Monday, December 31, 2012

Happy 2013



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Best Neurocancer Blog (2012)



1) http://www.neurocancer.com/2012/01/histological-analysis-of-third.html

Histological analysis of the third ventricle floor in hydrocephalic and nonhydrocephalic brains

 

2) http://www.neurocancer.com/2012/01/molecular-and-genetic-profiles-of.html

Molecular and genetic profiles of radiographically defined de novo meningiomas



3) http://www.neurocancer.com/2012/08/instagram-head-fixation.html

Instagram: head fixation



 4) http://www.neurocancer.com/2012/05/anamnesis-apps-iphone-and-ipad-english.html

Anamnesis ( apps iPhone and iPad) English and Portuguese




 5)  http://www.neurocancer.com/2012/12/blogs-for-neurosurgeons-surg-neurol-int.html

Blogs for neurosurgeons - Surg Neurol Int 2012



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Saturday, December 29, 2012

Ten years of experience with microsurgical treatment of large and giant petroclival meningiomas

Available online 28 December 2012
Publication year: 2012
Source:Journal of Clinical Neuroscience

During a 10-year period, 41 patients underwent surgery for resection of large or giant petroclival meningiomas. Gross total resection (GTR) was accomplished in 25 patients (61.0%), subtotal resection (STR) in 15 patients (36.6%), and partial resection in one patient (2.4%). Postoperative complications were observed in 27 patients (65.9%). Postoperative radiosurgery was administered in six patients who had residual tumors. Survival and postoperative quality of life are the goals of successful surgery on large or giant petroclival meningiomas, and the strategic surgical approach is based on the tumor location, the direction of growth, the invasion of adjacent structures, patient age and neurosurgeon expertise. Selectively pursuing STR with radiotherapy rather than GTR is a reasonable strategy.






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[Review] Molecular diagnostics in paediatric glial tumours

Glial tumours in children have distinct patterns of epigenetic alteration, chromosomal structure, and gene and protein expression that differentiate them from their histological counterparts in adults. Understanding paediatric gliomas at the molecular level provides important prognostic and therapeutic insights, such as which genetic alterations confer a favourable response to adjuvant therapy, or which signalling pathways might be amenable to specific molecularly targeted agents. For clinicians, the ultimate goal is to individualise therapeutic regimens on the basis of the molecular fingerprint of a particular tumour and the prognosis conferred by this profile.





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[Correspondence] Brain metastases from HER2-positive breast cancer

Intuitively, systemic therapy should be a crucial component of care for patients with brain metastases from HER2-positive breast cancer, considering that many of these patients will harbour distant metastases outside of the brain which also need to be treated to achieve long-term survival. In Thomas Bachelot and colleagues' phase 2 study, 45 patients with previously untreated brain metastases from HER2-positive breast cancer were treated with capecitabine and lapatinib. As discussed by the authors, previous studies suggested that these drugs are active against extracranial and intracranial metastases.





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[Editorial] Access to cancer medicine in low-resource settings

Awareness of the global burden of cancer is growing, with this chronic disease increasingly affecting countries of low to middle income. Although the clinical focus on prevention, treatment, and research still lies very much within the domain of high-income countries, greater efforts have to be made globally. Significant barriers remain, however, such as limited infrastructure for diagnosis and treatment, social stigma, and perceptions that cancer is a fatal disease. In low-income settings, access to therapeutic drugs is also part of the problem: an issue addressed by the Access to Medicines Index, published on Nov 28, 2012, which specifically examined the role of pharmaceutical companies in making their drug portfolios available to low-resource countries.





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State-of-the-art treatment alternatives for base of skull meningiomas: complementing and controversi

For skull base meningiomas, several treatment paradigms are available: Observation with serial imaging, surgical resection, stereotactic radiosurgery, radiation therapy or some combination of both. The choice depends on several factors. In this review we evaluate different treatment options, the outcome of modern irradiation techniques as well as the clinical results available, and establish recommendations for the treatment of patients with skull-base meningiomas.





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Friday, December 28, 2012

Endocrine surgery as a model for value-based health care delivery

Amer G Abdulla, Philip H. G. Ituarte, Randi Wiggins, Elizabeth O Teisberg, Avital Harari, Michael W Yeh

Surgical Neurology International 2012 3(1):163-163

Background: Experts advocate restructuring health care in the United States into a value-based system that maximizes positive health outcomes achieved per dollar spent. We describe how a value-based system implemented by the University of California, Los Angeles UCLA Section of Endocrine Surgery (SES) has optimized both quality and costs while increasing patient volume. Methods: Two SES clinical pathways were studied, one allocating patients to the most appropriate surgical care setting based on clinical complexity, and another standardizing initial management of papillary thyroid carcinoma (PTC). The mean cost per endocrine case performed from 2005 to 2010 was determined at each of three care settings: A tertiary care inpatient facility, a community inpatient facility, and an ambulatory facility. Blood tumor marker levels (thyroglobulin, Tg) and reoperation rates were compared between PTC patients who underwent routine central neck dissection (CND) and those who did not. Surgical patient volume and regional market share were analyzed over time. Results: The cost of care was substantially lower in both the community inpatient facility (14% cost savings) and the ambulatory facility (58% cost savings) in comparison with the tertiary care inpatient facility. Patients who underwent CND had lower Tg levels (6.6 vs 15.0 ng/mL; P = 0.024) and a reduced need for re-operation (1.5 vs 6.1%; P = 0.004) compared with those who did not undergo CND. UCLA maintained its position as the market leader in endocrine procedures while expanding its market share by 151% from 4.9% in 2003 to 7.4% in 2010. Conclusions: A value-driven health care delivery system can deliver improved clinical outcomes while reducing costs within a subspecialty surgical service. Broader application of these principles may contribute to resolving current dilemmas in the provision of care nationally.





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Fractionated stereotactic radiation therapy improves cranial neuropathies in patients with skull bas

Background: Skull base meningiomas commonly present with cranial neuropathies. Fractionated stereotactic radiation therapy (FSRT) has been used to treat these tumors with excellent local control, but rates of improvement in cranial neuropathies have not been well defined. We review the experience at Thomas Jefferson University using FSRT in the management of these patients with a focus on symptom outcomes. Methods: We identified 225 cases of skull base meningiomas treated with FSRT at Thomas Jefferson University from 1994 through 2009. The target volume was the enhancing tumor, treated to a standard prescription dose of 54 Gy. Symptoms at the time of RT were classified based on the cranial nerve affected. Logistic regression was performed to determine predictors of symptom improvement after FSRT. Results: The median follow-up time was 4.4 years. In 92% of cases, patients were symptomatic at the time of RT; the most common were impaired visual field/acuity (58%) or extraocular movements (34%). After FSRT, durable improvement of at least one symptom occurred in 57% of cases, including 40% of visual acuity/visual field deficits, and 40% of diplopia/ptosis deficits. Of all symptomatic patients, 27% experienced improvement of at least one symptom within 2 months of the end of RT. Conclusions: FSRT is very effective in achieving improvement of cranial neuropathies from skull base meningiomas, particularly visual symptoms. Over half of treated patients experience a durable improvement of at least one symptom, frequently within 2 months from the end of RT.





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Wednesday, December 26, 2012

Blogs for neurosurgeons - Surg Neurol Int 2012



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TECHNOLOGY
Surg Neurol Int 2012,  3:62

Blogs for neurosurgeons

1 Department of Neurosurgery, Santa Casa Hospital of Belo Horizonte, MG, Brazil
2 Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands3 Department of Neurosurgery, Santa Casa Hospital of Belo Horizonte; Lecturer at the Post-graduate and Research Program at Santa Casa Hospital of Belo Horizonte, MG, Brazil

Date of Submission02-Feb-2012
Date of Acceptance16-Apr-2012
Date of Web Publication09-Jun-2012

    

Correspondence Address:
Lucas Alverne Freitas de Albuquerque
Department of Neurosurgery, Santa Casa Hospital of Belo Horizonte, MG 
Brazil
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© 2012 Pereira et al; This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.4103/2152-7806.97006

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   Abstract 

Blogs are useful tools to research and to disseminate information. As they allow people who do not have specific knowledge on the building of sites to post content on the internet, they turned out to be very popular. In the past years, there has been a rapid expansion of blogs on several subjects and nowadays there are over 156 million blogs online. Neurosurgery was not out of this wave, and several blogs related to it can be found on the internet. The objective of this paper is to describe, in general, the functions of a blog and to provide initial guidance for the creation and the adequate use of neurosurgical blogs. Some interesting blogs and their features are also listed as examples.

Keywords: Actualization, blog, internet, neurosurgery


How to cite this article:
Pereira JB, Kubben PL, Freitas de Albuquerque LA, de Carvalho GC, de Sousa AA. Blogs for neurosurgeons. Surg Neurol Int 2012;3:62

How to cite this URL:
Pereira JB, Kubben PL, Freitas de Albuquerque LA, de Carvalho GC, de Sousa AA. Blogs for neurosurgeons. Surg Neurol Int [serial online] 2012 [cited 2012 Dec 26];3:62. Available from: http://www.surgicalneurologyint.com/text.asp?2012/3/1/62/97006


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Stroke Unit Care Combined With Early Supported Discharge Improves 5-Year Outcome: A Randomized Contr

Background and Purpose—

Early supported discharge (ESD) seems to be a promising alternative to conventional follow-up care after acute stroke. We have previously shown that stroke unit care combined with ESD has beneficial effects on functional outcome and the use of resources for up to 1 year. The aim of this trial was to evaluate outcome after 5 years.

Methods—

We performed a randomized controlled trial with 320 acute stroke patients allocated to ordinary stroke unit care (160 patients) or stroke unit care with ESD (160 patients). The ESD service consisted of a mobile team that co-coordinated hospital discharge and further rehabilitation during 1 month of follow-up in cooperation with the primary health care. Mortality, residence, and functional outcome including modified Rankin scale were registered after 5 years. All assessments were blinded.

Results—

There was no difference between the groups with modified Rankin scale score ≤2 (P=0.213), but there was a trend toward greater improvement in modified Rankin scale score in the ESD group from onset of stroke (38% versus 30%; P=0.106). More patients were dead or institutionalized in the ordinary stroke unit care group (P=0.032); 158 patients were alive, 84 were in ESD, and 74 were in ordinary stroke unit care. Of the 158 patients alive, a greater proportion were living at home in ESD (86%/70%; P=0.019).

Conclusions—

Stroke unit care combined with ESD seems to reduce death and institutional care and to improve patients' chances of living at home 5 years after stroke compared to traditional stroke care. There is a trend toward improved functional outcome in the ESD group.






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Infant Ependymoma in a 10-Year AIEOP (Associazione Italiana Ematologia Oncologia Pediatrica) Experie

Purpose: The protocols of the 1990s omitted or delayed irradiation, using upfront chemotherapy to spare the youngest children with ependymoma the sequelae of radiotherapy (RT). We treated 41 children under the age of 3 years with intracranial ependymoma between 1994 and 2003.Patients and Methods: After surgery, chemotherapy was given as follows: regimen I with four blocks of vincristine, high-dose methotrexate 5 g/m2, and cyclophosphamide 1.5 g/m2 alternating with cisplatin 90 mg/m2 plus VP16 450 mg/m2 for 14 months; subsequently, regimen II was used: VEC (VCR, VP16 300 mg/m2, and cyclophosphamide 3 g/m2) for 6 months. Radiotherapy was planned for residual tumor after the completion of chemotherapy or for progression.Results: We treated 23 boys and 18 girls who were a median 22 months old; 14 were given regimen I, 27 were given regimen II; 22 underwent complete resection, 19 had residual tumor. Ependymoma was Grade 2 in 25 patients and Grade 3 in 16; tumors were infratentorial in 37 patients and supratentorial in 4. One child had intracranial metastases; 29 had progressed locally after a median 9 months. Event-free survival was 26% at 3 and 5 years and 23% at 8 years. One child died of sepsis, and another developed a glioblastoma 72 months after RT. Progression-free survival was 27% at 3, 5, and 8 years, and overall survival was 48%, 37%, and 28% at 3, 5, and 8 years, respectively. Of the 13 survivors, 6 never received RT; their intellectual outcome did not differ significantly in those children than in those without RT.Conclusions: Our results confirm poor rates of event-free survival and overall survival for up-front chemotherapy in infant ependymoma. No better neurocognitive outcome was demonstrated in the few survivors who never received RT.





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Tuesday, December 25, 2012

Confira App Dor de Cabeça #medicina #neurologia #enxaqueca #saúde

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Categoria: Medicina

Atualizado: 19/10/2012
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Friday, December 21, 2012

Clinical characteristics and surgical outcomes of patients with interdural epidermoid cyst of the ca

January 2013
Publication year: 2013
Source:Journal of Clinical Neuroscience, Volume 20, Issue 1

Interdural epidermoid cysts of the cavernous sinus originate within the lateral dural wall of the cavernous sinus. Few data are available on the diagnosis and treatment of these tumors. In this study, four patients with interdural epidermoid cyst of the cavernous sinus are reported and data from six patients reported in the English literature are summarized. Trigeminal nerve dysfunction, ophthalmoplegia, and headache were the common symptoms and signs. MRI was the primary diagnostic tool. Contrast enhanced MRI showed slight or strong rim enhancement in six of the 10 patients. All patients were treated by surgical resection using frontotemporal or pterional craniotomy via the intradural or interdural approach. Total removal was achieved in three of the four patients, and four of 10 patients in the whole series. Postoperative neurological function improved in all patients. During follow-up, there were three known clinical recurrences in the total group, but no recurrence in the four patients treated at Qilu Hospital of Shandong University. The findings suggest that aggressive surgical management is associated with good results and with low complication and recurrence rates, but radical resection at the risk of impairing the cranial nerves is not recommended.






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Racial disparities in medicaid patients after brain tumor surgery

January 2013
Publication year: 2013
Source:Journal of Clinical Neuroscience, Volume 20, Issue 1

The presence of healthcare-related disparities is an ongoing, widespread, and well-documented societal and health policy issue. We investigated the presence of racial disparities among post-operative patients either with meningioma or malignant, benign, or metastatic brain tumors. We used the Medicaid component of the Thomson Reuter's MarketScan database from 2000 to 2009. Univariate and multivariate analysis assessed death, 30-day post-operative risk of complications, length of stay, and total charges. We identified 2321 patients, 73.7% were Caucasian, 57.8% were women; with Charlson comorbidity scores of <3 (56.2%) and treated at low-volume centers (73.4%). Among all, 26.3% of patients were of African-American ethnicity and 22.1% had meningiomas. Mortality was 2.0%, mean length of stay (LOS) was 9days, mean total charges were US$42,422, an adverse discharge occurred in 22.5% of patients, and overall 30-day complication rate was 23.4%. In a multivariate analysis, African-American patients with meningiomas had higher odds of developing a 30-day complication (p =0.05) and were significantly more likely to have longer LOS (p <0.001) and greater total charges (p <0.001) relative to Caucasian counterparts. The presence of one post-operative complication doubled LOS and nearly doubled total charges, while the presence of two post-operative complications tripled these outcomes. Patients of African-American ethnicity had significantly higher post-operative complications than those of Caucasian ethnicity. This higher rate of complications seems to have driven greater healthcare utilization, including greater LOS and total charges, among African-American patients. Interventions aimed at reducing complications among African-American patients with brain tumor may help reduce post-operative disparities.






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Chromosomal alterations, prognostic factors, and targeted molecular therapies for malignant meningio

January 2013
Publication year: 2013
Source:Journal of Clinical Neuroscience, Volume 20, Issue 1

Meningiomas are the second most common intracranial neoplasm in adults and originate from arachnoidal cap cells. Malignant meningiomas are resistant to conventional treatments such as surgery, chemotherapy, and radiotherapy. Unlike benign meningiomas, atypical and anaplastic tumors generally display more complex karyotypes associated with aggressive behavior. While these chromosomal anomalies are associated with greater malignancy in meningiomas, the specific genes involved remain unknown. Malignant meningiomas are characterized by increased tumor aggressiveness, rapid recurrence, local invasion, atypical histological appearance, and a high mitotic index. Potential prognostic factors include extent of resection, treatment with radiotherapy or stereotactic radiosurgery, Ki-67/MIB-1 labeling index, p53 overexpression, percentage of tumor cells in the S-phase, telomerase activity, and numerous genetic expression profiles. A greater understanding of prognostic factors and molecular markers involved in critical signaling pathways may aid in the identification of novel therapeutic targets. As such, further studies are needed to establish reliable prognostic factors and develop more effective treatments for malignant meningiomas.






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Hemangiopericytomas in the Spine: Clinical Features, Classification, Treatment, and Long-term Follo

imageBACKGROUND: Intraspinal hemangiopericytoma (HPC) is a rare and malignant extra-axial tumor with a strong tendency to recur and metastasize. There is a paucity in the literature of large case series of patients with intraspinal HPCs. OBJECTIVE: We retrospectively analyzed the clinical radiological and histological features, classification, and treatment of 26 patients with HPCs in the spine. METHODS: Twenty-six patients with HPCs in the spine were treated at our institution between 1987 and 2010. Medical records were reviewed retrospectively to collect data on the clinical features, tumor morphology, surgical resection, recurrence, and follow-up. RESULTS: The 26 patients were predominantly male, and the mean age at diagnosis was 33.8 years. The intraspinal HPCs were divided into 3 types and 5 subtypes. Most of them involved the neighboring segments and/or caused bony erosion. All tumors were immunohistochemically positive for vimentin and negative for epithelial membrane antigen. All patients underwent at least 1 surgery, and most of them received postsurgical radiotherapy. The 5-year Kaplan-Meier rate of survival was 76%. The 5-year recurrence-free rate of survival was 29.4%. Only the tumor pathological grade was significantly associated with survival time and recurrence. CONCLUSION: High-grade tumors had a shorter survival time and recurred earlier than low-grade tumors. Surgical removal and postoperative radiotherapy are critical for the treatment of intraspinal HPCs. However, total resection may not necessary for these tumors. Stereotactic radiosurgery may be a good alternative to control the recurrent lesions. ABBREVIATIONS: CNS, central nervous system HPC, hemangiopericytoma WHO, World Health Organization





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Increased xCT Expression Correlates With Tumor Invasion and Outcome in Patients With Glioblastomas

imageBACKGROUND: xCT is a light chain of the cystine/glutamate antiporter system xc−. Glutamate that is released by system xc− plays an important role in the infiltration of glioblastoma (GBM) cells. Furthermore, increased glutathione synthesis by system xc− may protect tumor cells against oxidative stress induced by radiotherapy and chemotherapy. OBJECTIVE: To investigate whether the levels of xCT expression correlated with infiltrative imaging phenotypes on magnetic resonance imaging and outcomes in patients with GBMs. METHODS: Forty patients with histologically confirmed primary GBMs were included in the study. Patient charts were retrospectively reviewed for age, sex, Karnofsky Performance Status Scale score, Mini-Mental State Examination score, magnetic resonance imaging features, xCT expression, isocitrate dehydrogenase 1 R132H expression, O6-methylguanine-DNA methyltransferase promoter methylation status, type of surgery, progression-free survival, and overall survival. RESULTS: In invasive margins, xCT expression was weak in 20 patients and strong in 20 patients. A Cox regression model revealed that a Karnofsky Performance Status Scale score less than 60 (hazard ratio [HR]: 4.525; P = .01), partial removal (HR: 2.839; P = .03), and strong xCT expression (HR: 4.134; P < .001) were significantly associated with shorter progression-free survival and that partial removal (HR: 2.865; P = .03), weak isocitrate dehydrogenase 1 R132H expression (HR: 15.729; P = .01), and strong xCT expression (HR: 2.863; P = .04) were significantly associated with shorter overall survival. CONCLUSION: These findings suggest that xCT is an independent predictive factor in GBMs. ABBREVIATIONS: EAAT-2, excitatory amino acid transporter 2 GBM, glioblastoma GSH, glutathione IDH1, isocitrate dehydrogenase 1 KPS, Karnofsky Performance Status Scale MGMT, O6-methylguanine–DNA methyltransferase MMSE, Mini-Mental Status Examination OS, overall survival PFS, progression-free survival





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Microsurgical Management of Jugular Foramen Schwannomas

imageBACKGROUND: Jugular foramen schwannomas are uncommon and surgically challenging lesions. OBJECTIVE: To determine the importance of surgical technique on morbidity and recurrence of jugular foramen schwannomas. METHODS: A retrospective review and case-control analysis of a single-senior-surgeon series of 81 patients with surgically treated jugular foramen schwannomas was performed, focusing on operative technique. Patients undergoing an aggressive, total tumor resection (series 1) were compared with those undergoing more conservative resection focusing on preserving the pars nervosa (series 2). RESULTS: There was a statistically significant (P = .04) decrease in permanent deficits of the cranial nerve 9/10 complex with a conservative technique. Recurrence was seen in 3 patients (5.7%) in series 1 and in 3 patients (10.7%) in series 2 (P = .36). Recurrence was treated with reoperation in 1 patient, radiation in 1 patient, and observation in the others. CONCLUSION: Although radical gross total resection is desirable, it is not optimal for cranial nerve preservation in patients with jugular foramen schwannomas. A more conservative approach resulted in a statistically significant decrease in lower cranial nerve deficits. There was a nonstatistically significant trend toward increasing recurrence, which may be treated with multiple modality therapy in the modern era. ABBREVIATION: JFS, jugular foramen schwannoma





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Spinal Glomus (Type II) Arteriovenous Malformations: A Pooled Analysis of Hemorrhage Risk and Resul

imageBACKGROUND: The natural history and treatment results for spinal glomus (type II) arteriovenous malformations (AVMs) remain relatively obscure. OBJECTIVE: To calculate spinal glomus (type II) AVM hemorrhages rates and amalgamate results of intervention. METHODS: We performed a pooled analysis via the PubMed database through May 2012, including studies with at least 3 cases. Data on individual patients were extracted and analyzed using a Cox proportional hazards regression model to obtain hazard ratios for hemorrhage risk factors. RESULTS: The annual hemorrhage rate before treatment was 4% (95% confidence interval [confidence interval]: 3%-6%), increasing to 10% (95% CI: 7%-16%) for AVMs with previous hemorrhage. The hazard ratio for hemorrhage after hemorrhagic presentation was 2.25 (95% CI: 0.71-7.07), increasing to 13.0 within the first 10 years (95% CI: 1.44-118). The overall rates of complete obliteration were 78% (95% CI: 72%-83%) for surgery and 33% (95% CI: 24%-43%) for endovascular treatment. Long-term clinical worsening occurred in 12% of patients after surgical treatment (95% CI: 8%-16%) and in 13% after endovascular treatment (95% CI: 7%-21%). No hemorrhages occurred after complete obliteration. After partial surgical treatment, the annual hemorrhage rate was 3% (95% CI: 1%-6%); no hemorrhages were reported over 196 patient-years after partial endovascular treatment. CONCLUSION: Spinal glomus (type II) AVMs with previous hemorrhage, particularly within 10 years, demonstrated a greater risk of hemorrhage. Complete obliteration and even partial endovascular treatment significantly decreased their hemorrhage rate. ABBREVIATIONS: AVM, arteriovenous malformation CI, confidence interval NBCA,N-butyl cyanoacrylate PVA, polyvinyl alcohol





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Sunday, December 16, 2012

Radiosurgery with photons or protons for benign and malignant tumours of the skull base: a review

Stereotactic radiosurgery (SRS) is an important treatment option for intracranial lesions. Many studies have shown the effectiveness of photon-SRS for the treatment of skull base (SB) tumours; however, limited data are available for proton-SRS.Several photon-SRS techniques, including Gamma Knife, modified linear accelerators (Linac) and CyberKnife, have been developed and several studies have compared treatment plan characteristics between protons and photons.The principles of classical radiobiology are similar for protons and photons even though they differ in terms of physical properties and interaction with matter resulting in different dose distributions.Protons have special characteristics that allow normal tissues to be spared better than with the use of photons, although their potential clinical superiority remains to be demonstrated.A critical analysis of the fundamental radiobiological principles, dosimetric characteristics, clinical results, and toxicity of proton- and photons-SRS for SB tumours is provided and discussed with an attempt of defining the advantages and limits of each radiosurgical technique.




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A proposed scheme for the classification and surgical planning of falcine meningioma treatment

December 2012
Publication year: 2012
Source:Journal of Clinical Neuroscience, Volume 19, Issue 12

Falcine meningiomas (FM) represent a surgical challenge even in the microsurgical era. An individualised surgical approach to different FM is indispensable, but there have been few reports in this regard. Thus, based on our series of 20 patients with FM who underwent surgery between October 2001 and June 2010, we propose a classification scheme for FM removal and demonstrate its effectiveness. FM in our series were classified into four types, according to tumour growth patterns on coronal MRI: Type I, hemispheroid-shaped tumours invaginating deeply into one hemisphere without shifting the falx (10 patients); Type II, olive-shaped tumours shifting the falx substantially to the contralateral side (six patients); Type IIIA, globular- or dumbbell-shaped tumours extending into both hemispheres, but to different extents (one patient); and Type IIIB, globular- or dumbbell-shaped tumours extending into both hemispheres to approximately equal extent (three patients). An ipsilateral interhemispheric approach was performed for Type I tumours, and a contralateral transfalcine approach for Type II. Type IIIA tumour was approached from the side where the smaller tumour was located. Type IIIB tumours were approached from the non-dominant hemisphere. Simpson grade I resection was achieved in all 20 patients. The follow-up ranged from 12months to 114months. There was no postoperative mortality, serious neurological deficits, or tumour recurrence. The preliminary results suggest that the proposed scheme can facilitate surgical planning and accomplish complete tumour resection with minimal invasion.





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Treatment outcomes after surgical resection of midline anterior skull base meningiomas at a single c

December 2012
Publication year: 2012
Source:Journal of Clinical Neuroscience, Volume 19, Issue 12

Meningiomas of the midline anterior skull base (ASB) typically grow around the optic chiasm. These tumors can displace or adhere to the optic apparatus, resulting in visual abnormalities. For this reason, in most studies of surgically resected meningiomas, only surgical and visual outcomes have been evaluated. However, in this study, we assessed overall clinical outcomes and the effects of different surgical approaches on outcomes. Clinical data for 126 patients who were treated surgically for midline ASB meningiomas between 1994 and 2009 were collected and reviewed retrospectively. The mean follow-up duration was 39months (range: 0.5–146months). Most procedures were performed via a pterional approach and did not require an aggressive skull base approach. Clinical outcomes were evaluated using our own criteria, and potential predictive factors for visual and clinical outcomes were tested statistically. The tumor control rate was 83% (105/126). Immediate postoperative visual status and optic canal involvement were correlated with visual outcome. Of the patients who ultimately had improved visual status, only six were originally categorized as having severe visual impairment (all were only able to count fingers). In terms of clinical outcome, 41 patients were classified as "excellent", 32 as "good", 29 as "fair", and 20 as "poor". A symptom duration of less than six months, less severe preoperative visual symptoms of the affected eye, and the extent of resection were all correlated with improved clinical outcome. Involvement of the optic canal, adherence of the tumor to the optic nerve, and major arterial encasement by the tumor were associated with poor clinical outcome. We recommend that in patients with unilateral severe visual impairment, the focus should be on improving visual function in the contralateral eye. Preoperative and postoperative evaluation of several variables allows for the prediction of clinical and visual outcomes.






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Incidence of venous thromboembolism in patients with cancer – A cohort study using linked United Kin

Available online 9 November 2012
Publication year: 2012
Source:European Journal of Cancer

Background Accurate population-based data are needed on the incidence of venous thromboembolism (VTE) in patients with different cancers in order to inform guidelines on which hospitalised and ambulatory cancer patients should receive VTE prophylaxis. Methods We conducted a cohort study using data from the Clinical Practice Research Datalink, linked to Hospital Episode Statistics, Cancer Registry data and Office for National Statistics cause of death data. We determined the incidence rates (cases per 1000 person–years) of VTE separately for 24 cancer sites. To determine relative risk, incidence rates were compared to frequency-matched controls (by age) with no record of cancer. Findings We identified 83,203 cancer patients and 577,207 controls. New cases of VTE were diagnosed in 3352 cancer patients, and 6353 controls. The absolute rate of VTE in all cancers was 13.9 per 1000 person–years (95% confidence interval [CI] 13.4–14.4), corresponding to an age, sex and calendar year adjusted hazard-ratio of 4.7 (CI 4.5–4.9) between cancer patients and the general population. Rates varied greatly by cancer site (range; 98 (CI 80–119) in pancreatic cancer to 3.1 (CI 1.5–6.5) in thyroid cancer), age (range; 16.9 for patients over 80years to 4.9 for those under 30years) and time from diagnosis (range; 75 in the first three months to 8.4, >1year after diagnosis). Interpretation VTE is strongly linked to cancer, but the annual rate varies greatly by cancer site, proximity to diagnosis and age. Prophylaxis guidelines should take account of cancer site and such intervention should also be targeted towards the three months following diagnosis.






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Correlation between Ki-67 immunohistochemistry and 18F-Fluorothymidine uptake in patients with cance

December 2012
Publication year: 2012
Source:European Journal of Cancer, Volume 48, Issue 18

Background Positron emission tomography (PET) imaging using the radiotracer 18F-Fluorothymidine (FLT) has been proposed as an imaging biomarker of tumour proliferation. If FLT-PET can be established as such it will provide a non-invasive, quantitative measurement of tumour proliferation across the entire tumour. Results from validation studies have so far been conflicting with some studies confirming a good correlation between FLT uptake and Ki-67 score and others presenting negative results. Methods Firstly we performed a systematic review of published studies between 1998 and 2011 that explored the correlation between FLT uptake and Ki-67 score and examined possible variations in the methods used. Studies were eligible if they: (a) included patients with cancer, (b) investigated the correlation between Ki-67 measured by immunohistochemistry and FLT uptake measured with PET scanning, and (c) were published as a full paper in a peer-reviewed scientific journal. Secondly a meta-analysis of the correlation coefficient values reported from each study was performed. Correlation coefficient (r) values were extracted from each study and 95% confidence intervals (CIs) were calculated after applying Fisher's z transformation. For subgroup analysis, studies were classified by the index used to characterise Ki-67 expression (average or maximum expression), the nature of the sample (whole specimen or biopsy) and the cancer type. Findings Twenty-seven studies were identified as eligible for the meta-analysis. In the studies we examined there were variations in aspects of the methods and reporting. The meta-analysis showed that given an appropriate study design the FLT/Ki-67 correlation is significant and independent of cancer type. Specifically subgroup analysis showed that FLT/Ki-67 correlation was high in studies measuring the Ki-67 average expression regardless of use of surgery or biopsy samples (r =0.70, 95% CI=0.43–0.86, p <0.001). Of the studies that measured Ki-67 maximum expression, only those that used the whole surgical specimen provided a significant r value (r =0.72, 95% CI=0.54–0.84, p <0.001). Studies that used biopsy samples for Ki-67 maximum measurements did not produce a significant r value (r =0.04, 95% CI=−0.18–0.26, p =0.71). In terms of the cancer type subgroup analysis there is sufficient data to support a strong FLT/Ki-67 correlation for brain, lung and breast cancer. No publication bias was detected. Interpretation This systematic review and meta-analysis highlights the importance of the methods used in validation studies comparing FLT-PET imaging with the biomarker Ki-67. The correlation is significant and independent of cancer type provided a study design that uses Ki-67 average measurements, regardless of nature of sample, or whole surgical samples when measuring Ki-67 maximum expression. Sufficient data to support a strong correlation for brain, lung and breast cancer exist. However, larger, prospective studies with improved study design are warranted to validate these findings for the rest of the cancer types.






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Thursday, December 13, 2012

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Categoria: Medicina

Atualizado: 19/10/2012
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Sunday, December 9, 2012

Endoscopic Endonasal Compared with Anterior Craniofacial and Combined Cranionasal Resection of Esthe

Available online 7 December 2012
Publication year: 2012
Source:World Neurosurgery

Objective Esthesioneuroblastomas represent a surgical challenge due to their anatomical location, the necessity to achieve negative margins and often cosmetically disfiguring transfacial approaches. Recently, expanded endonasal endoscopic approaches have been developed, either alone or in combination with a craniotomy. We conducted a systematic review of case series and case reports to compare outcomes between these various surgical approaches. Methods MEDLINE search of the modern literature (1985-2010) to identify open and endoscopic surgical series. Tumor and patient characteristics, Kadish stage, extent of resection, and progression-free and overall survival were recorded and analyzed by approach. Kaplan-Meier analysis was used to assess overall survival and progression-free survival. Results Forty seven studies, involving 453 patients, were included. The endoscopic cohort had a higher proportion of Kadish Stage A tumors compared with the craniofacial group. Gross total resection was achieved in 98.1% of patients undergoing an endoscopic approach, compared with 81.3% for the craniofacial and 100% for the cranionasal cohorts. Local recurrence occurred in 8.0% of patients in the endoscopic group, compared with 22.1% in the craniofacial and 16.7% in the cranionasal cohorts. Conclusion In well-selected cases, cranionasal and endonasal approaches can be safe and effective. Ongoing evaluation of the benefits and limitations are necessary to better define the ideal patient population and patient-specific risk factors for the use of these minimal access techniques.






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Saturday, December 1, 2012

Increased expression of tumor-associated antigens in pediatric and adult ependymomas: implication fo

Abstract  
Despite surgery and radiotherapy, as many as 50 % of children with ependymomas will suffer from tumor recurrences that will ultimately lead to death. Our group's initial peptide-based glioma vaccine targeting EphA2, IL-13Rα2, and Survivin, which are overexpressed in pediatric gliomas, has shown promise in its initial phase of testing. We therefore investigated whether EphA2, IL-13Rα2, Survivin, and, additionally, Wilms' Tumor 1 (WT1), are overexpressed in pediatric ependymomas to determine if a similar immunotherapy approach could be applicable. Immunohistochemistry was performed using antibodies specific for EphA2, IL-13Rα2, Survivin, and WT1 on paraffin-embedded specimens from 19 pediatric and 13 adult ependymomas. Normal brain and ependyma were used for background staining controls. Negative staining was defined as no staining or staining equaling the background intensity in normal brain tissues. In the 19 pediatric cases, 18 (95 %) demonstrated positive staining for EphA2, 16 (84 %) for IL-13Rα2, 18 (95 %) for Survivin, and only 7 (37 %) for WT1. Only 3 of 19 cases were positive for two or fewer tumor-associated antigens (TAAs); 16 of 19 cases were positive for three or more TAAs. In the 13 adult cases, all 13 demonstrated positive staining for EphA2, IL-13Rα2, and Survivin. Only 2 of 13 cases (15 %) demonstrated positive staining for WT1. All adult specimens were positive for three or more TAAs. Some ependymomas showed patchy variability in intensity. Pediatric and adult ependymomas frequently express EphA2, IL-13Rα2, and Survivin. This provides the basis for the utilization of an established multiple peptide vaccine for ependymoma in a clinical trial setting.

  • Content Type Journal Article
  • Category Laboratory Investigation
  • Pages 1-9
  • DOI 10.1007/s11060-012-0998-x
  • Authors
    • Jacky T. Yeung, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
    • Ronald L. Hamilton, Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
    • Hideho Okada, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
    • Regina I. Jakacki, Departments of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
    • Ian F. Pollack, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA





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Awake mapping for resection of cavernous angioma and surrounding gliosis in the left dominant hemisp

Journal of Neurosurgery, Volume 117, Issue 6, Page 1076-1081, December 2012.
Object Maximal resection of symptomatic cavernous angioma (CA), including its surrounding gliosis if possible, has been recommended to minimize the risk of seizures or (re)bleeding. However, despite recent neurosurgical advances, such extensive CA removal is still a challenge in eloquent areas. The authors report a consecutive series of patients who underwent awake surgery for CA within the left dominant hemisphere in which intraoperative cortical–subcortical electrical stimulation was used. Methods Nine patients harboring a CA that was revealed by seizures in 6 cases and bleeding in 3 cases underwent resection. All CAs were located in the left dominant hemisphere: 3 temporal, 2 insular, 2 parietal, and 2 in the parietotemporal region. Awake mapping was performed in all cases by using intraoperative cortical–subcortical electrical stimulation and ultrasonography (except in 1 insular CA in which a neuronavigation system was used). Results Total removal of the CA was achieved in all patients, with identification and preservation of language and sensory-motor structures. In addition, the pericavernomatous gliosis was removed in 7 cases, according to the functional boundaries provided by intraoperative subcortical stimulation. In 2 cases, subcortical mapping revealed eloquent areas within the surrounding gliosis, which was voluntarily avoided. There was no postsurgical permanent deficit, no rebleeding, and no epilepsy in 7 cases (2 patients had rare seizures in the 1st year or two after surgery, and then complete arrest), with a mean follow-up of 28.5 months (range 3–64 months). Conclusions These results suggest that intraoperative cortical–subcortical stimulation in awake patients represents a valuable adjunct to image-guided surgery with the aim of selecting the safer surgical approach for CAs involving eloquent areas. Moreover, such online mapping can be helpful when removing the pericavernomatous gliosis while preserving functional structures, which can persist within the hemosiderin rim. Thus, the authors propose that awake surgery be routinely considered, both to optimize the resection and to improve the quality of life through seizure control and avoidance of (re)bleeding for CAs located in the left dominant hemisphere.





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Validation of the superior interhemispheric approach for tuberculum sellae meningioma

Journal of Neurosurgery, Volume 117, Issue 6, Page 1013-1021, December 2012.
Object The objective of this study was to evaluate the ophthalmological outcome, nonvisual morbidity, and surgical complications after tuberculum sellae meningioma (TSM) removal using a superior interhemispheric approach. Methods In the last decade, 20 consecutive patients with TSM underwent operations using the superior interhemispheric approach. Visual acuity, visual field, and ocular fundus examination were assessed both preoperatively and 6-months postoperatively. Nonvisual morbidity was determined at an early postoperative period and at 6 months based on assessment of the Karnofsky Performance Scale score, leakage of CSF, endocrinological status, and olfactory function, which was assessed using a visual analog scale (VAS). The potential brain injury related to the approach was assessed by MRI at 6 months. Magnetic resonance imaging was then performed yearly to detect a recurrence. The mean follow up was 56.3 ± 34 months. Results The primary presenting symptom for diagnosis of TSM in 20 patients (female:male ratio of 6.6:1, mean age 59.1 ± 11.1 years) was visual disturbance in 12 patients (60%), headache in 4 (20%), cognitive alteration in 1 (5%), epilepsy in 2 (10%), and accidental in 1 (5%). In a total of 40 eyes, 17 eyes in 11 patients presented with preoperative deterioration of visual acuity. Postoperatively, the visual acuity improved in 13 eyes in 8 patients (72.8%), remained unchanged in 3 eyes in 2 patients (18.2%) and deteriorated in 1 patient (9%). The nonvisual morbidity included olfactory deterioration in 7 patients (35%), and panhypopituitarism in 1 patient (5%). No patients experienced a CSF leak. The impact of olfactory deterioration on the quality of life, as estimated by a VAS score (range 0–10), was a mean of 5.7 ± 2.2 (95% CI 4.1–7.3). On the follow-up MRI, no additional lesions or recurrences were observed on the medial aspect of the frontal lobe along the surgical corridor. Conclusions The superior interhemispheric approach appears to be effective in resolving the problem of visual deterioration due to a TSM, without inducing surgical injury on the brain surface along the surgical corridor. Olfactory deterioration remained the challenging predominant nonvisual morbidity using this approach.





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