCM, suspicious for a high grade tumor. Stereotactic biopsy revealed a glioblastoma multiforme. This is a unique case of glioblastoma multiforme arising from the "site" of a known CCM. We review the literature on the genetics of cavernous malformations and propose a mechanism for the tumorigenic potential of these vascular malformations.





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Thursday, November 17, 2011

Virtual 3D tumor marking - exact intraoperative coordinate mapping improve post-operative radiothera

The quality of the interdisciplinary interface in oncological treatment between surgery, pathology and radiotherapy is mainly dependent on reliable anatomical three-dimensional (3D) allocation of specimen and their context sensitive interpretation which defines further treatment protocols. Computer-assisted preoperative planning (CAPP) allows for outlining macroscopical tumor size and margins. A new technique facilitates the 3D virtual marking and mapping of frozen sections and resection margins or important surgical intraoperative information. These data could be stored in DICOM format (Digital Imaging and Communication in Medicine) in terms of augmented reality and transferred to communicate patient's specific tumor information (invasion to vessels and nerves, non-resectable tumor) to oncologists, radiotherapists and pathologists.





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Prognostic factors of visual field improvement after trans-sphenoidal approach for pituitary macroad

Abstract  
The objective of the study was to evaluate the preoperative visual field defect, the postoperative outcome and the possible prognostic factors in patients with pituitary macroadenoma, using a quantitative method (the mean deviation = MD), and to review the literature. A total of 73 patients, operated trough trans-sphenoidal approach, were selected, and data in single eyes were analysed by calculating the frequency and the degree of postoperative improvement (relative improvement). The visual field defect improved in 95.7% of eyes: The recovery was complete in 48.9% and partial in 46.8%. Multivariate logistic regression showed that factors, independently predictive for complete recovery, were as follows: low preoperative MD absolute value (p = 0.008), low cranio-caudal diameter of tumour (p = 0.02) and young age (p = 0.0001). The mean relative improvement in visual field defect (dMD%) was correlated with the preoperative visual acuity (p = 0.0001) and inversely related with the preoperative MD (p = 0.007) and the age (p = 0.017). The relative improvement was higher in tumours with a smaller cranio-caudal diameter (p = 0.0185). In conclusion, using a quantitative method, we can measure the degree of the postoperative visual field defect improvement. Predictive factors for a complete recovery were good preoperative visual function, young age and low cranio-caudal tumour.

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-11
  • DOI 10.1007/s10143-011-0365-y
  • Authors
    • Lina Raffaella Barzaghi, Pituitary Unit, Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132 Milan, Italy
    • Marzia Medone, Pituitary Unit, Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132 Milan, Italy
    • Marco Losa, Pituitary Unit, Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132 Milan, Italy
    • Stefania Bianchi, Department of Ophthalmology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
    • Massimo Giovanelli, Pituitary Unit, Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132 Milan, Italy
    • Pietro Mortini, Pituitary Unit, Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132 Milan, Italy





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Wednesday, November 16, 2011

Targeted agents: How to select the winners in preclinical and early clinical studies?

Publication year: 2011
Source: European Journal of Cancer, Available online 15 November 2011
Rachel Goodwin, Giuseppe Giaccone, Hilary Calvert, Marinus Lobbezoo, Elizabeth A. Eisenhauer
There has been a significant shift within oncology drug development away from empiric screening of cytotoxic compounds to the era of genomics and molecularly targeted agents. The drug development process is evolving with greater emphasis on proof-of-mechanism studies in both preclinical and early clinical development. The Methodology for the Development of Innovative Cancer Therapies (MDICT) Task Force, established as a forum for academic and pharmaceutical leaders to discuss methodological issues in targeted anticancer therapy development, met in March 2010 to review what were the minimal data required to make appropriate decisions about moving new targeted cancer agents from late preclinical development into phase I and from phase I into phase II trials. A number of specific questions were posed, and responses to each developed through survey, literature review and discussion at the face to face meeting of the MDICT Task Force. Consensus emerged around the necessity to demonstrate proof-of-mechanism and obtain information on key pharmacokinetic aspects of drug behaviour in late preclinical and early clinical trials. However, controversy remains on the extent ofin vivoanti-tumour efficacy required to support clinical development of targeted agents. A systematic review of the data in this area would be informative. Further, while objective response in phase I trials may be a favourable signal about the potential activity of a new agent, debate exists around the weight that should be placed on the observation of stable disease or functional imaging changes in driving drug development decisions in the absence of observing either responses or convincing pharmacodynamic data in phase I. MDICT made a number of recommendations that may aid in future development of targeted agents.





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Outcome, quality of life and cognitive function of patients with brain metastases from non-small cel

Publication year: 2011
Source: European Journal of Cancer, Available online 15 November 2011
Gianfranco A. Pesce, Dirk Klingbiel, Karin Ribi, Abderahim Zouhair, Roger von Moos, ...
PurposePatients with brain metastases (BM) rarely survive longer than 6 months and are commonly excluded from clinical trials. We explored two combined modality regimens with novel agents with single agent activity and radiosensitizing properties.Patients and methodsIn this randomised phase II trial patients with BM from NSCLC were randomly assigned to 30 Gy WBRT with either concomitant gefitinib (GFT) 250 mg/day continuously or temozolomide (TMZ) 75 mg/mfor 21/28 days. The primary end-point was overall survival, with quality of life and cognitive function as secondary end-points.ResultsWe enrolled 59 patients (GFT 16, TMZ 43), and 56 patients have died, mainly (80%) from disease progression. Four patients succumbed complications of the disease or corticosteroids (intestinal perforation (2), CNS haemorrhage and pulmonary emboli). Median overall survival in the gefitinib arm was 6.3 months (95% CI 2.1–14.6), and 4.9 months (95% CI 2.3–5.6) in TMZ treated patients. Fatigue was the main complaint.ConclusionsNo relevant toxicity with those therapeutic regimens was observed. Fatal outcome in three patients may have been related to corticosteroids. Cognitive function improved during treatment. However, median overall survival for all patients was only 4.9 months (95% CI 2.3–5.7) and 1-year survival 25.4% (95% CI 15.4–37.0%).





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Diffuse central neurocytoma with craniospinal dissemination

Publication year: 2011
Source: Journal of Clinical Neuroscience, Available online 15 November 2011
Christopher J. Stapleton, Brian P. Walcott, Kristopher T. Kahle, Patrick J. Codd, Brian V. Nahed, ...
Central neurocytomas (CN) are benign central nervous system (CNS) tumors of neuroglial origin that represent 0.25 to 0.5% of all intracranial tumors in adults and an even smaller proportion of pediatric CNS tumors. These tumors characteristically occur in the subependymal layer of the lateral ventricle near the foramen of Monro and appear as sharply demarcated, solitary lesions. Surgical resection is considered curative, as the reported recurrence rate is less than 5% for patients with localized disease. In this report, we describe the case of a three-year-old boy with a diffuse CN with craniospinal dissemination identified at the time of diagnosis. Given the extensive nature of the disease, surgical resection was not indicated and he underwent a chemotherapeutic regimen of vincristine and carboplatin. At 18 months followup, the patient has completed 6 of 8 total cycles of vincristine and carboplatin and serial imaging shows stable disease within the craniospinal axis.





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Tuesday, November 15, 2011

Neurological Impairment Associated With Chemotherapy

A report in the November issue of the Archives of Neurology, one of the JAMA/Archives journals outlines cases of women who survived breast cancer and showed neurological impairment. The problem seems to be markedly worse in those who received chemotherapy compared with those that did not...





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Many Oncologists Not On Top of Managing Pain

In new survey of cancer doctors in the U.S., many oncologists said they were good at managing their patients' pain -- but most failed to choose the right treatment option in a test, and said that figuring out how much pain patients have is still a major barrier to providing appropriate care.
Source: Reuters Health





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Risk assessment models for cancer-associated venous thromboembolism

Abstract

Venous thromboembolism (VTE) is common in cancer patients, and is associated with significant morbidity and mortality. Several factors, including procoagulant agents secreted by tumor cells, immobilization, surgery, indwelling catheters, and systemic treatment (including chemotherapy), contribute to an increased risk of VTE in cancer patients. There is growing interest in instituting primary prophylaxis in high-risk patients to prevent incident (first-time) VTE events. The identification of patients at sufficiently high risk of VTE to warrant primary thromboprophylaxis is essential, as anticoagulation may be associated with a higher risk of bleeding. Current guidelines recommend the use of pharmacological thromboprophylaxis in postoperative and hospitalized cancer patients, as well as ambulatory cancer patients receiving thalidomide or lenalidomide in combination with high-dose dexamethasone or chemotherapy, in the absence of contraindications to anticoagulation. However, the majority of cancer patients are ambulatory, and currently primary thromboprophylaxis is not recommended for these patients, even those considered at very high risk. In this concise review, the authors discuss risk stratification models that have been specifically developed to identify cancer patients at high risk for VTE, and thus might be useful in future studies designed to determine the potential benefit of primary thromboprophylaxis. Cancer 2011;. © 2011 American Cancer Society.






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Prolonged impact of chemotherapy on fatigue in breast cancer survivors

Abstract

BACKGROUND:

In this study, the authors examined the influence of prior treatment on the course of fatigue in breast cancer survivors. Patients who received chemotherapy were expected to have greater fatigue than patients who received radiotherapy and noncancer controls 6 months after the completion of treatment, but they were expected to recover to levels similar to those of the other 2 groups 3 years later.

METHODS:

Patients with stage 0 through II breast cancer completed the Fatigue Symptom Inventory (FSI) and the Profile of Mood States Fatigue Scale (POMS-FAT) 6 months (T1) and 42 months (T2) after completing chemotherapy with or without radiotherapy (the CT group; n = 103) or radiotherapy only (the RT group; n = 102). An age-matched group of women with no history of cancer (the NC group; n = 193) was assessed over a similar interval.

RESULTS:

A significant (P = .041) group × time effect for FSI severity scores revealed that fatigue worsened over time in the CT group but remained stable and lower in the RT and NC groups. There also were significant group effects for FSI days (P < .001) and POMS-FAT (P = .010) scores, indicating that fatigue was significantly greater across time in the CT group than in the NC group (POMS-FAT) or the RT and NC groups (FSI days).

CONCLUSIONS:

Contrary to expectations, fatigue did not diminish over time in patients with breast cancer who received chemotherapy. This finding has important implications for patient education and for fatigue monitoring during follow-up. The authors concluded that future research should seek to examine possible mechanisms to explain the apparent prolonged impact of chemotherapy on fatigue in breast cancer survivors. Cancer 2011;. © 2011 American Cancer Society.






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Brain Tumor Consortium narrows search for familial glioma susceptibility

Researchers have narrowed the search for the gene or genes associated with inherited susceptibility to glioma.





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Monday, November 14, 2011

Intra-operative high frequency ultrasound improves surgery of intramedullary cavernous malformations

Abstract  
Intra-operative ultrasound (ioUS) is a very useful tool in surgery of spinal lesions. Here we focus on modern ioUS to analyze its use for localisation, visualisation and resection control in intramedullary cavernous malformations (IMCM). A series of 35 consecutive intradural lesions were operated in our hospital in a time period of 24 months using modern ioUS with a high frequency 7–15 MHz transducer and a true real time 3D transducer (both Phillips iU 22 ultrasound system). Six of those cases were treated with the admitting diagnosis of a deep IMCM (two cervical, four thoracic lesions). IoUS images were performed before and after the IMCM resection. Pre-operative and early postoperative MRI images were performed in all patients. In all six IMCM cases a complete removal of the lesion was achieved microsurgically resulting in an improved neurological status of all patients. High frequency ioUS emerged to be a very useful tool during surgery for localization and visualization. Excellent resection control by ultrasound was possible in three cases. Minor resolution of true real time 3D ioUS decreases the actual advantage of simultaneous reconstruction in two planes. High frequency ioUS is the best choice for intra-operative imaging in deep IMCM to localize and to visualize the lesion and to plan the perfect surgical approach. Additionally, high frequency ioUS is suitable for intra-operative resection control of the lesion in selected IMCM cases.

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-7
  • DOI 10.1007/s10143-011-0364-z
  • Authors
    • Oliver Bozinov, Department of Neurosurgery, University Hospital Zurich, Frauenklinikstr. 10, 8091 Zurich, Switzerland
    • Jan-Karl Burkhardt, Department of Neurosurgery, University Hospital Zurich, Frauenklinikstr. 10, 8091 Zurich, Switzerland
    • Christoph M. Woernle, Department of Neurosurgery, University Hospital Zurich, Frauenklinikstr. 10, 8091 Zurich, Switzerland
    • Vincent Hagel, Department of Neurosurgery, University Hospital Zurich, Frauenklinikstr. 10, 8091 Zurich, Switzerland
    • Nils H. Ulrich, Department of Neurosurgery, University Hospital Zurich, Frauenklinikstr. 10, 8091 Zurich, Switzerland
    • Niklaus Krayenbühl, Department of Neurosurgery, University Hospital Zurich, Frauenklinikstr. 10, 8091 Zurich, Switzerland
    • Helmut Bertalanffy, Department of Neurosurgery, University Hospital Zurich, Frauenklinikstr. 10, 8091 Zurich, Switzerland





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Spinal cord tumor versus transverse myelitis

Publication year: 2011
Source: The Spine Journal, Available online 13 November 2011
Mario Habek, Ivan Adamec, Vesna V. Brinar
Background contextLongitudinally extensive transverse myelitis (LETM) is one of the defining features of neuromyelitis optica (NMO). Despite the well-established criteria, clinical and paraclinical features, the disease is often misdiagnosed and erroneously treated.PurposeWe report on a case of LETM in a patient with spatially limited NMO spectrum disorder that was misdiagnosed as spinal cord tumor and underwent spinal cord biopsy.Study designA 43-year-old female patient is described.MethodsThe patient developed spastic tetraparesis over 1 week. Spinal cord magnetic resonance imaging (MRI) revealed LETM, and she was treated with steroids and recovered. Nine months later, her condition worsened and repeat spinal cord MRI was interpreted as a large intramedullary tumor in the cervical region with irregular postcontrast enhancement. Biopsy revealed demyelination. Cerebrospinal fluid (CSF) analysis revealed positive oligoclonal IgG bands, and serum was positive for NMO-IgG antibody.ResultsThe patient was diagnosed with spatially limited NMO spectrum disorder, treated with plasma exchange, high-dose corticosteroids, and cyclophosphamide, and with good recovery.ConclusionsThe factors favoring inflammatory LETM are acute or subacute onset of clinical symptoms, positive oligoclonal bands in the CSF, positive NMO-IgG or other antibodies, and brain MRI showing demyelinating lesions. Postcontrast axial MRI sequences of the spinal cord can also be helpful. In doubtful situations, a trial of therapy and follow-up MRI a month later might be a more prudent approach if the patient is not rapidly deteriorating.





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Surgical treatment of cerebellar metastases

Ali J Ghods, Lorenzo Munoz, Richard Byrne

Surgical Neurology International 2011 2(1):159-159

Background: Cerebral metastases are a common neurosurgical finding. Surgery confers several advantages to other therapies, including immediate symptomatic improvement, diagnosis, and relief from corticosteroid dependence. Here we evaluate patients with cerebellar metastases who underwent surgery and compare their findings to those in the literature, and address the benefit of avoiding ventriculo-peritoneal shunting in patients undergoing surgery. Methods: We performed a retrospective analysis involving 50 patients with cerebellar metastases who underwent surgical resection. Ventriculo-peritoneal shunts were placed in patients necessitating permanent CSF drainage. We evaluated presentation, diagnosis, complications, and outcome. Results: Our review included 21 males and 29 females, 29 to 82 years of age. Primary tumors included lung (48%), breast (14%), GI (14%), endometrial/ovarian (6%), melanoma (6%), sarcoma (4%), lymphoma (4%), laryngeal (2%), and other (2%). Clinical symptoms at presentation commonly were those secondary to elevated intracranial pressure and were the initial complaint in 34% of patients. Preoperatively, 29 patients were noted to have hydrocephalus. Importantly, 76% of these patients were able to avoid placement of a ventriculo-peritoneal shunt following surgery. Only two complications were noted in our series of 50 patients, including a symptomatic pseudomeningocele and a wound infection. No symptomatic postoperative hematoma developed in any surgical case. Conclusion: A review of the literature has shown a high complication rate in patients undergoing surgical resection of cerebellar metastases. We have shown that surgical resection of cerebellar metastases is a safe procedure and is effective in the treatment of hydrocephalus in the majority of patients harboring cerebellar lesions.





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Neurosurgical management of leukoencephalopathy, cerebral calcifications, and cysts: A case report a

John Berry-Candelario, Ekkehard Kasper, Emad Eskandar, Clark C Chen

Surgical Neurology International 2011 2(1):160-160

Background: Leukoencephalopathy, Calcification, and Cyst (LCC) is a syndrome describing the rare concurrence of these three unusual radiographic findings. Here, we describe the neurosurgical management in a patient afflicted with LCC and review the existing literature on surgical indications and outcomes. Case Description: A 24-year-old man presented with symptoms of progressive headache, gait imbalance and horizontal diplopia. Magnetic resonance imaging (MRI) showed radiographic findings typically associated with LCC, including a large pontine cyst with significant mass effect. The patient's symptoms resolved after open surgical cyst drainage. However, he suffered cyst re-accumulation 3 months after the initial procedure and ultimately underwent placement of a ventriculo-cysto-peritoneal shunt. At the 3-year follow-up, the patient remained symptom free with continued cyst decompression. Conclusion: Our case report suggests that ventriculo-cysto-peritoneal shunting appeared an effective strategy in LCC patients in whom the cyst fenestration failed. We present this case report in the context of the first systematic review of literature on neurosurgical management strategies for patients afflicted with LCC.





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Peripheral doses in patients undergoing Cyberknife treatment for intracranial lesions. A single cent

Background: Stereotactic radiosurgery/radiotherapy procedures are known to deliver a very high dose per fraction, and thus, the corresponding peripheral dose could be a limiting factor for the long term surviving patients. The aim of this clinical study was to measure the peripheral dose delivered to patients undergoing intracranial Cyberknife treatment, using the MOSFET dosimeters. The influence of the supplemental shielding, the number of monitor units and the collimator size to the peripheral dose were investigated. Methods: MOSFET dosimeters were placed in preselected anatomical regions of the patient undergoing Cyberknife treatment, namely the thyroid gland, the nipple, the umbilicus and the pubic symphysis. Results: The mean peripheral doses before the supplemental shielding was added to the Cyberknife unit were 51.79 cGy, 13.31 cGy and 10.07 cGy while after the shielding upgrade they were 38.40 cGy, 10.94 cGy, and 8.69 cGy, in the thyroid gland, the umbilicus and the pubic symphysis, respectively. The increase of the collimator size corresponds to an increase of the PD and becomes less significant at larger distances, indicating that at these distances the PD is predominate due to the head leakage and collimator scatter. Conclusion: Weighting the effect of the number of monitor units and the collimator size can be effectively used during the optimization procedure in order to choose the most suitable treatment plan that will deliver the maximum dose to the tumor, while being compatible with the dose constraints for the surrounding organs at risk. Attention is required in defining the thyroid gland as a structure of avoidance in the treatment plan especially in patients with benign diseases.





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Breast Cancer Itself May Cause 'Brain Fog' (CME/CE)

(MedPage Today) -- Cognitive impairment in breast cancer patients -- sometimes called "brain fog" or "chemobrain" -- results from the disease itself, although chemotherapy makes it worse, a small study suggested.





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Coping With Death and Dying on a Neurology Inpatient Service: Death Rounds as an Educational Initiat

Background  Residents in neurology may feel unprepared to care for dying patients. We developed Death Rounds to provide emotional support and end-of-life care teaching for residents caring for dying patients on the inpatient neurology service. Death Rounds are monthly 1-hour clinical case discussions where residents identify issues through shared experiences.

Objective  To survey neurology residents' perceptions of Death Rounds with respect to end-of-life care teaching and emotional support.

Design, Setting, and Participants  We conducted an electronic survey of all (n = 26) neurology residents and recent residency graduates at the University of Washington 2 years after instituting monthly Death Rounds.

Main Outcome Measure  The survey consisted of 10 questions examining residents' perceptions of the extent to which Death Rounds provided emotional support and end-of-life care teaching. We dichotomized responses to statements about Death Rounds as agree or disagree.

Results  All 26 residents responded to the survey and attended at least 1 Death Rounds session. More than half of residents attended more than 3 sessions. Residents agreed that Death Rounds helped them cope with dying patients (17 residents [65%]), delivered closure for the team (16 residents [61%]), and provided emotional support, more for the team (18 residents [69%]) than the individual (10 residents [38%]). Most residents felt that Death Rounds provided useful teaching about end-of-life care (18 residents [69%]), and they were satisfied overall with Death Rounds (16 residents [61%]).

Conclusions  Death Rounds afford an opportunity for physicians-in-training to process as a group their feelings, intense emotions, and insecurities while learning from the dying process. In our inpatient neurology service, most residents found it a rewarding and valuable experience.






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Saturday, November 12, 2011

Management of Giant Pituitary Tumors Affecting Vision in Nigeria

Publication year: 2011
Source: World Neurosurgery, Available online 11 November 2011
Wilfred Chukwuemeka Mezue, Samuel Chukwuma Ohaegbulam, Mark Chukwunweike Chikani, David Ndubuisi Achebe
ObjectiveThe management of pituitary tumors has evolved considerably in the past few decades. One of the indices for effective surgical outcome is the size of the tumor on presentation. Reports from West and Central Africa have largely indicated late presentation with very large tumors. In the present study we examined this trend and the impact of late presentation on visual outcomes.MethodsThis is a retrospective analysis of the patterns of visual presentation of giant pituitary tumors and the factors that influenced treatment outcomes. We analyzed 44 patients who presented with pituitary tumors extending into the suprasellar region during a five-year period. All patients had computerized tomography or magnetic resonance imaging confirmation of their tumor.ResultsAbout 43% of patients were referred from ophthalmologists. The main symptoms were impaired vision (100%) and visual field defect was present in 47.1%. Optic atrophy was found in 38 eyes (43.1%) and 30% of the patients were already blind on presentation. An additional 23% were functionally blind. Five patients had hydrocephalus from third ventricle obstruction. Of those who had surgery, five patients had additional radiotherapy. There were no perioperative deaths but there were two deaths during follow-up. Vision improved in 14 patients, was unchanged in nine and deteriorated in two.ConclusionsTumors of the pituitary present late in developing countries resulting in increased morbidity. Intervention even at this stage results in visual improvement and efforts must be made to cascade this information to frontier health workers.





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