Neuro-Oncology

Monday, October 6, 2014

Endoscopic supraorbital eyebrow approach for the surgical treatment of extraaxialand intraaxial tumors

Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents

Neurosurgical Focus, Volume 37, Issue 4, Page E20, October 2014.
Object The supraorbital eyebrow approach is a minimally invasive technique that offers wide access to the anterior skull base region and parasellar area through asubfrontal corridor. The use of neuroendoscopy allows one to extend the approach further to the pituitary fossa, the anterior third ventricle, the interpeduncular cistern, the anterior and medial temporal lobe, and the middle fossa. The supraorbital approach involves a limited skin incision, with minimal soft-tissue dissection and a small craniotomy, thus carrying relatively low approach-related morbidity. Methods All consecutive patients who underwent the endoscopic supraorbital eyebrow approach were retrospectively analyzed for lesion location, pathology, length of stay, complications, and cosmetic results. Results During a 56-month period, 97 patients (mean age 58.5 years) underwent an endoscopic eyebrow approach to resect extra- and intraaxial brain lesions. The most common pathologies treated were meningiomas (n = 41); craniopharyngiomas (n = 22); dermoid tumors (n = 7); metastases (n = 4); gliomas (n = 3); and other miscellaneous frontal, parasellar, and midbrain (n = 23) lesions. The median length of postoperative hospital stay was 2.7 days (range 1–8 days). In 82 patients a total removal of the lesion was performed, while in 15 patients a near-total or subtotal removal was achieved. There were no postoperative hematomas, cerebrospinal fluid leaks, or severe neurological deficits, with the exception of 2 cases of visual deterioration and 1 case each of meningitis, stroke, and third cranial nerve paresis. Other complications directly related to the approach included 2 cases of skin burn as a direct result of heat transmission from the microscope light, 1 case of right frontal palsy, 2 cases of frontal numbness, and 1 case of bone remodeling 1 year after surgery. Conclusions The endoscopic supraorbital eyebrow approach is a safe and effective minimally invasive approach to remove extra- and intraaxial anterior skull base, parasellar, and frontal lesions, promoting a rapid recovery and short hospital stay. The location of the eyebrow incision demands a meticulous cosmetic closure, but, with proper technique, cosmetic results are excellent.

Original Article: http://thejns.org/doi/abs/10.3171/2014.7.FOCUS14203?ai=rw&mi=3ba5z2&af=R

Residual tumor volume and patient survival following reoperation for recurrent glioblastoma

Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 121, Issue 4, Page 802-809, October 2014.
Object Maximal safe tumor resection is part of the standard of care for patients with newly diagnosed glioblastoma. The role of reoperation in the care of patients with recurrent glioblastoma is less clear, and less than a quarter of patients undergo a second surgery. Previous studies have identified preoperative variables associated with the improved survival of patients following reoperation, and guidelines for the selection of patients for reoperation have been devised and validated. In this study, the authors analyzed the relative survival benefit of maximal safe tumor removal in a series of patients with recurrent glioblastoma who all underwent reoperation. Methods In this longitudinal study, the clinical and radiological data of 97 consecutive patients who underwent reoperation for recurrent glioblastoma were prospectively collected. Multiple regression analyses and Kaplan-Meier plotting were performed to identify pre- and postoperative clinical and radiological variables associated with increased survival following reoperation. Results The median postoperative survival of all patients following reoperation was 12.4 months (95% confidence interval [CI] 9.0–15.6 months). Multiple Cox regression analysis revealed that patients with large (> 3 cm3) residual tumors following reoperation had significantly decreased survival relative to those with residual tumors that were small (> 0–3 cm3; hazard ratio [HR] = 3.10, 95% CI 1.69–5.70; p < 0.001) or radiologically absent (0 cm3; HR = 5.82, 95% CI 2.98–11.37; p < 0.001). Large residual tumors had faster rates of subsequent regrowth than small (odds ratio [OR] = 4.22, 95% CI 1.19–14.97; p = 0.026) or radiologically absent (OR = 11.00, 95% CI 2.79–43.43; p = 0.001) residual tumors, and a faster regrowth rate was significantly associated with decreased survival (HR = 4.01, 95% CI 2.26–7.14; p < 0.001). Conclusions The overall survival of patients with recurrent glioblastoma who underwent reoperations increased with decreasing postoperative residual tumor volumes. For patients meeting prognostic criteria for reoperation, the surgical goal should be to minimize residual tumor volume to maximize overall survival. Clinical trial registration no.: NCT00060541 (ClinicalTrials.gov).

Original Article: http://thejns.org/doi/abs/10.3171/2014.6.JNS132038?ai=ru&mi=0&af=R

Is the absolute value of O6-methylguanine-DNA methyltransferase gene messenger RNA a prognostic factor, and does it predict the results of treatment of glioblastoma with temozolomide?

Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 121, Issue 4, Page 818-826, October 2014.
Object Methylation of O6-methylguanine-DNA methyltransferase (MGMT) has been reported to be a good prognostic factor for patients with glioblastoma multiforme (GBM). To determine whether the absolute value of MGMT messenger RNA (mRNA) might be a prognostic factor and useful for predicting the therapeutic effectiveness of temozolomide, especially with regard to GBMs, the authors measured the absolute value of MGMT mRNA in gliomas by using real-time reverse-transcription polymerase chain reaction (RT-PCR). Methods MGMT mRNA was measured in 140 newly diagnosed gliomas by real-time RT-PCR using the Taq-Man probe. Among 73 GBMs, 45 had been initially treated with temozolomide and radiation. Results The mean MGMT mRNA value was significantly lower in oligodendroglial tumors than in other tumors. In the 73 GBMs, a significant prognostic factor for progression-free survival was fewer than 1000 copies/ μgRNA of MGMT mRNA (p = 0.0150). Of 45 patients with GBMs that had been treated with temozolomide and radiation, progression-free survival was significantly longer for those whose GMB had fewer than 1000 copies/μgRNA of MGMT mRNA than for those whose GBM had more than 1000 copies/μgRNA (p = 0.0090). In 32 patients with GBMs treated by temozolomide and radiation whose age was younger than 75 years and whose Karnofsky Performance Scale score was more than 70, progression-free and overall survival times were longer for those with GBMs of fewer than 5000 copies/μgRNA of MGMT mRNA than for those with GBMs of more than 5000 copies/μgRNA (p = 0.0365 and p = 0.0312). Conclusions MGMT mRNA might be useful as a prognostic factor and for predicting the results of therapy for GBMs treated by temozolomide. New individual adjuvant therapy based on the results of MGMT mRNA quantitation has been proposed.

Original Article: http://thejns.org/doi/abs/10.3171/2014.6.JNS132535?ai=ru&mi=0&af=R

Awake craniotomy for gliomas in a high-field intraoperative magnetic resonance imaging suite: analysis of 42 cases

Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 121, Issue 4, Page 810-817, October 2014.
Object The object of this study was to describe the experience of combining awake craniotomy techniques with high-field (1.5 T) intraoperative MRI (iMRI) for tumors adjacent to eloquent cortex. Methods From a prospective database the authors obtained and evaluated the records of all patients who had undergone awake craniotomy procedures with cortical and subcortical mapping in the iMRI suite. The integration of these two modalities was assessed with respect to safety, operative times, workflow, extent of resection (EOR), and neurological outcome. Results Between February 2010 and December 2011, 42 awake craniotomy procedures using iMRI were performed in 41 patients for the removal of intraaxial tumors. There were 31 left-sided and 11 right-sided tumors. In half of the cases (21 [50%] of 42), the patient was kept awake for both motor and speech mapping. The mean duration of surgery overall was 7.3 hours (range 4.0–13.9 hours). The median EOR overall was 90%, and gross-total resection (EOR ≥ 95%) was achieved in 17 cases (40.5%). After viewing the first MR images after initial resection, further resection was performed in 17 cases (40.5%); the mean EOR in these cases increased from 56% to 67% after further resection. No deficits were observed preoperatively in 33 cases (78.5%), and worsening neurological deficits were noted immediately after surgery in 11 cases (26.2%). At 1 month after surgery, however, worsened neurological function was observed in only 1 case (2.3%). Conclusions There was a learning curve with regard to patient positioning and setup times, although it did not adversely affect patient outcomes. Awake craniotomy can be safely performed in a high-field (1.5 T) iMRI suite to maximize tumor resection in eloquent brain areas with an acceptable morbidity profile at 1 month.

Original Article: http://thejns.org/doi/abs/10.3171/2014.6.JNS132285?ai=ru&mi=0&af=R

Survival after surgery and stereotactic radiosurgery for patients with multiple intracranial metastases: results of a single-center retrospective study

Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 121, Issue 4, Page 839-845, October 2014.
Object Patients with systemic cancer and a single brain metastasis who undergo treatment with resection plus radiotherapy live longer and have a better quality of life than those treated with radiotherapy alone. Historically, whole-brain radiotherapy (WBRT) has been the mainstay of radiation therapy; however, it is associated with significant delayed neurocognitive sequelae. In this study, the authors looked at survival in patients with single and multiple intracranial metastases who had undergone surgery and adjuvant stereotactic radiosurgery (SRS) to the tumor bed and synchronous lesions. Methods The authors retrospectively reviewed the records from an 8-year period at a single institution for consecutive patients with brain metastases treated via complete resection of dominant lesions and adjuvant radiosurgery. The cohort was analyzed for time to local progression, synchronous lesion progression, new intracranial lesion development, systemic progression, and overall survival. The Kaplan-Meier method (stratified by age, sex, tumor histology, and number of intracranial lesions prior to surgery) was used to calculate both progression-free and overall survival. A Cox proportional-hazards regression model was also fitted with the number of intracranial lesions as the predictor and survival as the outcome controlling for disease severity, age, sex, and primary histology. Results The median overall follow-up among the 150-person cohort eligible for analysis was 17 months. Patients had an average age of 46.2 years (range 16–82 years), and 62.7% were female. The mean (± standard deviation) number of intracranial lesions per patient was 2.5 ± 2.3. The mean time between surgery and stereotactic radiosurgery (SRS) was 3.2 ± 4.1 weeks. Primary cancers included lung cancer (43.3%), breast cancer (21.3%), melanoma (10.0%), renal cell carcinoma (6.7%), and colon cancer (6.7%). The average number of isocenters per treated lesion was 7.6 ± 6.6, and the average treatment dose was 17.8 ± 2.8 Gy. One-year survival for patients in this cohort was 52%, and the 1-year local control rate was 77%. The median (±standard error) overall survival was 13.2 ± 1.9 months. There was no difference in survival between patients with a single lesion and those with multiple lesions (p = 0.319) after controlling for age, sex, and histology of primary tumor. Patients with primary breast histology had the greatest overall median survival (22.9 ± 6.2 months); patients with colorectal cancer had the shortest overall median survival (5.3 ± 1.8 months). The most common cause of death in this series was systemic progression (79%). Conclusions These results confirm that 1-year survival for patients with multiple intracranial metastases treated with resection followed by SRS to both the tumor bed and synchronous lesions is similar to established outcomes for patients with a single intracranial metastasis.

Original Article: http://thejns.org/doi/abs/10.3171/2014.4.JNS13789?ai=ru&mi=0&af=R

Recurrence after gross-total resection of low-grade pediatric brain tumors: the frequency and timing of postoperative imaging

Journal of Neurosurgery: Journal of Neurosurgery: Pediatrics: Table of Contents

Journal of Neurosurgery: Pediatrics, Volume 14, Issue 4, Page 356-364, October 2014.
Object Low-grade glial and glioneuronal brain tumors are frequently encountered in the pediatric population and can be effectively treated by resection. The authors aimed to use imaging to evaluate how often tumors recurred and to determine if recurrences were associated with any clinical symptoms, along with the financial costs of imaging, in patients with radiographically proven gross-total resection (GTR) at Boston Children's Hospital. These data were assessed to propose guidelines regarding postoperative surveillance. Methods The authors performed a retrospective cohort analysis of the Pediatric Brain Tumor Program database from 1993 to 2003 to identify patients with glial or glioneuronal tumors initially evaluated at Boston Children's Hospital. Among the 888 patients evaluated for any type of brain tumor during this period, 67 patients had WHO Grade I glial or glioneuronal lesions with radiographically proven GTR and available follow-up data. The frequency and timing of postoperative imaging was compared with the institutional protocol. Recurrence-free survival was calculated using the Kaplan-Meier method. Financial costs of imaging were available from 2001 to 2009 and were averaged to extrapolate the postoperative surveillance costs. Results Among the 67 patients with GTR, 13 recurrences were detected radiographically with a mean time to recurrence of 32.4 months (range 2.9–128.5 months). The mean duration of follow-up after surgery was 6.6 years. The recurrence-free survival at 2 and 5 years after GTR for all low-grade glial and glioneuronal tumors was 0.90 (95% CI 0.82–0.97) and 0.82 (95% CI 0.73–0.92), respectively. No clinical symptoms were associated with any of the recurrences, and no deaths occurred. Under the institutional protocol of surveillance imaging, the estimated cost per recurrence at 5 years was $104,094 per patient. The proposed protocol would reduce the number of MR scans in the first 5 years from 10 to 5, providing a potential cost savings of $52,047 per recurrence. Conclusions Given the slow-growing, clinically asymptomatic nature of low-grade glial and glioneuronal tumors coupled with the financial and psychological costs of repeated imaging, the authors propose a postoperative surveillance MRI schedule that is less intensive than current institutional practice.

Original Article: http://thejns.org/doi/abs/10.3171/2014.6.PEDS1321?ai=3f6&mi=3ba5z2&af=R

Brain metastases in patients diagnosed with a solid primary cancer during childhood: experience from a single referral cancer center

Journal of Neurosurgery: Journal of Neurosurgery: Pediatrics: Table of Contents

Journal of Neurosurgery: Pediatrics, Volume 14, Issue 4, Page 372-385, October 2014.
Object Metastasis to the brain is frequent in adult cancer patients but rare among children. Advances in primary tumor treatment and the associated prolonged survival are said to have increased the frequency of brain metastasis in children. The authors present a series of cases of brain metastases in children diagnosed with a solid primary cancer, evaluate brain metastasis trends, and describe tumor type, patterns of occurrence, and prognosis. Methods Patients with brain metastases whose primary cancer was diagnosed during childhood were identified in the 1990–2012 Tumor Registry at The University of Texas M.D. Anderson Cancer Center. A review of their hospital records provided demographic data, history, and clinical data, including primary cancer sites, number and location of brain metastases, sites of extracranial metastases, treatments, and outcomes. Results Fifty-four pediatric patients (1.4%) had a brain metastasis from a solid primary tumor. Sarcomas were the most common (54%), followed by melanoma (15%). The patients' median ages at diagnosis of the primary cancer and the brain metastasis were 11.37 years and 15.03 years, respectively. The primary cancer was localized at diagnosis in 48% of patients and disseminated regionally in only 14%. The primary tumor and brain metastasis presented synchronously in 15% of patients, and other extracranial metastases were present when the primary cancer was diagnosed. The remaining patients were diagnosed with brain metastasis after initiation of primary cancer treatment, with a median presentation interval of 17 months after primary cancer diagnosis (range 2–77 months). At the time of diagnosis, the brain metastasis was the first site of systemic metastasis in only 4 (8%) of the 51 patients for whom data were available. Up to 70% of patients had lung metastases when brain metastases were found. Symptoms led to the brain metastasis diagnosis in 65% of cases. Brain metastases were single in 60% of cases and multiple in 35%; 6% had only leptomeningeal disease. The median Kaplan-Meier estimates of survival after diagnoses of primary cancer and brain metastasis were 29 months (95% CI 24–34 months) and 9 months (95% CI 6–11 months), respectively. Untreated patients survived for a median of 0.9 months after brain metastasis diagnosis (95% CI 0.3–1.5 months). Those receiving treatment survived for a median of 8 months after initiation of therapy (95% CI 6–11 months). Conclusions The results of this study challenge the current notion of an increased incidence of brain metastases among children with a solid primary cancer. The earlier diagnosis of the primary cancer, prior to its dissemination to distant sites (especially the brain), and initiation of presumably more effective treatments may support such an observation. However, although the actual number of cases may not be increasing, the prognosis after the diagnosis of a brain metastasis remains poor regardless of the management strategy.

Original Article: http://thejns.org/doi/abs/10.3171/2014.7.PEDS13318?ai=3f6&mi=3ba5z2&af=R

Novel therapeutic strategies show promise for treating glioblastma multiforme

Neurology News & Neuroscience News from Medical News Today

Glioblastma multiforme (GBM) is one of the most lethal primary brain tumors, with median survival for these patients only slightly over one year.

Original Article: http://www.medicalnewstoday.com/releases/283388.php

Tuesday, September 30, 2014

Stereotactic radiosurgery alone for small cell lung cancer: a neurocognitive benefit?

Radiation Oncology

Yomo and Hayashi reported results of stereotactic radiosurgery alone for brain metastases from small cell lung cancer. This strategy aims to avoid the neurocognitive effects of whole-brain radiation therapy. However, radiosurgery alone increases the risk of distant intracranial relapse, which can independently worsen cognition. This concern is heightened in histologies like small cell with high predilection for intracranial spread. The majority of study patients developed new brain disease, suggesting radiosurgery alone may not be an optimal strategy for preserving neurocognitive function in this population. We suggest whole-brain radiation therapy should remain the standard of care for small cell lung cancer.

Original Article: http://www.ro-journal.com/content/9/1/218

Monday, September 29, 2014

Pearls & Oy-sters: Anorexia and emaciation in patients with cerebellar hemangioblastoma

Neurology current issue

Anorexia and emaciation result from various conditions, including digestive diseases, metabolic disorders, chronic inflammation, chronic infections, malignancies, and psychiatric problems. Intracranial tumors can also cause a reduction in food intake, thus mimicking anorexia nervosa, through various mechanisms. Fourth ventricular tumors, particularly hemangioblastomas, can cause prolonged appetite loss and extreme body weight loss, without any apparent focal neurologic deficits.

Original Article: http://www.neurology.org/cgi/content/short/83/14/1298?rss=1

Neuro-Oncology

Monday, October 6, 2014

Endoscopic supraorbital eyebrow approach for the surgical treatment of extraaxialand intraaxial tumors

Residual tumor volume and patient survival following reoperation for recurrent glioblastoma

Is the absolute value of O6-methylguanine-DNA methyltransferase gene messenger RNA a prognostic factor, and does it predict the results of treatment of glioblastoma with temozolomide?

Awake craniotomy for gliomas in a high-field intraoperative magnetic resonance imaging suite: analysis of 42 cases

Survival after surgery and stereotactic radiosurgery for patients with multiple intracranial metastases: results of a single-center retrospective study

Recurrence after gross-total resection of low-grade pediatric brain tumors: the frequency and timing of postoperative imaging

Brain metastases in patients diagnosed with a solid primary cancer during childhood: experience from a single referral cancer center

Novel therapeutic strategies show promise for treating glioblastma multiforme

Tuesday, September 30, 2014

Stereotactic radiosurgery alone for small cell lung cancer: a neurocognitive benefit?

Monday, September 29, 2014

Pearls & Oy-sters: Anorexia and emaciation in patients with cerebellar hemangioblastoma

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