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Mirian C, Jensen LR, Juratli TA, Maier AD, Torp SH, Shih HA, Morshed RA, Young JS, Magill ST, Bertero L, Stummer W, Spille DC, Brokinkel B, Oya S, Miyawaki S, Saito N, Proescholdt M, Kuroi Y, Gousias K, Simon M, Moliterno J, Prat-Acin R, Goutagny S, Prabhu VC, Tsiang JT, Wach J, Güresir E, Yamamoto J, Kim YZ, Lee JH, Koshy M, Perumal K, Baskaya MK, Cannon DM, Shrieve DC, Suh CO, Chang JH, Kamenova M, Straumann S, Soleman J, Eyüpoglu IY, Catalan T, Lui A, Theodosopoulos PV, McDermott MW, Wang F, Guo F, Góes P, de Paiva Neto MA, Jamshidi A, Komotar R, Ivan M, Luther E, Souhami L, Guiot MC, Csonka T, Endo T, Barrett OC, Jensen R, Gupta T, Patel AJ, Klisch TJ, Kim JW, Maiuri F, Barresi V, Tabernero MD, Skyrman S, Broechner A, Bach MJ, Law I, Scheie D, Kristensen BW, Munch TN, Meling T, Fugleholm K, Blanche P, Mathiesen T. The importance of considering competing risks in recurrence analysis of intracranial meningioma. J Neurooncol 2024; 166:503-511. [PMID: 38336917 PMCID: PMC10876814 DOI: 10.1007/s11060-024-04572-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 01/11/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND The risk of recurrence is overestimated by the Kaplan-Meier method when competing events, such as death without recurrence, are present. Such overestimation can be avoided by using the Aalen-Johansen method, which is a direct extension of Kaplan-Meier that accounts for competing events. Meningiomas commonly occur in older individuals and have slow-growing properties, thereby warranting competing risk analysis. The extent to which competing events are considered in meningioma literature is unknown, and the consequences of using incorrect methodologies in meningioma recurrence risk analysis have not been investigated. METHODS We surveyed articles indexed on PubMed since 2020 to assess the usage of competing risk analysis in recent meningioma literature. To compare recurrence risk estimates obtained through Kaplan-Meier and Aalen-Johansen methods, we applied our international database comprising ~ 8,000 patients with a primary meningioma collected from 42 institutions. RESULTS Of 513 articles, 169 were eligible for full-text screening. There were 6,537 eligible cases from our PERNS database. The discrepancy between the results obtained by Kaplan-Meier and Aalen-Johansen was negligible among low-grade lesions and younger individuals. The discrepancy increased substantially in the patient groups associated with higher rates of competing events (older patients with high-grade lesions). CONCLUSION The importance of considering competing events in recurrence risk analysis is poorly recognized as only 6% of the studies we surveyed employed Aalen-Johansen analyses. Consequently, most of the previous literature has overestimated the risk of recurrence. The overestimation was negligible for studies involving low-grade lesions in younger individuals; however, overestimation might have been substantial for studies on high-grade lesions.
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Affiliation(s)
- Christian Mirian
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Lasse Rehné Jensen
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tareq A Juratli
- Department of Neurosurgery, Division of Neuro-Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307, Dresden, Germany
- Department of Neurosurgery, Laboratory of Translational Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, USA
| | - Andrea Daniela Maier
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Pathology, Bartholin Institute, Rigshospitalet, Copenhagen University Hospital , Copenhagen, Denmark
| | - Sverre H Torp
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian, University of Science and Technology (NTNU), Laboratory Centre, St. Olavs Hospital, NO-7491, Trondheim, Norway
- Department of Pathology, Laboratory Centre, St. Olavs Hospital, NO-7030, Trondheim, Norway
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Jacob S Young
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Stephen T Magill
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Illinois, USA
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University and Città Della Salute E Della Scienza University Hospital of Turin, Turin, Italy
| | - Walter Stummer
- Department of Neurosurgery, University of Münster, Münster, Germany
| | | | - Benjamin Brokinkel
- Department of Neurosurgery, University of Münster, Münster, Germany
- Institute for Neuropathology, University of Münster, Münster, Germany
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center/University, Saitama, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Martin Proescholdt
- Department of Neurosurgery, University Regensburg Medical Center, Regensburg, Germany
| | - Yasuhiro Kuroi
- Department of Neurosurgery, Adachi Medical Center, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Matthias Simon
- Department of Neurosurgery, Bethel Clinic University of Bielefeld Medical Center, Bielefeld, Germany
| | - Jennifer Moliterno
- Department of Neurosurgery, Yale School of Medicine Yale New Haven Hospital, Smilow Cancer Hospital, New Haven, USA
| | | | - Stéphane Goutagny
- Department of Neurosurgery, Université Paris Cité, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Vikram C Prabhu
- Department of Neurological Surgery, Loyola University Medical Center, Stritch School of Medicine, Illinois, USA
| | - John T Tsiang
- Department of Neurological Surgery, Loyola University Medical Center, Stritch School of Medicine, Illinois, USA
| | - Johannes Wach
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Junkoh Yamamoto
- Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Young Zoon Kim
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Joo Ho Lee
- Department of Radiation Oncology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Matthew Koshy
- Department of Radiation Oncology, University of Illinois Hospital and Health Sciences System, Illinois, USA
| | - Karthikeyan Perumal
- Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mustafa K Baskaya
- Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Donald M Cannon
- Department of Radiation Oncology Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Dennis C Shrieve
- Department of Radiation Oncology Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Maria Kamenova
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Sven Straumann
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Ilker Y Eyüpoglu
- Department of Neurosurgery, Division of Neuro-Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307, Dresden, Germany
| | - Tony Catalan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Austin Lui
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Michael W McDermott
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Division of Neurosurgery, Miami Neuroscience Institute, Miami, FL, USA
| | - Fang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Pedro Góes
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | | | - Aria Jamshidi
- Department of Neurological Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Ricardo Komotar
- Department of Neurological Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Michael Ivan
- Department of Neurological Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Evan Luther
- Department of Neurological Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Luis Souhami
- Division of Radiation Oncology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | | | - Tamás Csonka
- Department of Pathology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Toshiki Endo
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University, Tohoku, Japan
| | | | - Randy Jensen
- Department of Neurosurgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Tejpal Gupta
- Department of Radiation Oncology ACTREC, Tata Memorial Centre, HBNI Kharghar, Navi Mumbai, 410210, India
| | - Akash J Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX , USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, TX , USA
| | - Tiemo J Klisch
- Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, TX , USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Francesco Maiuri
- Department of Neurosurgery, University of Naples Federico II, Naples, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - María Dolores Tabernero
- Instituto de Investigación Biomédica de Salamanca (IBSAL), University Hospital of Salamanca, Salamanca, Spain
| | - Simon Skyrman
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anders Broechner
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Ian Law
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - David Scheie
- Department of Pathology, Bartholin Institute, Rigshospitalet, Copenhagen University Hospital , Copenhagen, Denmark
| | - Bjarne Winther Kristensen
- Department of Pathology, Bartholin Institute, Rigshospitalet, Copenhagen University Hospital , Copenhagen, Denmark
- Department of Clinical Medicine and Biotech Research and Innovation Center (BRIC), University of Copenhagen, Copenhagen, Denmark
| | - Tina Nørgaard Munch
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Torstein Meling
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Neurological Surgery, Istituto Nazionale Neurologico "C.Besta", Milan, Italy
| | - Kåre Fugleholm
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Paul Blanche
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Tiit Mathiesen
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Harms JWA, Streckert EMS, Kiolbassa NM, Thomas C, Grauer O, Oertel M, Eich HT, Stummer W, Paulus W, Brokinkel B. Confounders of intraoperative frozen section pathology during glioma surgery. Neurosurg Rev 2023; 46:286. [PMID: 37891361 DOI: 10.1007/s10143-023-02169-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/31/2023] [Accepted: 09/24/2023] [Indexed: 10/29/2023]
Abstract
Although frozen section pathology (FSP) is commonly performed during surgery for glioma-suspicious lesions, confounders of accuracy are largely unknown. FSP and final diagnosis were compared in 398 surgeries for glioma-suspicious lesions. Diagnostic accuracy, risk factors for diagnostic shift from neoplastic to non-neoplastic tissue and vice versa according to the final diagnosis, and the impact on intraoperative and postoperative decision-making were analyzed. Diagnostic shift occurred in 70 cases (18%), and sensitivity, specificity, and the positive (PPV) and negative (NPV) predictive value of FSP were 82.5%, 77.8%, 99.4%, and 9.3%, respectively. No correlations between shift and patients' age and sex, sample fluorescence or volume, tumor location, correct information on the pathology form, final high- or low-grade histology, or molecular alterations were found (p > .05, each). Shift was more common after irradiation (25% vs 15%; p = .025) or chemotherapy (26% vs 15%; p = .022) than in treatment naïve cases and correlated with the type of surgery (p = .002). FSP altered intraoperative decision-making in 25 cases (6%). Postoperative shift led to repeated surgery in 12 patients (3%). In 45 cases, in which FSP and final diagnosis based on the same tissue, shift occurred in only 5 patients (11%), and sensitivity, specificity, PPV, and NPV for FSP were 77.4%, 78.6%, 88.9%, and 61.1%, respectively. No correlations between diagnostic shift and any of the analyzed variables were found (p > .05, each). Although accuracy of FSP during glioma surgery is sufficient, moderate NPV should be considered during intraoperative decision-making. While confounders are sparse, accuracy might be increased by repeated sampling. Diagnostic shift rarely alters postoperative treatment strategy.
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Affiliation(s)
| | | | | | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Oliver Grauer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Michael Oertel
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.
- Institute of Neuropathology, University Hospital Münster, Münster, Germany.
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3
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Akkurt BH, Spille DC, Peetz-Dienhart S, Kiolbassa NM, Mawrin C, Musigmann M, Heindel WL, Paulus W, Stummer W, Mannil M, Brokinkel B. Radiomics-Based Prediction of TERT Promotor Mutations in Intracranial High-Grade Meningiomas. Cancers (Basel) 2023; 15:4415. [PMID: 37686690 PMCID: PMC10486806 DOI: 10.3390/cancers15174415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE In meningiomas, TERT promotor mutations are rare but qualify the diagnosis of anaplasia, directly impacting adjuvant therapy. Effective screening for patients at risk for promotor mutations could enable more targeted molecular analyses and improve diagnosis and treatment. METHODS Semiautomatic segmentation of intracranial grade 2/3 meningiomas was performed on preoperative magnetic resonance imaging. Discriminatory power to predict TERT promoter mutations was analyzed using a random forest algorithm with an increasing number of radiomic features. Two final models with five and eight features with both fixed and differing radiomics features were developed and adjusted to eliminate random effects and to avoid overfitting. RESULTS A total of 117 image sets including training (N = 94) and test data (N = 23) were analyzed. To eliminate random effects and demonstrate the robustness of our approach, data partitioning and subsequent model development and testing were repeated a total of 100 times (each time with repartitioned training and independent test data). The established five- and eight-feature models with both fixed and different radiomics features enabled the prediction of TERT with similar but excellent performance. The five-feature (different/fixed) model predicted TERT promotor mutation status with a mean AUC of 91.8%/94.3%, mean accuracy of 85.5%/88.9%, mean sensitivity of 88.6%/91.4%, mean specificity of 83.2%/87.0%, and a mean Cohen's Kappa of 71.0%/77.7%. The eight-feature (different/fixed) model predicted TERT promotor mutation status with a mean AUC of 92.7%/94.6%, mean accuracy of 87.3%/88.9%, mean sensitivity of 89.6%/90.6%, mean specificity of 85.5%/87.5%, and a mean Cohen's Kappa of 74.4%/77.6%. Of note, the addition of further features of up to N = 8 only slightly increased the performance. CONCLUSIONS Radiomics-based machine learning enables prediction of TERT promotor mutation status in meningiomas with excellent discriminatory performance. Future analyses in larger cohorts should include grade 1 lesions as well as additional molecular alterations.
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Affiliation(s)
- Burak Han Akkurt
- Department of Radiology, University Hospital Muenster, DE-48149 Muenster, Germany (M.M.)
| | | | - Susanne Peetz-Dienhart
- Institute of Neuropathology, University Hospital Muenster, DE-48149 Muenster, Germany (W.P.)
| | - Nora Maren Kiolbassa
- Department of Neurosurgery, University Hospital Muenster, DE-48149 Muenster, Germany
| | - Christian Mawrin
- Department of Neuropathology, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Manfred Musigmann
- Department of Radiology, University Hospital Muenster, DE-48149 Muenster, Germany (M.M.)
| | | | - Werner Paulus
- Institute of Neuropathology, University Hospital Muenster, DE-48149 Muenster, Germany (W.P.)
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Muenster, DE-48149 Muenster, Germany
| | - Manoj Mannil
- Department of Radiology, University Hospital Muenster, DE-48149 Muenster, Germany (M.M.)
- Institute for Diagnostic and Interventional Radiology, Caritas-Hospital, DE-97980 Bad Mergentheim, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Muenster, DE-48149 Muenster, Germany
- Institute of Neuropathology, University Hospital Muenster, DE-48149 Muenster, Germany (W.P.)
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4
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Spille DC, Thomas C, Wagner A, Grauer OM, Canisius J, Bunk EC, Stummer W, Eich HT, Paulus W, Senner V, Brokinkel B. Molecular predictors for decitabine efficacy in meningiomas - a pilot study. J Neurooncol 2023; 164:97-105. [PMID: 37477823 DOI: 10.1007/s11060-023-04379-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE Effective chemotherapeutical agents for the treatment of meningiomas are still lacking. Previous in-vitro analyses revealed efficacy of decitabine (DCT), a DNA methyltransferase (DNMT) inhibitor established in the treatment of leukemia, in a yet undefined subgroup of meningiomas. METHODS Effects of DCT on proliferation and viability was analyzed in primary meningioma cells by immunofluorescence and MTT assays, and cases were classified as drug responders and non-responders. Molecular preconditions for efficacy were analyzed using immunofluorescence for Ki67, DNMT1, and five oncogenes (TRIM58, FAM84B, ELOVL2, MAL2, LMO3) previously found to be differentially methylated after DCT exposition, as well as by genome-wide DNA methylation analyses. RESULTS Efficacy of DCT (10µM) was found in eight (62%) of 13 meningioma cell lines 48 h after drug exposition (p < .05). DCT significantly reduced DNMT1 expression in all but two cell lines, and median ΔDNMT1 reduction 48 h after drug exposition was lower in DCT-resistant (-11.1%) than in DCT-sensitive (-50.5%, p = .030) cells. Rates of cell lines responsive to DCT exposition distinctly decreased to 25% after 72 h. No significant correlation of the patients´ age, sex, histological subtype, location of the paternal tumor, expression of Ki67, DNMT1 or the analyzed oncogenes with treatment response was found (p > .05, each). DCT efficacy was further independent of the methylation class and global DNA methylation of the paternal tumor. CONCLUSION Early effects of DCT in meningiomas are strongly related with DNMT1 expression, while clinical, histological, and molecular predictors for efficacy are sparse. Kinetics of drug efficacy might indicate necessity of repeated exposition and encourage further analyses.
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Affiliation(s)
- Dorothee C Spille
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine-Westphalia, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine-Westphalia, Germany
| | - Andrea Wagner
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine-Westphalia, Germany
| | - Oliver Martin Grauer
- Department of Neurology, University of Münster, Münster, North Rhine-Westphalia, Germany
| | - Julian Canisius
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine-Westphalia, Germany
| | - Eva Christine Bunk
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine-Westphalia, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine-Westphalia, Germany
| | - Hans T Eich
- Department of Radiation Oncology, University Hospital Münster, Münster, North Rhine-Westphalia, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine-Westphalia, Germany
| | - Volker Senner
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine-Westphalia, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine-Westphalia, Germany.
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine-Westphalia, Germany.
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5
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Kopf L, Warneke N, Grauer O, Thomas C, Hess K, Schwake M, Mannil M, Akkurt BH, Paulus W, Stummer W, Brokinkel B, Spille DC. Prognosis and histology of sporadic synchronous and metachronous meningiomas and comparative analyses with singular lesions. Neurosurg Rev 2023; 46:55. [PMID: 36781550 PMCID: PMC9925510 DOI: 10.1007/s10143-023-01958-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/27/2022] [Accepted: 01/26/2023] [Indexed: 02/15/2023]
Abstract
Synchronous or metachronous growth of multiple tumors (≥ 2) is found in up to 20% of meningioma patients. However, biological as well as histological features and prognosis are largely unexplored. Clinical and histological characteristics were retrospectively investigated in 95 patients harboring 226 multiple meningiomas (MMs) and compared with 135 cases of singular meningiomas (SM) using uni- and multivariate analyses. In MM, tumors occurred synchronously and metachronously in 62% and 38%, respectively. WHO grade was intra-individually constant in all but two MMs, and histological subtype varied in 13% of grade 1 tumors. MM occurred more commonly in convexity/parasagittal locations, while SM were more frequent at the skull base (p < .001). In univariate analyses, gross total resection (p = .014) and high-grade histology in MM were associated with a prolonged time to progression (p < .001). Most clinical characteristics and rates of high-grade histology were similar in both groups (p ≥ .05, each). Multivariate analyses showed synchronous/metachronous meningioma growth (HR 4.50, 95% CI 2.26-8.96; p < .001) as an independent predictor for progression. Compared to SM, risk of progression was similar in cases with two (HR 1.56, 95% CI .76-3.19; p = .224), but exponentially raised in patients with 3-4 (HR 3.25, 1.22-1.62; p = .018) and ≥ 5 tumors (HR 13.80, 4.06-46.96; p < .001). Clinical and histological characteristics and risk factors for progression do not relevantly differ between SM and MM. Although largely constant, histology and WHO grade occasionally intra-individually vary in MM. A distinctly higher risk of disease progression in MM as compared to SM might reflect different underlying molecular alterations.
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Affiliation(s)
- Lisa Kopf
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Oliver Grauer
- Department of Neurology, University of Münster, Münster, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
- Department of Pathology, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Michael Schwake
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Manoj Mannil
- Clinic for Radiology, University Hospital Münster, Münster, Germany
| | - Burak Han Akkurt
- Clinic for Radiology, University Hospital Münster, Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Dorothee Cäcilia Spille
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
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6
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Muruato-Araiza F, Oekenpöhler S, Wagner NM, Förster P, Warneke N, Holling M, Mannil M, Grauer OM, Stummer W, Brokinkel B. Iatrogenic lumbosacral infiltration with petroleum (hydrodesulfurized heavy) with secondary intrathecal distribution-a case report. Acta Neurochir (Wien) 2023; 165:1141-1144. [PMID: 36735094 PMCID: PMC10140093 DOI: 10.1007/s00701-023-05505-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/18/2023] [Indexed: 02/04/2023]
Abstract
Petroleum is commonly used as a solvent, and primary intrathecal administration or secondary diffusion and subsequent clinical management has not been reported. We report the case of a male patient with intrathecal petroleum diffusion following accidental lumbar infiltration. After the onset of secondary myeloencephalopathy with coma and tetraparesis, continuous cranio-lumbar irrigation using an external ventricular and a lumbar drain was established. Cranial imaging revealed distinct supra- and infratentorial alterations. The patient improved slowly and was referred to rehabilitation. Intrathecal petroleum leads to myeloencephalopathy and continuous cranio-lumbar irrigation might be a safe treatment option.
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Affiliation(s)
- Fernando Muruato-Araiza
- Department of Neurosurgery, University Hospital Münster, North Rhine-Westphalia, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Simon Oekenpöhler
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Münster, North Rhine-Westphalia, Münster, Germany
| | - Nana-Maria Wagner
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, North Rhine-Westphalia, Münster, Germany
| | - Petra Förster
- Poison Center Bonn, Children's University Hospital, North Rhine-Westphalia, Bonn, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital Münster, North Rhine-Westphalia, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, North Rhine-Westphalia, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Manoj Mannil
- Institute for Clinical Radiology, University Hospital Münster, North Rhine-Westphalia, Münster, Germany
| | - Oliver Martin Grauer
- Department of Neurology, University of Münster, North Rhine-Westphalia, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, North Rhine-Westphalia, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, North Rhine-Westphalia, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.
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Hinrichs FL, Brokinkel C, Adeli A, Sporns PB, Hess K, Paulus W, Stummer W, Grauer O, Spille DC, Brokinkel B. Risk factors for preoperative seizures in intracranial meningiomas. J Neurosurg Sci 2023; 67:66-72. [PMID: 33056948 DOI: 10.23736/s0390-5616.20.05068-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND About 25% of patients with intracranial meningioma display seizures at the time of initial presentation. Hence, identification of risk factors for preoperative seizures is crucial during perioperative care of meningioma patients. METHODS Associations of preoperative seizures with clinical, radiological and histological variables were analyzed in 945 patients (689 females, 73% and 256 males, 27%; median age: 58 years) who underwent surgery for primary diagnosed intracranial meningioma. RESULTS Preoperative seizures were found in 189 patients (20%). In univariate analyses, male gender (OR=1.91, 95% CI: 1.37-2.68; P<0.001), grade II/III histology (OR=2.24, 95% CI: 1.46-3.46; P<0.001), brain invasion (OR=2.59, 95% CI: 1.45-4.63; P=001), non-skull base tumor location (OR=3.07, 95% CI: 2.13-4.41; P<0.001), heterogeneous contrast-enhancement (OR=1.60, 95% CI: 1.04-2.46; P=0.031), intratumoral calcifications (OR=1.91, 95% CI: 1.17-3.10; P=0.009), an irregular shape (OR=2.07, 95% CI: 1.32-3.26; P=0.002) as well as tumor (OR=1.01 per ccm, 95% CI: 1.00-1.02; P=0.001) and edema volumes (OR=1.01 per ccm, 95% CI: 1.00-1.01; P<0.001) were correlated with seizures. Semiology was not related to any of the analyzed variables (P>0.05, each). No associations were found between seizures and histological subtype of 832 grade I meningiomas (P=0.391). In multivariate analyses, only non-skull base tumor location (OR=3.12, 95% CI: 1.74-5.59; P<0.001) and a rising peritumoral edema volume (OR=1.01 per ccm, 95% CI: 1.00-1.01; P<0.001) were identified as independent predictors for preoperative seizures. CONCLUSIONS Several mostly radiological variables were identified as risk factors for epilepsy. However, multivariate analyses confirmed only peritumoral edema and non-skull base tumor location as independent predictors for preoperative seizures. None of the variables predicts semiology.
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Affiliation(s)
- Fynn L Hinrichs
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Caroline Brokinkel
- Department of Clinical Radiology, University of Münster, Münster, Germany
| | - Alborz Adeli
- Department of Clinical Radiology, University of Münster, Münster, Germany
| | - Peter B Sporns
- Department of Clinical Radiology, University of Münster, Münster, Germany.,Department of Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital of Münster, Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital of Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Oliver Grauer
- Department of Neurology, Institute for Translational Neurology, University Hospital of Münster, Münster, Germany
| | - Dorothee C Spille
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany -
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Krähling H, Musigmann M, Akkurt BH, Sartoretti T, Sartoretti E, Henssen DJHA, Stummer W, Heindel W, Brokinkel B, Mannil M. A magnetic resonance imaging based radiomics model to predict mitosis cycles in intracranial meningioma. Sci Rep 2023; 13:969. [PMID: 36653482 PMCID: PMC9849352 DOI: 10.1038/s41598-023-28089-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023] Open
Abstract
The aim of this study was to develop a magnetic resonance imaging (MRI) based radiomics model to predict mitosis cycles in intracranial meningioma grading prior to surgery. Preoperative contrast-enhanced T1-weighted (T1CE) cerebral MRI data of 167 meningioma patients between 2015 and 2020 were obtained, preprocessed and segmented using the 3D Slicer software and the PyRadiomics plugin. In total 145 radiomics features of the T1CE MRI images were computed. The criterion on the basis of which the feature selection was made is whether the number of mitoses per 10 high power field (HPF) is greater than or equal to zero. Our analyses show that machine learning algorithms can be used to make accurate predictions about whether the number of mitoses per 10 HPF is greater than or equal to zero. We obtained our best model using Ridge regression for feature pre-selection, followed by stepwise logistic regression for final model construction. Using independent test data, this model resulted in an AUC (Area under the Curve) of 0.8523, an accuracy of 0.7941, a sensitivity of 0.8182, a specificity of 0.7500 and a Cohen's Kappa of 0.5576. We analyzed the performance of this model as a function of the number of mitoses per 10 HPF. The model performs well for cases with zero mitoses as well as for cases with more than one mitosis per 10 HPF. The worst model performance (accuracy = 0.6250) is obtained for cases with one mitosis per 10 HPF. Our results show that MRI-based radiomics may be a promising approach to predict the mitosis cycles in intracranial meningioma prior to surgery. Specifically, our approach may offer a non-invasive means of detecting the early stages of a malignant process in meningiomas prior to the onset of clinical symptoms.
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Affiliation(s)
- Hermann Krähling
- University Clinic for Radiology, University Hospital Muenster, Westfälische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Manfred Musigmann
- University Clinic for Radiology, University Hospital Muenster, Westfälische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Burak Han Akkurt
- University Clinic for Radiology, University Hospital Muenster, Westfälische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | | | | | - Dylan J H A Henssen
- Department of Medical Imaging, Radboud University Medical Center, Radboud University, 6500HB, Nijmegen, The Netherlands
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Muenster, Westfälische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Walter Heindel
- University Clinic for Radiology, University Hospital Muenster, Westfälische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Muenster, Westfälische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Manoj Mannil
- University Clinic for Radiology, University Hospital Muenster, Westfälische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
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Spille DC, Bunk EC, Thomas C, Özdemir Z, Wagner A, Akkurt BH, Mannil M, Paulus W, Grauer OM, Stummer W, Senner V, Brokinkel B. Protoporphyrin IX (PpIX) Fluorescence during Meningioma Surgery: Correlations with Histological Findings and Expression of Heme Pathway Molecules. Cancers (Basel) 2023; 15:cancers15010304. [PMID: 36612300 PMCID: PMC9818642 DOI: 10.3390/cancers15010304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 12/25/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Background: The usefulness of 5-ALA-mediated fluorescence-guided resection (FGR) in meningiomas is controversial, and information on the molecular background of fluorescence is sparse. Methods: Specimens obtained during 44 FGRs of intracranial meningiomas were analyzed for the presence of tumor tissue and fluorescence. Protein/mRNA expression of key transmembrane transporters/enzymes involved in PpIX metabolism (ABCB6, ABCG2, FECH, CPOX) were investigated using immunohistochemistry/qPCR. Results: Intraoperative fluorescence was observed in 70 of 111 specimens (63%). No correlation was found between fluorescence and the WHO grade (p = 0.403). FGR enabled the identification of neoplastic tissue (sensitivity 84%, specificity 67%, positive and negative predictive value of 86% and 63%, respectively, AUC: 0.75, p < 0.001), and was improved in subgroup analyses excluding dura specimens (86%, 88%, 96%, 63% and 0.87, respectively; p < 0.001). No correlation was found between cortical fluorescence and tumor invasion (p = 0.351). Protein expression of ABCB6, ABCG2, FECH and CPOX was found in meningioma tissue and was correlated with fluorescence (p < 0.05, each), whereas this was not confirmed for mRNA expression. Aberrant expression was observed in the CNS. Conclusion: FGR enables the intraoperative identification of meningioma tissue with limitations concerning dura invasion and due to ectopic expression in the CNS. ABCB6, ABCG2, FECH and CPOX are expressed in meningioma tissue and are related to fluorescence.
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Affiliation(s)
- Dorothee C. Spille
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
- Correspondence: ; Tel.: +49251-83-43959/-47472; Fax: +49251-83-45646
| | - Eva C. Bunk
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Zeynep Özdemir
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Andrea Wagner
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Burak H. Akkurt
- Department of Radiology, University Hospital Münster, 48149 Münster, Germany
| | - Manoj Mannil
- Department of Radiology, University Hospital Münster, 48149 Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Oliver M. Grauer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Volker Senner
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
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Spille DC, Lohmann S, Schwake M, Spille J, Alsofy SZ, Stummer W, Brokinkel B, Schipmann S. Can Currently Suggested Quality Indicators Be Transferred to Meningioma Surgery?-A Single-Center Pilot Study. J Neurol Surg A Cent Eur Neurosurg 2022. [PMID: 35901814 DOI: 10.1055/a-1911-8678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Risk stratification based on standardized quality measures has become crucial in neurosurgery. Contemporary quality indicators have often been developed for a wide range of neurosurgical procedures collectively. The accuracy of tumor-inherent characteristics of patients diagnosed with meningioma remains questionable. The objective of this study was the analysis of currently applied quality indicators in meningioma surgery and the identification of potential new measures. METHODS Data of 133 patients who were operated on due to intracranial meningiomas were subjected to a retrospective analysis. The primary outcomes of interest were classical quality indicators such as the 30-day readmission, 30-day reoperation, 30-day mortality, 30-day nosocomial infection, and the 30-day surgical site infection rate. Uni- and multivariate analyses were performed. The occurrence of a new postoperative neurologic deficit was analyzed as a potential new quality indicator. RESULTS The overall unplanned readmission rate was 3.8%; 13 patients were reoperated within 30 days (9.8%). The 30-day nosocomial infection and surgical site infection rates were 6.8 and 1.5%, respectively. A postoperative new neurologic deficit or neurologic deterioration as a currently assessed quality feature was observed in 12 patients (9.2%). The edema volume on preoperative scans proved to have a significant impact on the occurrence of a new postoperative neurologic deficit (p = 0.023). CONCLUSIONS Classical quality indicators in neurosurgery have proved to correlate with considerable deterioration of the patient's health in meningioma surgery and thus should be taken into consideration for application in meningioma patients. The occurrence of a new postoperative neurologic deficit is common and procedure specific. Thus, this should be elucidated for application as a complementary quality indicator in meningioma surgery.
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Affiliation(s)
- Dorothee C Spille
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Sebastian Lohmann
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Michael Schwake
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Johannes Spille
- Department of Oral and Maxillofacial Surgery, Christian Albrechts University, UKSH, Kiel, Germany
| | | | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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Heming M, Haessner S, Wolbert J, Lu IN, Li X, Brokinkel B, Müther M, Holling M, Stummer W, Thomas C, Schulte-Mecklenbeck A, de Faria F, Stoeckius M, Hailfinger S, Lenz G, Kerl K, Wiendl H, Meyer zu Hörste G, Grauer OM. Intratumor heterogeneity and T cell exhaustion in primary CNS lymphoma. Genome Med 2022; 14:109. [PMID: 36153593 PMCID: PMC9509601 DOI: 10.1186/s13073-022-01110-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 09/05/2022] [Indexed: 11/15/2022] Open
Abstract
Background Primary central nervous system lymphoma (PCNSL) is a rare lymphoma of the central nervous system, usually of diffuse large B cell phenotype. Stereotactic biopsy followed by histopathology is the diagnostic standard. However, limited material is available from CNS biopsies, thus impeding an in-depth characterization of PCNSL. Methods We performed flow cytometry, single-cell RNA sequencing, and B cell receptor sequencing of PCNSL cells released from biopsy material, blood, and cerebrospinal fluid (CSF), and spatial transcriptomics of biopsy samples. Results PCNSL-released cells were predominantly activated CD19+CD20+CD38+CD27+ B cells. In single-cell RNA sequencing, PCNSL cells were transcriptionally heterogeneous, forming multiple malignant B cell clusters. Hyperexpanded B cell clones were shared between biopsy- and CSF- but not blood-derived cells. T cells in the tumor microenvironment upregulated immune checkpoint molecules, thereby recognizing immune evasion signals from PCNSL cells. Spatial transcriptomics revealed heterogeneous spatial organization of malignant B cell clusters, mirroring their transcriptional heterogeneity across patients, and pronounced expression of T cell exhaustion markers, co-localizing with a highly malignant B cell cluster. Conclusions Malignant B cells in PCNSL show transcriptional and spatial intratumor heterogeneity. T cell exhaustion is frequent in the PCNSL microenvironment, co-localizes with malignant cells, and highlights the potential of personalized treatments. Supplementary Information The online version contains supplementary material available at 10.1186/s13073-022-01110-1.
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12
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Lüthge S, Steinbicker A, Schipmann S, Streckert EMS, Hess K, Grauer O, Paulus W, Stummer W, Brokinkel B, Spille DC. P18.01.A The applicability of established clinical and histopathological risk factors for tumor recurrence during long-term perioperative care in meningioma patients. Neuro Oncol 2022. [DOI: 10.1093/neuonc/noac174.328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Risk factors for the prediction of late-onset tumor recurrence in meningioma patients are sparse but needed to estimate duration and control intervals during long-term follow-up in meningioma patients. In this study, we therefore analyzed the value of established risk factors for postoperative meningioma recurrence for the prediction of long-term prognosis in a large, single-center series.
Material and methods
Correlations of established clinical (age, sex, tumor location, extent of resection), radiological (postoperative tumor volume) and histopathological variables (WHO grade, brain invasion) with tumor relapse were analyzed separately after 3, 5, and 10 years following microsurgery for primary diagnosed intracranial meningioma between 1991 and 2021 in uni- and multivariate analyses. The prognostic value was compared to findings in the entire cohort.
Results
Within a median follow-up of 29 months (range: 0-307 months), recurrence was observed in 141 patients (12%) after a median PFS of 36 months. PFS among the entire cohort (n=1218) at 3, 5, 10 and 15 years postoperatively were 90%, 84%, 74% and 70%, respectively. Among all patients included, skull base location (HR: 1.51, 95%CI 1.05-2.16; p=.026), Simpson ≥IV resections (HR: 2.41, 95%CI 1.52-3.84; p<.001), high-grade histology (HR: 3.70, 95%CI 2.50-5.47; p<.001) and male gender (HR: 1.46, 95%CI 1.01-2.11; p=.042) were independent risk factors for recurrence. Skull base location (HR: 1.92, 95%CI 1.17-3.17; p=.010 and HR: 2.02, 95%CI 1.04-3.95; p=.038) and high-grade histology (HR: 1.87, 95%CI 1.04-3.38; p=.038 and HR: 2.29, 95%CI 1.07-4.01; p=.034) but not subtotal resection (HR: 1.53, 95%CI .68-3.45; p=.303 and HR: 1.75, 95%CI .52-5.96; p=.369) remained independently correlated with recurrence after an event-free PFS of at least three (n=485) and five years (n=346), respectively. Similarly, postoperative tumor volume was related with recurrence in the entire cohort (p<.001) but not beyond a follow-up of ≥ three years (p>.05). In 147 patients with a follow-up of ≥ ten years, ten recurrences occurred, and no correlation was found with any of the analyzed variables.
Conclusion
Skull base tumor location and high-grade histology but not the extent of resection should be considered when planning follow-up duration and intervals following ≥5 years after meningioma surgery. Tumor relapses following more than ten years after surgery are very rare, and corresponding predictors are lacking.
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Affiliation(s)
- S Lüthge
- University hospital Münster , Münster , Germany
| | | | - S Schipmann
- University hospital Münster , Münster , Germany
| | | | - K Hess
- University hospital Münster , Münster , Germany
| | - O Grauer
- University hospital Münster , Münster , Germany
| | - W Paulus
- University hospital Münster , Münster , Germany
| | - W Stummer
- University hospital Münster , Münster , Germany
| | - B Brokinkel
- University hospital Münster , Münster , Germany
| | - D C Spille
- University hospital Münster , Münster , Germany
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Musigmann M, Akkurt BH, Krähling H, Nacul NG, Remonda L, Sartoretti T, Henssen D, Brokinkel B, Stummer W, Heindel W, Mannil M. Testing the applicability and performance of Auto ML for potential applications in diagnostic neuroradiology. Sci Rep 2022; 12:13648. [PMID: 35953588 PMCID: PMC9366823 DOI: 10.1038/s41598-022-18028-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/03/2022] [Indexed: 11/25/2022] Open
Abstract
To investigate the applicability and performance of automated machine learning (AutoML) for potential applications in diagnostic neuroradiology. In the medical sector, there is a rapidly growing demand for machine learning methods, but only a limited number of corresponding experts. The comparatively simple handling of AutoML should enable even non-experts to develop adequate machine learning models with manageable effort. We aim to investigate the feasibility as well as the advantages and disadvantages of developing AutoML models compared to developing conventional machine learning models. We discuss the results in relation to a concrete example of a medical prediction application. In this retrospective IRB-approved study, a cohort of 107 patients who underwent gross total meningioma resection and a second cohort of 31 patients who underwent subtotal resection were included. Image segmentation of the contrast enhancing parts of the tumor was performed semi-automatically using the open-source software platform 3D Slicer. A total of 107 radiomic features were extracted by hand-delineated regions of interest from the pre-treatment MRI images of each patient. Within the AutoML approach, 20 different machine learning algorithms were trained and tested simultaneously. For comparison, a neural network and different conventional machine learning algorithms were trained and tested. With respect to the exemplary medical prediction application used in this study to evaluate the performance of Auto ML, namely the pre-treatment prediction of the achievable resection status of meningioma, AutoML achieved remarkable performance nearly equivalent to that of a feed-forward neural network with a single hidden layer. However, in the clinical case study considered here, logistic regression outperformed the AutoML algorithm. Using independent test data, we observed the following classification results (AutoML/neural network/logistic regression): mean area under the curve = 0.849/0.879/0.900, mean accuracy = 0.821/0.839/0.881, mean kappa = 0.465/0.491/0.644, mean sensitivity = 0.578/0.577/0.692 and mean specificity = 0.891/0.914/0.936. The results obtained with AutoML are therefore very promising. However, the AutoML models in our study did not yet show the corresponding performance of the best models obtained with conventional machine learning methods. While AutoML may facilitate and simplify the task of training and testing machine learning algorithms as applied in the field of neuroradiology and medical imaging, a considerable amount of expert knowledge may still be needed to develop models with the highest possible discriminatory power for diagnostic neuroradiology.
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Affiliation(s)
- Manfred Musigmann
- University Clinic for Radiology, Westfälische Wilhelms-University Muenster and University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Burak Han Akkurt
- University Clinic for Radiology, Westfälische Wilhelms-University Muenster and University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Hermann Krähling
- University Clinic for Radiology, Westfälische Wilhelms-University Muenster and University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Nabila Gala Nacul
- University Clinic for Radiology, Westfälische Wilhelms-University Muenster and University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Luca Remonda
- Institute of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland.,Faculty of Medicine, University of Bern, Bern, Switzerland
| | | | - Dylan Henssen
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Benjamin Brokinkel
- Department of Neurosurgery, Westfälische Wilhelms-University Muenster and University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Walter Stummer
- Department of Neurosurgery, Westfälische Wilhelms-University Muenster and University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Walter Heindel
- University Clinic for Radiology, Westfälische Wilhelms-University Muenster and University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Manoj Mannil
- University Clinic for Radiology, Westfälische Wilhelms-University Muenster and University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
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Sönmez C, Wölfer J, Holling M, Brokinkel B, Stummer W, Wiendl H, Thomas C, Schulte-Mecklenbeck A, Grauer OM. Blockade of inhibitory killer cell immunoglobulin-like receptors and IL-2 triggering reverses the functional hypoactivity of tumor-derived NK-cells in glioblastomas. Sci Rep 2022; 12:6769. [PMID: 35474089 PMCID: PMC9042843 DOI: 10.1038/s41598-022-10680-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/11/2022] [Indexed: 11/09/2022] Open
Abstract
Killer cell immunoglobulin-like receptors (KIRs) comprise a group of highly polymorphic inhibitory receptors which are specific for classical HLA class-I molecules. Peripheral blood and freshly prepared tumor cell suspensions (n = 60) as well as control samples (n = 32) were investigated for the distribution, phenotype, and functional relevance of CD158ab/KIR2DL1,-2/3 expressing NK-cells in glioblastoma (GBM) patients. We found that GBM were scarcely infiltrated by NK-cells that preferentially expressed CD158ab/KIR2DL1,-2/3 as inhibitory receptors, displayed reduced levels of the activating receptors CD335/NKp46, CD226/DNAM-1, CD159c/NKG2C, and showed diminished capacity to produce IFN-γ and perforin. Functional hypoactivity of GBM-derived NK-cells persisted despite IL-2 preactivation. Blockade with a specific KIR2DL-1,2/3 monoclonal antibody reversed NK-cell inhibition and significantly enhanced degranulation and IFN-γ production of IL-2 preactivated NK-cells in the presence of primary GBM cells and HLA-C expressing but not HLA class-I deficient K562 cells. Additional analysis revealed that significant amounts of IL-2 could be produced by tumor-derived CD4+ and CD8+CD45RA- memory T-cells after combined anti-CD3/anti-CD28 stimulation. Our data indicate that both blockade of inhibitory KIR and IL-2 triggering of tumor-derived NK-cells are necessary to enhance NK-cell responsiveness in GBM.
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Affiliation(s)
- Cüneyt Sönmez
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.,Department of Spine Surgery, Klinikum Herford, 32049, Herford, Germany
| | - Johannes Wölfer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.,Department of Neurosurgery and Spine Surgery, Hufeland Klinikum GmbH, 99974, Mühlhausen, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Oliver M Grauer
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
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15
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Canisius J, Wagner A, Bunk EC, Spille DC, Stögbauer L, Grauer O, Hess K, Thomas C, Paulus W, Stummer W, Senner V, Brokinkel B. Expression of decitabine-targeted oncogenes in meningiomas in vivo. Neurosurg Rev 2022; 45:2767-2775. [PMID: 35445910 PMCID: PMC9349086 DOI: 10.1007/s10143-022-01789-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/11/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Abstract
Treatment of meningiomas refractory to surgery and irradiation is challenging and effective chemotherapies are still lacking. Recently, in vitro analyses revealed decitabine (DCT, 5-aza-2’–deoxycytidine) to be effective in high-grade meningiomas and, moreover, to induce hypomethylation of distinct oncogenes only sparsely described in meningiomas in vivo yet. Expression of the corresponding onco- and tumor suppressor genes TRIM58, FAM84B, ELOVL2, MAL2, LMO3, and DIO3 were analyzed and scored by immunohistochemical staining and RT-PCR in samples of 111 meningioma patients. Correlations with clinical and histological variables and prognosis were analyzed in uni- and multivariate analyses. All analyzed oncogenes were highly expressed in meningiomas. Expression scores of TRIM58 tended to be higher in benign than in high-grade tumors 20 vs 16 (p = .002) and all 9 samples lacking TRIM58 expression displayed WHO grade II/III histology. In contrast, median expression scores for both FAM84B (6 vs 4, p ≤ .001) and ELOVL2 (9 vs 6, p < .001) were increased in high-grade as compared to benign meningiomas. DIO3 expression was distinctly higher in all analyzed samples as compared to the reference decitabine-resistant Ben-Men 1 cell line. Increased ELOVL2 expression (score ≥ 8) correlated with tumor relapse in both uni- (HR: 2.42, 95%CI 1.18–4.94; p = .015) and multivariate (HR: 2.09, 95%CI 1.01–4.44; p = .046) analyses. All oncogenes involved in DCT efficacy in vitro are also widely expressed in vivo, and expression is partially associated with histology and prognosis. These results strongly encourage further analyses of DCT efficiency in meningiomas in vitro and in situ.
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Affiliation(s)
- Julian Canisius
- Department of Neurosurgery, University Hospital Münster, North Rhine Westphalia, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine Westphalia, Germany
| | - Andrea Wagner
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine Westphalia, Germany
| | - Eva Christina Bunk
- Department of Neurosurgery, University Hospital Münster, North Rhine Westphalia, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Dorothee Cäcilia Spille
- Department of Neurosurgery, University Hospital Münster, North Rhine Westphalia, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Louise Stögbauer
- Department of Neurosurgery, University Hospital Münster, North Rhine Westphalia, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Oliver Grauer
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, North Rhine-Westphalia, Münster, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine Westphalia, Germany
- Department of Pathology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine Westphalia, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine Westphalia, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, North Rhine Westphalia, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Volker Senner
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine Westphalia, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, North Rhine Westphalia, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
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16
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von Spreckelsen N, Kesseler C, Brokinkel B, Goldbrunner R, Perry A, Mawrin C. Molecular neuropathology of brain-invasive meningiomas. Brain Pathol 2022; 32:e13048. [PMID: 35213084 PMCID: PMC8877755 DOI: 10.1111/bpa.13048] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 12/24/2022] Open
Abstract
Invasion of brain tissue by meningiomas has been identified as one key factor for meningioma recurrence. The identification of meningioma tumor tissue surrounded by brain tissue in neurosurgical samples has been touted as a criterion for atypical meningioma (CNS WHO grade 2), but is only rarely seen in the absence of other high-grade features, with brain-invasive otherwise benign (BIOB) meningiomas remaining controversial. While post-surgery irradiation therapy might be initiated in brain-invasive meningiomas to prevent recurrences, specific treatment approaches targeting key molecules involved in the invasive process are not established. Here we have compiled the current knowledge about mechanisms supporting brain tissue invasion by meningiomas and summarize preclinical models studying targeted therapies with potential inhibitory effects.
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Affiliation(s)
- Niklas von Spreckelsen
- Department of Neuropathology, University Hospital Magdeburg, Magdeburg, Germany.,Department of General Neurosurgery, Center for Neurosurgery, Cologne University Hospital, Faculty of Medicine and University Hospital, University of Cologne, Germany
| | - Christoph Kesseler
- Department of Neuropathology, University Hospital Magdeburg, Magdeburg, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Roland Goldbrunner
- Department of General Neurosurgery, Center for Neurosurgery, Cologne University Hospital, Faculty of Medicine and University Hospital, University of Cologne, Germany
| | - Arie Perry
- Department of Pathology, UCSF, San Francisco, California, USA.,Department of Neurological Surgery, UCSF, San Francisco, California, USA
| | - Christian Mawrin
- Department of Neuropathology, University Hospital Magdeburg, Magdeburg, Germany
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17
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Lüthge S, Spille DC, Steinbicker AU, Schipmann S, Streckert EMS, Hess K, Grauer OM, Paulus W, Stummer W, Brokinkel B. The applicability of established clinical and histopathological risk factors for tumor recurrence during long-term postoperative care in meningioma patients. Neurosurg Rev 2021; 45:1635-1643. [PMID: 34802073 PMCID: PMC8976784 DOI: 10.1007/s10143-021-01697-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 11/26/2022]
Abstract
Risk factors to predict late-onset tumor recurrence in meningioma patients are urgently needed to schedule control intervals during long-term follow-up. We therefore analyzed the value of established risk factors for postoperative meningioma recurrence for the prediction of long-term prognosis. Correlations of clinical and histopathological variables with tumor relapse after 3, 5, and 10 years following microsurgery were analyzed in uni- and multivariate analyses, and compared to findings in the entire cohort. In the entire cohort (N = 1218), skull base location (HR: 1.51, 95%CI 1.05–2.16; p = .026), Simpson ≥ IV resections (HR: 2.41, 95%CI 1.52–3.84; p < .001), high-grade histology (HR: 3.70, 95%CI 2.50–5.47; p < .001), and male gender (HR: 1.46, 95%CI 1.01–2.11; p = .042) were independent risk factors for recurrence. Skull base location (HR: 1.92, 95%CI 1.17–3.17; p = .010 and HR: 2.02, 95%CI 1.04–3.95; p = .038) and high-grade histology (HR: 1.87, 95%CI 1.04–3.38; p = .038 and HR: 2.29, 95%CI 1.07–4.01; p = .034) but not subtotal resection (HR: 1.53, 95%CI .68–3.45; p = .303 and HR: 1.75, 95%CI .52–5.96; p = .369) remained correlated with recurrence after a recurrence-free follow-up of ≥ 3 and ≥ 5 years, respectively. Postoperative tumor volume was related with recurrence in general (p < .001) but not beyond a follow-up of ≥ 3 years (p > .05). In 147 patients with a follow-up of ≥ 10 years, ten recurrences occurred and were not correlated with any of the analyzed variables. Skull base tumor location and high-grade histology but not the extent of resection should be considered when scheduling the long-term follow-up after meningioma surgery. Recurrences ≥ 10 years after surgery are rare, and predictors are lacking.
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Affiliation(s)
- Swenja Lüthge
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Dorothee Cäcilia Spille
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Andrea Ulrike Steinbicker
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital, Münster, Germany
| | - Stephanie Schipmann
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Eileen Maria Susanne Streckert
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine Westphalia, Germany
- Department of Pathology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine Westphalia, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
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18
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Menke C, Lohmann S, Baehr A, Grauer O, Holling M, Brokinkel B, Schwake M, Stummer W, Schipmann S. Classical and disease-specific quality indicators in glioma surgery—Development of a quality checklist to improve treatment quality in glioma patients. Neurooncol Pract 2021; 9:59-67. [DOI: 10.1093/nop/npab063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
There is a pressing demand for more accurate, disease-specific quality measures in the field of neurosurgery. Aiming at most adequately measuring and reflecting the quality of glioma therapy, we developed a novel quality indicator bundle in form of a checklist for all patients that are treated operatively for glioma.
Methods
On the basis of possible glioma-specific quality indicators retrieved from the literature and quality guidelines, a multidisciplinary team developed a checklist containing 13 patient-need-specific outcome measures. Subsequently, the checklist was prospectively applied to a total of 78 patients compared with a control group consisting of 322 patients. A score was generated based on the maximum of quality measures achieved.
Results
Significant improvements in quality after prospectively introducing the checklist were achieved for supplemental physical and occupational therapy during inpatient stay (89.4% vs 100%, P = .002), consultation of a social worker during inpatient stay (64% vs 92.3%, P < .001), psycho-oncological screening (14.3% vs 70.5%, P < .001), psycho-oncological consultation (31.1% vs 82.1%, P < .001), and consultation of the palliative care team (20% vs 40%, P = .031). Overall, after introduction of the checklist one-third (n = 23) of patients reached best-practice measures in all categories, and over half of the patients (n = 44) achieved above 90% with respect to the outcome measures.
Conclusions
Aiming at ensuring comprehensive, consistent, and timely care of glioma patients, the implementation of the checklist for routine use in glioma surgery represents an efficient, easily reproducible, and powerful tool for significant improvements.
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Affiliation(s)
- Christiane Menke
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Sebastian Lohmann
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Andrea Baehr
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Oliver Grauer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Michael Schwake
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Stephanie Schipmann
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
- Department of Neurosurgery, Haukeland University Hospital Bergen, Bergen, Norway
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19
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Spille DC, Adeli A, Sporns PB, Heß K, Streckert EMS, Brokinkel C, Mawrin C, Paulus W, Stummer W, Brokinkel B. Correction to: Predicting the risk of postoperative recurrence and high-grade histology in patients with intracranial meningiomas using routine preoperative MRI. Neurosurg Rev 2021; 45:1815. [PMID: 34546450 PMCID: PMC8976785 DOI: 10.1007/s10143-021-01630-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Dorothee Cäcilia Spille
- Department of Neurosurgery, University Hospital Münster, Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine Westphalia, Germany
| | - Alborz Adeli
- Institute of Clinical Radiology, University of Münster, Münster, North Rhine Westphalia, Germany
| | - Peter B Sporns
- Institute of Clinical Radiology, University of Münster, Münster, North Rhine Westphalia, Germany
| | - Katharina Heß
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine Westphalia, Germany
| | - Eileen Maria Susanne Streckert
- Department of Neurosurgery, University Hospital Münster, Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine Westphalia, Germany
| | - Caroline Brokinkel
- Institute of Clinical Radiology, University of Münster, Münster, North Rhine Westphalia, Germany
| | - Christian Mawrin
- Institute of Neuropathology, Otto-von-Guericke University, Magdeburg, Saxony-Anhalt, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, North Rhine Westphalia, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine Westphalia, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine Westphalia, Germany.
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20
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Brokinkel B, Spille DC, Brokinkel C, Hess K, Paulus W, Bormann E, Stummer W. Correction to: The Simpson grading: defining the optimal threshold for gross total resection in meningioma surgery. Neurosurg Rev 2021; 45:1813. [PMID: 34546451 PMCID: PMC8976786 DOI: 10.1007/s10143-021-01629-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Munster, Germany.
| | - Dorothee Cäcilia Spille
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Munster, Germany
| | - Caroline Brokinkel
- Institute for Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Eike Bormann
- Institute of Biostatistics and Clinical Research, University Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Munster, Germany
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21
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Brokinkel B, Spille DC, Schipmann S, Hess K, Paulus W, Stummer W. Letter to the Editor: "Surgery for Recurrent Meningiomas: The Minor Prognostic Role of the Extent of Resection". World Neurosurg 2021; 145:514-516. [PMID: 33348495 DOI: 10.1016/j.wneu.2020.09.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.
| | | | | | - Katharina Hess
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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22
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Stögbauer L, Thomas C, Wagner A, Warneke N, Bunk EC, Grauer O, Canisius J, Paulus W, Stummer W, Senner V, Brokinkel B. Efficacy of decitabine in malignant meningioma cells: relation to promoter demethylation of distinct tumor suppressor and oncogenes and independence from TERT. J Neurosurg 2020:1-10. [PMID: 33307532 DOI: 10.3171/2020.7.jns193097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 07/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chemotherapeutic options for meningiomas refractory to surgery or irradiation are largely unknown. Human telomerase reverse transcriptase (hTERT) promoter methylation with subsequent TERT expression and telomerase activity, key features in oncogenesis, are found in most high-grade meningiomas. Therefore, the authors investigated the impact of the demethylating agent decitabine (5-aza-2'-deoxycytidine) on survival and DNA methylation in meningioma cells. METHODS hTERT promoter methylation, telomerase activity, TERT expression, and cell viability and proliferation were investigated prior to and after incubation with decitabine in two benign (HBL-52 and Ben-Men 1) and one malignant (IOMM-Lee) meningioma cell line. The global effects of decitabine on DNA methylation were additionally explored with DNA methylation profiling. RESULTS High levels of TERT expression, telomerase activity, and hTERT promoter methylation were found in IOMM-Lee and Ben-Men 1 but not in HBL-52 cells. Decitabine induced a dose-dependent significant decrease of proliferation and viability after incubation with doses from 1 to 10 μM in IOMM-Lee but not in HBL-52 or Ben-Men 1 cells. However, effects in IOMM-Lee cells were not related to TERT expression, telomerase activity, or hTERT promoter methylation. Genome-wide methylation analyses revealed distinct demethylation of 14 DNA regions after drug administration in the decitabine-sensitive IOMM-Lee but not in the decitabine-resistant HBL-52 cells. Differentially methylated regions covered promoter regions of 11 genes, including several oncogenes and tumor suppressor genes that to the authors' knowledge have not yet been described in meningiomas. CONCLUSIONS Decitabine decreases proliferation and viability in high-grade but not in benign meningioma cell lines. The effects of decitabine are TERT independent but related to DNA methylation changes of promoters of distinct tumor suppressor genes and oncogenes.
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Affiliation(s)
| | | | | | | | | | - Oliver Grauer
- 3Department of Neurology, University Hospital Münster, North Rhine-Westphalia, Germany
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23
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Illy E, Gerss J, Fischer BR, Stummer W, Brokinkel B, Holling M. Influence of Meteorological Conditions on the Incidence of Chronic Subdural Haematoma, Subarachnoid and Intracerebral Haemorrhages - the "Bleeding Weather Hypothesis". Turk Neurosurg 2020; 30:892-898. [PMID: 33216333 DOI: 10.5137/1019-5149.jtn.29821-20.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIM To elucidate possible causal relationships on climate change and intracranial haematomas. MATERIAL AND METHODS In a retrospective study we examined all patients (N=1169) treated for subarachnoid haemorrhage (SAH; n=484), intracerebral haemorrhage (ICH; n=417) or chronic subdural haematoma (CSDH; n=268) in our department over a 7-yearperiod between 1st June 2005 until 31th May 2012. The date of admission was correlated with the corresponding meteorological parameters which included; mean daily temperature (°C), relative humidity (%), vapor pressure (hPa), barometric pressure (hPa), cloud amount (/8), and wind speed (m/s). RESULTS Incidence of SAH tended to increase in April, ICH in January and CSDH in July, respectively, but ?² test did not reveal any statistical significance in seasonality for the three bleeding pathologies. Comparing the arithmetic average of meteorological key parameters of uneventful and eventful days by using student?s t-test within the three groups (SAH, ICH, CSDH) we could not demonstrate any statistical significance (p > 0.05). For SAH, logistic regression analyses revealed an increased risk associated with a decrease of barometric pressure (p=0.021). CONCLUSION Although our data suggest seasonal variabilities of SAH, ICH and CSDH, the single weather parameters do not demonstrate causal relationships with the incidence of cerebrovascular events. However, incidence of SAH tended to increase with changes of barometric pressure which confirms previously published results and might indicate a possible underlying relationship.
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Affiliation(s)
- Elisabeth Illy
- University Hospital Münster, Department of Neurosurgery, Albert-Schweitzer-Campus 1, Münster, Germany
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24
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Kaneko S, Brokinkel B, Suero Molina E, Warneke N, Holling M, Bunk EC, Hess K, Senner V, Paulus W, Stummer W. Real-time in vivo kinetics of protoporphyrin IX after administration of 5-aminolevulinic acid in meningiomas and comparative analyses with glioblastomas. Acta Neurochir (Wien) 2020; 162:2197-2202. [PMID: 32361907 DOI: 10.1007/s00701-020-04353-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The usefulness of 5-aminolevulinic acid (5-ALA)-mediated fluorescence-guided surgery (FGS) in meningiomas is intensely discussed. However, data about kinetics of 5-ALA and protoporphyrin (Pp) IX in meningiomas are lacking. METHODS As the first study so far, we performed longitudinal intraoperative real-time ex situ measurements of fluorescence intensity and PpIX concentrations during FGS of ten benign and two atypical meningiomas. Kinetics were subsequently compared with data from 229 glioblastomas. RESULTS Spectroscopy revealed fluorescence (median 2945.65 a.u.) and PpIX accumulation (median 18.31 μg/ml) in all 43 analyzed samples. Fluorescence intensity (2961.50 a.u. vs 118.41 a.u.; p < .001) and PpIX concentrations (18.72 μg/ml vs .98 μg/ml; p < .001) were higher in samples with (N = 30) than without (N = 2) visible intraoperative tumor fluorescence. ROC curve analyses revealed a PpIX cut-off concentration of 3.85 μg/ml (AUC = .992, p = .005) and a quantitative fluorescence cut-off intensity of 286.73 a.u. (AUC = .983, p = .006) for intraoperative visible tumor fluorescence. Neither fluorescence intensity (p = .356) nor PpIX (p = .631) differed between atypical and benign meningiomas. Fluorescence and PpIX peaked 7-8 h following administration of 5-ALA. Meningiomas displayed a higher fluorescence intensity (p = .012) and PpIX concentration (p = .005) than glioblastomas 5-6 h after administration of 5-ALA. Although fluorescence was basically maintained, PpIX appeared to be cleared faster in meningiomas than in glioblastomas. CONCLUSIONS Kinetics of PpIX and fluorescence intensity differ between meningiomas and glioblastomas in the early phase after 5-ALA administration. Modification of the timing of drug administration might impact visibility of intraoperative fluorescence and helpfulness of FGS and should be investigated in future analyses.
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Affiliation(s)
- Sadahiro Kaneko
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Eva Christina Bunk
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Volker Senner
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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Müther M, Roll W, Brokinkel B, Zinnhardt B, Sporns PB, Seifert R, Schäfers M, Weckesser M, Stegger L, Stummer W, Rahbar K. Response assessment of somatostatin receptor targeted radioligand therapies for progressive intracranial meningioma. Nuklearmedizin 2020; 59:348-355. [PMID: 32691404 DOI: 10.1055/a-1200-0989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In somatostatin receptor (SSTR) expressing progressive meningioma, peptide receptor radionuclide therapy (PRRT) has shown effect in small clinical series. However, standardized treatment and response assessment protocols are lacking. We present our experience on PPRT with 177Lu-DOTATATE in progressive meningioma with a special emphasis on state-of-the-art response assessment. METHODS Retrospective analysis on PRRT with 177Lu-DOTATATE from 2015 to 2019. Pre- and post-therapy imaging was performed using MRI and 68Ga-DOTATATE-PET for standard bidimensional and volumetric analyses, respectively, following novel RANO guidelines. RESULTS Seven patients with progressive intracranial meningioma (median age 73 years, interquartile range 60-76; 5 WHO II, 2 WHO I; 5 multifocal) received a median of 4 cycles 2 3 4 of PRRT with 177Lu-DOTATATE in eight-week intervals. Three patients did not undergo post-therapy 68Ga-DOTATATE-PET due to early symptomatic progression and subsequent cessation of PRRT. After completion of 4 PRRT cycles volumetric PET imaging showed stable disease in two of four patients. According to bidimensional MRI response assessment, only one patient was stable. Progression free survival at six months was 42.9 %. CONCLUSION In this heterogeneous collective of seven patients with progressive meningioma, 177Lu-DOTATATE therapies showed heterogeneous effectiveness. PET-based volumetric assessment should be used for response assessment in PRRT additionally to bidimensional imaging.
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Affiliation(s)
- Michael Müther
- Department of Neurosurgery, University Hospital Münster, Germany
| | - Wolfgang Roll
- Department of Nuclear Medicine, University Hospital Münster, Germany
| | | | | | - Peter B Sporns
- Institute of Clinical Radiology, University Hospital Münster, Germany
| | - Robert Seifert
- Department of Nuclear Medicine, University Hospital Münster, Germany
| | | | | | - Lars Stegger
- Department of Nuclear Medicine, University Hospital Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Germany
| | - Kambiz Rahbar
- Department of Nuclear Medicine, University Hospital Münster, Germany
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Spille DC, Hess K, Bormann E, Sauerland C, Brokinkel C, Warneke N, Mawrin C, Paulus W, Stummer W, Brokinkel B. Risk of tumor recurrence in intracranial meningiomas: comparative analyses of the predictive value of the postoperative tumor volume and the Simpson classification. J Neurosurg 2020; 134:1764-1771. [PMID: 32679565 DOI: 10.3171/2020.4.jns20412] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In meningiomas, the Simpson grading system is applied to estimate the risk of postoperative recurrence, but might suffer from bias and limited overview of the resection cavity. In contrast, the value of the postoperative tumor volume as an objective predictor of recurrence is largely unexplored. The objective of this study was to compare the predictive value of residual tumor volume with the intraoperatively assessed extent of resection (EOR). METHODS The Simpson grade was determined in 939 patients after surgery for initially diagnosed intracranial meningioma. Tumor volume was measured on initial postoperative MRI within 6 months after surgery. Correlation between both variables and recurrence was compared using a tree-structured Cox regression model. RESULTS Recurrence correlated with Simpson grading (p = 0.003). In 423 patients (45%) with available imaging, residual tumor volume covered a broad range (0-78.5 cm3). MRI revealed tumor remnants in 8% after gross-total resection (Simpson grade I-III, range 0.12-33.5 cm3) with a Cohen's kappa coefficient of 0.7153. Postoperative tumor volume was correlated with recurrence in univariate analysis (HR 1.05 per cm3, 95% CI 1.02-1.08 per cm3, p < 0.001). A tree-structured Cox regression model revealed any postoperative tumor volume > 0 cm3 as a critical cutoff value for the prediction of relapse. Multivariate analysis confirmed the postoperative tumor volume (HR 1.05, p < 0.001) but not the Simpson grading (p = 0.398) as a predictor for recurrence. CONCLUSIONS EOR according to Simpson grading was overrated in 8% of tumors compared to postoperative imaging. Because the predictive value of postoperative imaging is superior to the Simpson grade, any residual tumor should be carefully considered during postoperative care of meningioma patients.
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Affiliation(s)
| | | | - Eike Bormann
- 3Institute of Biostatistics and Clinical Research, University of Münster; and
| | - Cristina Sauerland
- 3Institute of Biostatistics and Clinical Research, University of Münster; and
| | | | | | - Christian Mawrin
- 5Institute of Neuropathology, Otto von Guericke University Magdeburg, Saxony-Anhalt, Germany
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Jaber M, Ewelt C, Wölfer J, Brokinkel B, Thomas C, Hasselblatt M, Grauer O, Stummer W. Is Visible Aminolevulinic Acid-Induced Fluorescence an Independent Biomarker for Prognosis in Histologically Confirmed (World Health Organization 2016) Low-Grade Gliomas? Neurosurgery 2020; 84:1214-1224. [PMID: 30107580 PMCID: PMC6537633 DOI: 10.1093/neuros/nyy365] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 07/14/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Approximately 20% of low-grade gliomas (LGG) display visible protoporphyrin fluorescence during surgery after 5-aminolevulinic acid (5-ALA) administration. OBJECTIVE To determine if fluorescence represents a prognostic marker in LGG. METHODS Seventy-four consecutive patients with LGG (World Health Organization 2016) were operated on with 5-ALA. Fluorescent tissue was specifically biopsied. Tumor size, age, Karnofsky index, contrast-enhancement, fluorescence, and molecular factors (IDH1/IDH2-mutations, Ki67/MIB1 Index, 1p19q codeletions, ATRX, EGFR, p53 expression, and O6-methylguanine DNA methyltransferase promotor methylation), were related to progression-free survival (PFS), malignant transformation-free survival (MTFS) and overall survival (OS). RESULTS Sixteen of seventy-four LGGs (21.6%) fluoresced. Fluorescence was partially related to weak enhancement on magnetic resonance imaging and increased (positron emission tomography)PET-FET uptake, but not to Karnofsky Performance Score, tumor size, or age. Regarding molecular markers, only EGFR expression differed marginally (fluorescing vs nonfluorescing: 19% vs 5%; P = .057). Median follow-up was 46.4 mo (95% confidence interval [CI]: 41.8-51.1). PFS, MTFS, and OS were shorter in fluorescing tumors (PFS: median 9.8 mo, 95% CI: 1.00-27.7 vs 45.8, 31.9-59.7, MTFS: 43.0 [27.5-58.5] vs 64.6 [57.7-71.5], median not reached, P = .015; OS: 51.6, [34.8-68.3] vs [68.2, 62.7-73.8], P = .002). IDH mutations significantly predicted PFS, MTFS, and OS. In multivariate analysis IDH status and fluorescence both independently predicted MTFS and OS. PFS was not independently predicted by fluorescence. CONCLUSION This is the first report investigating the role of ALA-induced fluorescence in histologically confirmed LGG. Fluorescence appeared to be a marker for inherent malignant transformation and OS, independently of known prognostic markers. Fluorescence in LGG might be taken into account when deciding on adjuvant therapies.
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Affiliation(s)
- Mohammed Jaber
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Johannes Wölfer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Martin Hasselblatt
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Oliver Grauer
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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Schipmann S, Müther M, Stögbauer L, Zimmer S, Brokinkel B, Holling M, Grauer O, Suero Molina E, Warneke N, Stummer W. Combination of ALA-induced fluorescence-guided resection and intraoperative open photodynamic therapy for recurrent glioblastoma: case series on a promising dual strategy for local tumor control. J Neurosurg 2020:1-11. [PMID: 31978877 DOI: 10.3171/2019.11.jns192443] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE High-grade glioma (HGG) prognosis remains dismal, with inevitable, mostly local recurrence. Regimens for improving local tumor control are therefore needed. Photodynamic therapy (PDT) using porfimer sodium has been investigated but was abandoned due to side effects and lack of survival benefits. Intracellular porphyrins induced by 5-aminolevulinic acid (5-ALA) are approved for fluorescence-guided resections (FGRs), but are also photosensitizers. Activated by light, they generate reactive oxygen species with resultant cytotoxicity. The authors present a combined approach of 5-ALA FGR and PDT. METHODS After 5-ALA FGR in recurrent HGG, laser diffusors were strategically positioned inside the resection cavity. PDT was applied for 60 minutes (635 nm, 200 mW/cm diffusor, for 1 hour) under continuous irrigation for maintaining optical clarity and ventilation with 100% oxygen. MRI was performed at 24 hours, 14 days, and every 3 months after surgery, including diffusion tensor imaging and apparent diffusion coefficient maps. RESULTS Twenty patients were treated. One surgical site infection after treatment was noted at 6 months as the only adverse event. MRI revealed cytotoxic edema along resection margins in 16 (80%) of 20 cases, mostly annular around the cavity, corresponding to prior laser diffusor locations (mean volume 3.3 cm3). Edema appeared selective for infiltrated tissue or nonresected enhancing tumor. At the 14-day follow-up, enhancement developed in former regions of edema, in some cases vanishing after 4-5 months. Median progression-free survival (PFS) was 6 months (95% CI 4.8-7.2 months). CONCLUSIONS Combined 5-ALA FGR and PDT provides an innovative and safe method of local tumor control resulting in promising PFS. Further prospective studies are warranted to evaluate long-term therapeutic effects.
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Affiliation(s)
| | | | | | | | | | | | - Oliver Grauer
- 3Department of Neurology, University Hospital Münster, Germany
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Suero Molina E, Brokinkel B. Letter to the Editor. Sodium fluorescein versus 5-aminolevulinic acid to visualize high-grade gliomas. J Neurosurg 2020; 133:1-3. [PMID: 31978890 DOI: 10.3171/2019.12.jns193180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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30
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Peetz-Dienhart S, Spille DC, Sporns PB, Adeli A, Bunk EC, Wagner A, Paulus W, Stummer W, Hess K, Brokinkel B. Letter: Parasagittal/Falcine Tumor Location Strongly Predicts Human Telomerase Reverse Transcriptase Promoter Mutations in High-Grade Meningiomas. Neurosurgery 2019; 86:E362-E365. [PMID: 31792502 DOI: 10.1093/neuros/nyz474] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/28/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Peter B Sporns
- Institute for Clinical Radiology University Hospital Münster North Rhine Westphalia, Germany
| | - Alborz Adeli
- Institute for Clinical Radiology University Hospital Münster North Rhine Westphalia, Germany
| | - Eva Christine Bunk
- Department of Neurosurgery University Hospital Münster North Rhine Westphalia, Germany
| | - Andrea Wagner
- Institute of Neuropathology University Hospital Münster North Rhine Westphalia, Germany
| | - Werner Paulus
- Institute of Neuropathology University Hospital Münster North Rhine Westphalia, Germany
| | - Walter Stummer
- Department of Neurosurgery University Hospital Münster North Rhine Westphalia, Germany
| | - Katharina Hess
- Institute of Neuropathology University Hospital Münster North Rhine Westphalia, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery University Hospital Münster North Rhine Westphalia, Germany
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Schwake M, Grauer O, Holling M, Brokinkel B, Müther M, Bruns AK, Wölfer J, Stummer W. SURG-12. “NANOPASTE” THERAPY AS POTENTIAL TREATMENT OPTION FOR RECURRENT GLIOBLASTOMA. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.1013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
We recently showed that intracavitary thermotherapy with superparamagnetic iron-oxide nanoparticles can induce persistent inflammatory reactions which might lead to long-term stabilization in recurrent glioblastoma (GBM) patients.
METHODS
Here, we report further data from a series of ten recurrent GBM WHO IV patients (IDH WT, MGMT: methylated 30%, unmethylated 70%; median age: 59 years) who were treated with intracavitary thermotherapy after coating the resection cavity wall (“NanoPaste”) with NanoTherm® particles (MagForce AG, Berlin, Germany). All patients underwent six one-hour semi-weekly hyperthermia sessions in an alternating magnetic field (mean maximum temperature 52.3° C, SD +/- 6.0 °C). Six patients received concurrent radiotherapy at a dose of 39.6 Gy (5 x 1.8 Gy/week).
RESULTS
No major side effects were observed during active treatment. However, all patients developed cerebral edema and increasing clinical symptoms during treatment follow-up (median 92 days, range 73 to 144). Patients were treated with dexamethasone and, if necessary, underwent re-operation to remove nanoparticles (n=5). Histopathology revealed sustained necrosis and large amounts of nanoparticles without evidence for tumor activity as well as a prominent inflammatory reaction characterized by increased T-cell and myeloid cell infiltration. Median overall survival (mOS) for the study population was 10.1 months (CI 95% 8.0–12.2). A survival benefit was observed for patients treated at first recurrence (n=5) when compared to patients treated at second recurrence or later (mOS = 20.6 vs 9.4 months). Patients who received thermotherapy and concurrent radiotherapy (n=6) showed longer mOS than patients treated with thermotherapy alone (17.3 vs 8.6 months). Two patients had long-lasting treatment responses > 23 months with one patient still alive at 3.5 years after treatment without receiving any further therapy.
CONCLUSION
Our results warrant further investigations. A European clinical registry will be rolled out to further evaluate the potential of “NanoPaste” therapy for patients with recurrent glioblastoma.
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Reinhardt A, Stichel D, Schrimpf D, Koelsche C, Wefers AK, Ebrahimi A, Sievers P, Huang K, Casalini MB, Fernández-Klett F, Suwala A, Weller M, Gramatzki D, Felsberg J, Reifenberger G, Becker A, Hans VH, Prinz M, Staszewski O, Acker T, Dohmen H, Hartmann C, Paulus W, Heß K, Brokinkel B, Schittenhelm J, Buslei R, Deckert M, Mawrin C, Hewer E, Pohl U, Jaunmuktane Z, Brandner S, Unterberg A, Hänggi D, Platten M, Pfister SM, Wick W, Herold-Mende C, Korshunov A, Reuss DE, Sahm F, Jones DTW, Capper D, von Deimling A. Tumors diagnosed as cerebellar glioblastoma comprise distinct molecular entities. Acta Neuropathol Commun 2019; 7:163. [PMID: 31661039 PMCID: PMC6816155 DOI: 10.1186/s40478-019-0801-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 11/29/2022] Open
Abstract
In this multi-institutional study we compiled a retrospective cohort of 86 posterior fossa tumors having received the diagnosis of cerebellar glioblastoma (cGBM). All tumors were reviewed histologically and subjected to array-based methylation analysis followed by algorithm-based classification into distinct methylation classes (MCs). The single MC containing the largest proportion of 25 tumors diagnosed as cGBM was MC anaplastic astrocytoma with piloid features representing a recently-described molecular tumor entity not yet included in the WHO Classification of Tumours of the Central Nervous System (WHO classification). Twenty-nine tumors molecularly corresponded to either of 6 methylation subclasses subsumed in the MC family GBM IDH wildtype. Further we identified 6 tumors belonging to the MC diffuse midline glioma H3 K27 M mutant and 6 tumors allotted to the MC IDH mutant glioma subclass astrocytoma. Two tumors were classified as MC pilocytic astrocytoma of the posterior fossa, one as MC CNS high grade neuroepithelial tumor with BCOR alteration and one as MC control tissue, inflammatory tumor microenvironment. The methylation profiles of 16 tumors could not clearly be assigned to one distinct MC. In comparison to supratentorial localization, the MC GBM IDH wildtype subclass midline was overrepresented, whereas the MCs GBM IDH wildtype subclass mesenchymal and subclass RTK II were underrepresented in the cerebellum. Based on the integration of molecular and histological findings all tumors received an integrated diagnosis in line with the WHO classification 2016. In conclusion, cGBM does not represent a molecularly uniform tumor entity, but rather comprises different brain tumor entities with diverse prognosis and therapeutic options. Distinction of these molecular tumor classes requires molecular analysis. More than 30% of tumors diagnosed as cGBM belong to the recently described molecular entity of anaplastic astrocytoma with piloid features.
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Hess K, Spille DC, Adeli A, Sporns PB, Brokinkel C, Grauer O, Mawrin C, Stummer W, Paulus W, Brokinkel B. Brain invasion and the risk of seizures in patients with meningioma. J Neurosurg 2019; 130:789-796. [PMID: 29701550 DOI: 10.3171/2017.11.jns172265] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 11/04/2017] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Identification of risk factors for perioperative epilepsy remains crucial in the care of patients with meningioma. Moreover, associations of brain invasion with clinical and radiological variables have been largely unexplored. The authors hypothesized that invasion of the cortex and subsequent increased edema facilitate seizures, and they compared radiological data and perioperative seizures in patients with brain-invasive or noninvasive meningioma. METHODS Correlations of brain invasion with tumor and edema volumes and preoperative and postoperative seizures were analyzed in univariate and multivariate analyses. RESULTS Totals of 108 (61%) females and 68 (39%) males with a median age of 60 years and harboring totals of 92 (52%) grade I, 79 (45%) grade II, and 5 (3%) grade III tumors were included. Brain invasion was found in 38 (22%) patients and was absent in 138 (78%) patients. The tumors were located at the convexity in 72 (41%) patients, at the falx cerebri in 26 (15%), at the skull base in 69 (39%), in the posterior fossa in 7 (4%), and in the ventricle in 2 (1%); the median tumor and edema volumes were 13.73 cm3 (range 0.81-162.22 cm3) and 1.38 cm3 (range 0.00-355.80 cm3), respectively. As expected, edema volume increased with rising tumor volume (p < 0.001). Brain invasion was independent of tumor volume (p = 0.176) but strongly correlated with edema volume (p < 0.001). The mean edema volume in noninvasive tumors was 33.0 cm3, but in invasive tumors, it was 130.7 cm3 (p = 0.008). The frequency of preoperative seizures was independent of the patients' age, sex, and tumor location; however, the frequency was 32% (n = 12) in patients with invasive meningioma and 15% (n = 21) in those with noninvasive meningioma (p = 0.033). In contrast, the probability of detecting brain invasion microscopically was increased more than 2-fold in patients with a history of preoperative seizures (OR 2.57, 95% CI 1.13-5.88; p = 0.025). In univariate analyses, the rate of preoperative seizures correlated slightly with tumor volume (p = 0.049) but strongly with edema volume (p = 0.014), whereas seizure semiology was found to be independent of brain invasion (p = 0.211). In multivariate analyses adjusted for age, sex, tumor location, tumor and edema volumes, and WHO grade, rising tumor volume (OR 1.02, 95% CI 1.00-1.03; p = 0.042) and especially brain invasion (OR 5.26, 95% CI 1.52-18.15; p = 0.009) were identified as independent predictors of preoperative seizures. Nine (5%) patients developed new seizures within a median follow-up time of 15 months after surgery. Development of postoperative epilepsy was independent of all clinical variables, including Simpson grade (p = 0.133), tumor location (p = 0.936), brain invasion (p = 0.408), and preoperative edema volume (p = 0.081), but was correlated with increasing preoperative tumor volume (p = 0.004). Postoperative seizure-free rates were similar among patients with invasive and those with noninvasive meningioma (p = 0.372). CONCLUSIONS Brain invasion was identified as a new and strong predictor for preoperative, but not postoperative, seizures. Although also associated with increased peritumoral edema, seizures in patients with invasive meningioma might be facilitated substantially by cortical invasion itself. Consideration of seizures in consultations between the neurosurgeon and neuropathologist can improve the microscopic detection of brain invasion.
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Affiliation(s)
| | | | - Alborz Adeli
- 3Department of Clinical Radiology, University of Münster, North Rhine-Westphalia; and
| | - Peter B Sporns
- 3Department of Clinical Radiology, University of Münster, North Rhine-Westphalia; and
| | - Caroline Brokinkel
- 3Department of Clinical Radiology, University of Münster, North Rhine-Westphalia; and
| | | | - Christian Mawrin
- 5Institute of Neuropathology, Otto-von-Guericke University, Magdeburg, Saxony-Anhalt, Germany
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Müther M, Roll W, Zinnhardt B, Schäfers M, Rahbar K, Brokinkel B, Stummer W. P09.05 177Lu-DOTATATE therapy in progressive meningioma. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz126.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Progressive meningioma is a challenging condition with a decreasing number of treatment options over the course of disease. Neurovascular involvement and multifocal disease often complicate surgical management. In addition, repeated radiotherapy carriers a risk of side effects. In somatostatin receptor expressing meningioma, peptide receptor radiotherapy (PPRT) with 177Lu-DOTATATE poses a promising alternative. However, current evidence is scarce. Hereby we present our single center experience of (PPRT) with 177Lu-DOTATATE in progressive meningioma.
METHODS
Eight patients (median age: 71 years; range 56–77) with progressive meningioma underwent PRRT using 177Lu-DOTATATE were included in this retrospective analysis. Response to therapy was assessed by interim and post-therapy 68Ga-DOTATATE-PET-CT and MRI. 177Lu-DOTATATE scintigraphies 48h p.i. were evaluated according to Krenning scale. Additionally, clinical outcome and follow up imaging were analyzed for progression free interval times.
RESULTS
Eight patients were included: Six patients with grade II and two patients with grade I meningiomas, according to the 2016 WHO classification. Six of eight patients harbored multifocal disease. One patients suffered systemic metastatic disease. Patients received a median of three cycles (range: 1 - 5) of PRRT with 177Lu-DOTATATE (mean injected dose 7.1 GBq) between 1/2015 and 1/2019. Tumor uptake in 48h p.i. 177Lu-Scintigraphies was heterogeneous (Krenning scale; median: 3; range: 1–4). Post-therapy imaging scheduled eight weeks after completion of therapy showed progressive disease in five patients, three patients had stable disease. Median follow-up post therapy response evaluation was 24 months in patients with stable disease. Median time to progression was 10 months.
CONCLUSION
In this cohort of eight progressive meningioma patients 177Lu-DOTATATE therapy showed heterogeneous efficacy.
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Affiliation(s)
- M Müther
- University Hospital Münster, Dept. of Neurosurgery, Münster, Germany
| | - W Roll
- University Hospital Münster, Dept. of Nuclear Medicine, Münster, Germany
| | - B Zinnhardt
- University Hospital Münster, Dept. of Nuclear Medicine, Münster, Germany
| | - M Schäfers
- University Hospital Münster, Dept. of Nuclear Medicine, Münster, Germany
| | - K Rahbar
- University Hospital Münster, Dept. of Nuclear Medicine, Münster, Germany
| | - B Brokinkel
- University Hospital Münster, Dept. of Neurosurgery, Münster, Germany
| | - W Stummer
- University Hospital Münster, Dept. of Neurosurgery, Münster, Germany
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Timme M, Thomas C, Spille DC, Stummer W, Ebel H, Ewelt C, Hans FJ, Schick U, Puchner M, Wildförster U, Bruns B, Trost HA, Holling M, Grauer O, Hess K, Brokinkel B. Brain invasion in meningiomas: does surgical sampling impact specimen characteristics and histology? Neurosurg Rev 2019; 43:793-800. [DOI: 10.1007/s10143-019-01125-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/16/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
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Bruns AK, Jeibmann A, Brokinkel B, Holling M, Stummer W, Ewelt C. Heterotopic Neuroglial Tissue in Sphenoid Ridge. World Neurosurg 2019; 122:671-673. [PMID: 31108067 DOI: 10.1016/j.wneu.2018.10.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/13/2018] [Accepted: 10/16/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Extracerebral neuroglial heterotopias are rare manifestations of cerebral tissue outside the brain whose most common form is the so-called nasal glioma. In this case report we illustrate the first case of heterotopic neuroglial tissue within the bone of the skull. CASE DESCRIPTION Our patient underwent surgery for a sphenoid ridge meningioma. Aside from the expected meningioma, histopathologic examination showed a small amount of intraosseous heterotopic neuroglial tissue. CONCLUSIONS The pathogenesis of cerebral heterotopias is diverse. Most of the midline lesions are probably residuals of former meningoencephaloceles. The pathogenesis of extracranial nonmidline lesions is more questionable. Their cause might be a former trauma, inflammatory disease, or surgery. Another option is that they represent primary neuroglial heterotopias, as it is supposed for manifestations of the lung. The coexistence of a heterotopia and a meningioma in this case is probably a coincidence. It is also debatable whether the broad tumor extension within the bone and/or the heterotopia might go back to alterations of the bone structure.
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Affiliation(s)
- Ann-Katrin Bruns
- Department of Neurosurgery, University Hospital of Muenster, Muenster, Germany.
| | - Astrid Jeibmann
- Institute of Neuropathology, University Hospital of Muenster, Muenster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital of Muenster, Muenster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital of Muenster, Muenster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Muenster, Muenster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, University Hospital of Muenster, Muenster, Germany
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Spille DC, Sporns PB, Heß K, Stummer W, Brokinkel B. Prediction of High-Grade Histology and Recurrence in Meningiomas Using Routine Preoperative Magnetic Resonance Imaging: A Systematic Review. World Neurosurg 2019; 128:174-181. [PMID: 31082555 DOI: 10.1016/j.wneu.2019.05.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Estimating the risk of recurrence after surgery remains crucial during care of patients with meningioma. Numerous studies identified correlations of characteristics on routine preoperative magnetic resonance imaging (MRI) with postoperative recurrence or high-grade histology but showed partially inconclusive results. METHODS A systematic review of the literature was performed about findings on preoperative MRI and their correlation with high-grade histology and recurrence. Quality of the included studies was analyzed using standardized Quality Assessment of Diagnostic Accuracy Studies criteria. RESULTS Among the 35 studies included, quality of the series according to the Quality Assessment of Diagnostic Accuracy Studies criteria differed widely. Remarkably, MRI variables found to be associated with high-grade histology were commonly not consistently associated with prognosis and vice versa. Correlations of the tumor size, the peritumoral edema size, and contrast-enhancement of the tumor capsule with high-grade histology were controversial. In most studies, non-skull base tumor location, cyst formation, heterogenous contrast-enhancement, an irregular tumor shape, and disruption of the tumor/brain border but not intensity of the lesion on T2-weighted images, calcifications, or bone involvement were associated with grade II/III histology. Although tumor and edema size were usually found to correlate with recurrence, heterogenous contrast enhancement, cyst formation, intensity of the tumor on T2-weighted MRI, and enhancement of the tumor capsule were mostly not related with progression. CONCLUSIONS Several mostly consistent but partially inconsistent variables associated with high-grade histology or prognosis were identified. Although standardized studies are needed to provide further clarification, consideration of these findings can help to improve estimation of prognosis and can therefore improve postoperative care in patients with meningioma.
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Affiliation(s)
| | - Peter B Sporns
- Institute of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Katharina Heß
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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Stögbauer L, Stummer W, Senner V, Brokinkel B. Telomerase activity, TERT expression, hTERT promoter alterations, and alternative lengthening of the telomeres (ALT) in meningiomas – a systematic review. Neurosurg Rev 2019; 43:903-910. [DOI: 10.1007/s10143-019-01087-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
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Schipmann S, Brix T, Varghese J, Warneke N, Schwake M, Brokinkel B, Ewelt C, Dugas M, Stummer W. Adverse events in brain tumor surgery: incidence, type, and impact on current quality metrics. Acta Neurochir (Wien) 2019; 161:287-306. [PMID: 30635727 DOI: 10.1007/s00701-018-03790-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of the study was to determine pre-operative factors associated with adverse events occurring within 30 days after neurosurgical tumor treatment in a German center, adjusting for their incidence in order to prospectively compare different centers. METHODS Adult patients that were hospitalized due to a benign or malignant brain were retrospectively assessed for quality indicators and adverse events. Analyses were performed in order to determine risk factors for adverse events and reasons for readmission and reoperation. RESULTS A total of 2511 cases were enrolled. The 30 days unplanned readmission rate to the same hospital was 5.7%. The main reason for readmission was tumor progression. Every 10th patient had an unplanned reoperation. The incidence of surgical revisions due to infections was 2.3%. Taking together all monitored adverse events, male patients had a higher risk for any of these complications (OR 1.236, 95%CI 1.025-1.490, p = 0.027). Age, sex, and histological diagnosis were predictors of experiencing any complication. Adjusted by incidence, the increased risk ratios greater than 10.0% were found for male sex, age, metastatic tumor, and hemiplegia for various quality indicators. CONCLUSIONS We found that most predictors of outcome rates are based on preoperative underlying medical conditions and are not modifiable by the surgeon. Comparing our results to the literature, we conclude that differences in readmission and reoperation rates are strongly influenced by standards in decision making and that comparison of outcome rates between different health-care providers on an international basis is challenging. Each health-care system has to develop own metrics for risk adjustment that require regular reassessment.
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Affiliation(s)
- Stephanie Schipmann
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Tobias Brix
- Institute of Medical Informatics, University Hospital Münster, Münster, Germany
| | - Julian Varghese
- Institute of Medical Informatics, University Hospital Münster, Münster, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Michael Schwake
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Martin Dugas
- Institute of Medical Informatics, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Sievers P, Stichel D, Hielscher T, Schrimpf D, Reinhardt A, Wefers AK, Reuss D, Jones DTW, Bewerunge-Hudler M, Hartmann C, Baumgarten P, Wirsching HG, Winther-Kristensen B, Brokinkel B, Ketter R, Idoate Gastearena MA, Lamszus K, Seiz-Rosenhagen M, Mawrin C, Harter PN, Felsberg J, Hänggi D, Herold-Mende C, Berghoff AS, Weller M, Pfister SM, Wick W, Reifenberger G, Preusser M, von Deimling A, Sahm F. Chordoid meningiomas can be sub-stratified into prognostically distinct DNA methylation classes and are enriched for heterozygous deletions of chromosomal arm 2p. Acta Neuropathol 2018; 136:975-978. [PMID: 30382370 DOI: 10.1007/s00401-018-1924-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/24/2018] [Accepted: 10/24/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Philipp Sievers
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Damian Stichel
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniel Schrimpf
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Annekathrin Reinhardt
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Annika K Wefers
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David Reuss
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David T W Jones
- Hopp Children's Cancer Center at the NCT Heidelberg (KiTZ), Heidelberg, Germany
- Pediatric Glioma Research Group, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Melanie Bewerunge-Hudler
- Genomics and Proteomics Core Facility, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Hartmann
- Department of Neuropathology, Institute of Pathology, Hannover Medical School (MHH), Hannover, Germany
| | - Peter Baumgarten
- Institute of Neurology (Edinger Institute), University Hospital and Medical Faculty, Goethe University, Frankfurt, Germany
- Department of Neurosurgery, University Hospital and Medical Faculty, Goethe University, Frankfurt, Germany
| | - Hans-Georg Wirsching
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Bjarne Winther-Kristensen
- Department of Pathology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Ralf Ketter
- Department of Neurosurgery, University Hospital Saarland, Homburg, Saar, Germany
| | | | - Katrin Lamszus
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcel Seiz-Rosenhagen
- Department of Neurosurgery, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christian Mawrin
- Department of Neuropathology, University Magdeburg, Magdeburg, Germany
| | - Patrick N Harter
- Institute of Neurology (Edinger Institute), University Hospital and Medical Faculty, Goethe University, Frankfurt, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt, Germany
| | - Jörg Felsberg
- Institute of Neuropathology, Heinrich Heine University, Düsseldorf, Germany
- German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christel Herold-Mende
- Division of Experimental Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna Sophie Berghoff
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Stefan M Pfister
- Hopp Children's Cancer Center at the NCT Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
- Clinical Cooperation Unit Neurooncology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Guido Reifenberger
- Institute of Neuropathology, Heinrich Heine University, Düsseldorf, Germany
- German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, Düsseldorf, Germany
| | - Matthias Preusser
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Andreas von Deimling
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany.
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Hopp Children's Cancer Center at the NCT Heidelberg (KiTZ), Heidelberg, Germany.
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Suero Molina E, van Eck ATCJ, Sauerland C, Schipmann S, Horstmann G, Stummer W, Brokinkel B. Local Tumor Control and Clinical Symptoms After Gamma Knife Radiosurgery for Residual and Recurrent Vestibular Schwannomas. World Neurosurg 2018; 122:e1240-e1246. [PMID: 30447443 DOI: 10.1016/j.wneu.2018.11.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The use of Gamma Knife radiosurgery (GKRS) for recurrent or residual vestibular schwannoma (VS) after microsurgery (MS) has been investigated in several retrospective studies. The purpose of this study was to identify potential risk factors for both neurologic deterioration and tumor progression after GKRS for previously operated VSs in a prospective setting. METHODS Patients who underwent GKRS for previously operated and histopathologically confirmed VS between 1998 and 2015 were prospectively followed-up. Risk factors for therapy side effects and predictors for tumor control were investigated in uni- and multivariate analyses. RESULTS A total of 160 individuals with a median age of 55 years were included. Median tumor volume prior to GKRS was 1.40 cm3 (range, 0.06-35.80 cm3). After a median follow-up of 36 months, hearing and facial nerve function were serviceable (modified Gardner-Robertson and House-Brackmann grades I and II) in 7 (5%) and 82 (55%) patients, respectively. Deterioration to a nonserviceable facial nerve function after GKRS was found in 3% (3/89) and tended to increase with rising tumor volume (odds ratio, 1.65 per cm3; 95% confidence interval, 1.00-2.71; P = 0.051). Median tumor volume prior to GKRS was higher in patients with radiologic (P = 0.020) or clinical tumor progression (P < 0.001). Critical tumor volume prior to GKRS to predict clinical and radiologic tumor progression was 1.30 cm3 (P < 0.001) and 3.30 cm3 (P = 0.019), respectively. However, in multivariate analyses, none of the analyzed variables were found to independently predict tumor progression. CONCLUSIONS Intended submaximal resection followed by GKRS is a viable treatment for VS. Because tumor remnant size after MS is an important predictor for recurrence after adjuvant GKRS, both brainstem and cerebellar decompression and maximal safely achievable resection should remain major goals of microsurgery.
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Affiliation(s)
- Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | | | - Cristina Sauerland
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | | | | | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.
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Schipmann S, Schwake M, Sporns PB, Voß KM, Sicking J, Spille DC, Hess K, Paulus W, Stummer W, Brokinkel B. Is the Simpson Grading System Applicable to Estimate the Risk of Tumor Progression After Microsurgery for Recurrent Intracranial Meningioma? World Neurosurg 2018; 119:e589-e597. [DOI: 10.1016/j.wneu.2018.07.215] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
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Suero Molina E, Schipmann S, Mueller I, Wölfer J, Ewelt C, Maas M, Brokinkel B, Stummer W. Conscious sedation with dexmedetomidine compared with asleep-awake-asleep craniotomies in glioma surgery: an analysis of 180 patients. J Neurosurg 2018; 129:1223-1230. [DOI: 10.3171/2017.7.jns171312] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/14/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVEAwake craniotomies have become a feasible tool over time to treat brain tumors located in eloquent regions. Different techniques have been applied in neurooncology centers. Both “asleep-awake-asleep” (asleep) and “conscious sedation” were used subsequently at the authors’ neurosurgical department. Since 2013, the authors have only performed conscious sedation surgeries, predominantly using the α2-receptor agonist dexmedetomidine as the anesthetic drug. The aim of this study was to compare both mentioned techniques and evaluate the clinical use of dexmedetomidine in the setting of awake craniotomies for glioma surgery.METHODSThe authors retrospectively analyzed patients who underwent operations either under the asleep condition using propofol-remifentanil or under conscious sedation conditions using dexmedetomidine infusions. In the asleep group patients were intubated with a laryngeal mask and extubated for the assessment period. Adverse events, as well as applied drugs with doses and frequency of usage, were recorded.RESULTSFrom 224 awake surgeries between 2009 and 2015, 180 were performed for the resection of gliomas and included in the study. In the conscious sedation group (n = 75) significantly fewer opiates (p < 0.001) and vasoactive (p < 0.001) and antihypertensive (p < 0.001) drugs were used in comparison with the asleep group (n = 105). Furthermore, the postoperative length of stay (p < 0.001) and the surgical duration (p < 0.001) were significantly lower in the conscious sedation group.CONCLUSIONSUse of dexmedetomidine creates excellent conditions for awake surgeries. It sedates moderately and acts as an anxiolytic. Thus, after ceasing infusion it enables quick and reliable clinical neurological assessment of patients. This might lead to reducing the amount of administered antihypertensive and vasoactive drugs as well as the length of hospitalization, while likely ensuring more rapid surgery.
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Affiliation(s)
| | | | | | | | | | - Matthias Maas
- 2Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital of Münster, Germany
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Schwake M, Adeli A, Sporns P, Ewelt C, Schmitz T, Sicking J, Hess K, Cäcilia Spille D, Paulus W, Stummer W, Brokinkel B. Spinal meningiomas – Risks and potential of an increasing age at the time of surgery. J Clin Neurosci 2018; 57:86-92. [DOI: 10.1016/j.jocn.2018.08.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/13/2018] [Indexed: 11/16/2022]
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Sicking J, Voß KM, Spille DC, Schipmann S, Holling M, Paulus W, Hess K, Steinbicker AU, Stummer W, Grauer O, Wölfer J, Brokinkel B. The evolution of cranial meningioma surgery-a single-center 25-year experience. Acta Neurochir (Wien) 2018; 160:1801-1812. [PMID: 29974236 DOI: 10.1007/s00701-018-3617-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND There have been major developments in diagnostic and surgical and non-surgical techniques used in the management of meningiomas over last three decades. We set out to describe these changes in a systematic manner. METHOD Clinical and radiological data, surgical procedures, complications, and outcome of 817 patients who underwent surgery for primarily diagnosed meningioma between 1991 and 2015 were investigated. RESULTS Median age at diagnosis increased significantly from 56 to 59 years (p = .042), while tumor location and preoperative Karnofsky performance status did not change during the observation period. Availability of preoperative MRI increased, and rates of angiography and tumor embolization decreased (p < .001, each). Median duration of total, pre-, and postoperative stay was 13, 2, and 9 days, respectively, and decreased between 1991 and 2015 (p < .001, each). Median incision-suture time varied annually (p < .001) but without becoming clearly longer or shorter during the entire observation period. The use of intraoperative neuronavigation and neuromonitoring increased, while the rates of Simpson grade I and III surgeries decreased (p < .001). Rates of postoperative hemorrhage (p = .997), hydrocephalus (p = .632), and wound infection (p = .126) did not change, while the frequency of early postoperative neurological deficits decreased from 21% between 1991 and 1995 to 13% between 2011 and 2015 (p = .003). During the same time, the rate of surgeries for postoperative cerebrospinal fluid leakage slightly increased from 2 to 3% (p = .049). Within a median follow-up of 62 months, progression was observed in 114 individuals (14%). Progression-free interval did not significantly change during observation period (p > .05). Multivariate analyses confirmed the lack of correlation between year of surgery and tumor relapse (HR: 1.1, p > .05). CONCLUSIONS Preoperative diagnosis and surgery of meningiomas have been substantially evolved. Although early neurological outcome has improved, long-term prognosis remains unchanged.
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Brokinkel B, Sicking J, Spille DC, Hess K, Paulus W, Stummer W. Letter to the Editor. Brain invasion and the risk for postoperative hemorrhage and neurological deterioration after meningioma surgery. J Neurosurg 2018; 129:849-851. [DOI: 10.3171/2018.5.jns181287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Brokinkel B, Kröger S, Senner V, Jeibmann A, Karst U, Stummer W. Visualizing protoporphyrin IX formation in the dura tail of meningiomas by mass spectrometry imaging. Acta Neurochir (Wien) 2018; 160:1433-1437. [PMID: 29450654 DOI: 10.1007/s00701-018-3488-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/07/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The advantages of 5-aminolevulinacid (5-ALA)-induced fluorescence-guided surgery in meningiomas are increasingly discussed. In this context, despite detectable tumor tissue in histopathologial analyses, no fluorescence was shown at the dura tail using the standard operating microscope. Thus, 5-ALA metabolism in this surgically important site remains unknown but needs to be elucidated when further evaluating indications of fluorescence-guided surgery in meningiomas. METHOD We here present the spatially resolved identification of protoporphyrin IX (PpIX) in sphenoid ridge meningioma cryosections from a patient who underwent fluorescence-guided microsurgery using molecular imaging analysis by matrix-assisted laser desorption/ionization tandem mass spectrometry (MALDI-MS/MS). RESULTS Despite a strong fluorescence of the main tumor, no fluorescence could be detected at the dura tail using the standard operating microscope (blue-light, 405 nm). However, histopathological analyses clearly showed meningioma tissue. Remarkably, MALDI-MS/MS analysis revealed PpIX formation also at the non-fluorescing dura tail. However, no PpIX was detected in the tumor free dura mater. CONCLUSION MALDI-MS/MS visualized a selective accumulation of PpIX within the tumor tissue including the dura tail. Thus, absence of fluorescence in the dura tail as visualized by the operating microscope is not caused by the lack of PpIX formation.
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Affiliation(s)
- Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine-Westphalia, Germany.
| | - Sabrina Kröger
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster, North Rhine-Westphalia, Germany
| | - Volker Senner
- Institute of Neuropathology, University Hospital, Münster, North Rhine-Westphalia, Germany
| | - Astrid Jeibmann
- Institute of Neuropathology, University Hospital, Münster, North Rhine-Westphalia, Germany
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster, North Rhine-Westphalia, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, North Rhine-Westphalia, Germany
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Brokinkel B, Hess K, Mawrin C. Brain invasion in meningiomas-clinical considerations and impact of neuropathological evaluation: a systematic review. Neuro Oncol 2018; 19:1298-1307. [PMID: 28419308 DOI: 10.1093/neuonc/nox071] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
With the release of the 2016 edition of the World Health Organization (WHO) Classification of Central Nervous System Tumors, brain invasion in meningiomas has been added as a stand-alone criterion for atypia and can therefore impact grading and indirectly adjuvant therapy. Regarding this rising clinical importance, we have reviewed the current knowledge about brain invasion with emphasis on its implications on current and future clinical practice. We found various definitions of brain invasion and approaches for evaluation in surgically obtained specimens described over the past decades. This heterogeneity is reflected by weak correlation with prognosis and remains controversial. Similarly, associated clinical factors are largely unknown. Preoperative, imaging-guided detection of brain invasion is unspecific, and intraoperative assessment using standard and new high-magnification microscopic techniques remains imprecise. Despite the increasing knowledge about molecular alterations of the tumor/ brain surface, pharmacotherapeutic options targeting brain invasive meningiomas are lacking. Finally, we summarize the impact of brain invasion on histopathological grading in the WHO classifications of brain tumors since 1979.In conclusion, standardized neurosurgical sampling and neuropathological analyses could improve diagnostic reliability and reproducibility of future studies. Further research is needed to improve pre- and intraoperative visualization of brain invasion and to develop adjuvant, targeted therapies.
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Affiliation(s)
- Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany; Institute of Neuropathology, University Hospital Münster, Münster, Germany; Institute of Neuropathology, Otto-von-Guericke University, Magdeburg, Germany
| | - Katharina Hess
- Department of Neurosurgery, University Hospital Münster, Münster, Germany; Institute of Neuropathology, University Hospital Münster, Münster, Germany; Institute of Neuropathology, Otto-von-Guericke University, Magdeburg, Germany
| | - Christian Mawrin
- Department of Neurosurgery, University Hospital Münster, Münster, Germany; Institute of Neuropathology, University Hospital Münster, Münster, Germany; Institute of Neuropathology, Otto-von-Guericke University, Magdeburg, Germany
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Suero Molina E, Wölfer J, Ewelt C, Ehrhardt A, Brokinkel B, Stummer W. Dual-labeling with 5-aminolevulinic acid and fluorescein for fluorescence-guided resection of high-grade gliomas: technical note. J Neurosurg 2018; 128:399-405. [PMID: 28338432 DOI: 10.3171/2016.11.jns161072] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fluorescence guidance with 5-aminolevulinic acid (5-ALA) helps improve resections of malignant gliomas. However, one limitation is the low intensity of blue light for background illumination. Fluorescein has recently been reintroduced into neurosurgery, and novel microscope systems are available for visualizing this fluorochrome, which highlights all perfused tissues but has limited selectivity for tumor detection. Here, the authors investigate a combination of both fluorochromes: 5-ALA for distinguishing tumor and fluorescein for providing tissue fluorescence of adjacent brain tissue. METHODS The authors evaluated 6 patients who harbored cerebral lesions suggestive of high-grade glioma. Patients received 5-ALA (20 mg/kg) orally 4 hours before induction of anesthesia. Low-dose fluorescein (3 mg/kg intravenous) was injected immediately after anesthesia induction. Pentero microscopes (equipped either with Yellow 560 or Blue 400 filters) were used to visualize fluorescence. To simultaneously visualize both fluorochromes, the Yellow 560 module was combined with external blue light illumination (D-light C System). RESULTS Fluorescein-induced fluorescence created a useful background for protoporphyrin IX (PPIX) fluorescence, which appeared orange to red, surrounded by greenly fluorescent normal brain and edematous tissue. Green brain-tissue fluorescence was helpful in augmenting background. Levels of blue illumination that were too strong obscured PPIX fluorescence. Unspecific extravasation of fluorescein was noted at resection margins, which did not interfere with PPIX fluorescence detection. CONCLUSIONS Dual labeling with both PPIX and fluorescein fluorescence is feasible and gives superior background information during fluorescence-guided resections. The authors believe that this technique carries potential as a next step in fluorescence-guided resections if it is completely integrated into the surgical microscope.
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Affiliation(s)
| | - Johannes Wölfer
- 1Department of Neurosurgery, University Hospital Münster; and
| | - Christian Ewelt
- 1Department of Neurosurgery, University Hospital Münster; and
| | | | | | - Walter Stummer
- 1Department of Neurosurgery, University Hospital Münster; and
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Heß K, Spille DC, Wagner A, Stummer W, Paulus W, Brokinkel B. Letter: Brain Invasion in Meningiomas-Sex-Associated Differences are not Related to Estrogen- and Progesterone Receptor Expression. Neurosurgery 2017; 81:E25-E27. [PMID: 28383708 DOI: 10.1093/neuros/nyx147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Katharina Heß
- Institute of Neuropathology University Hospital Münster, Münster North Rhine-Westphalia, Germany
| | - Dorothee Cäcilia Spille
- Institute of Neuropathology University Hospital Münster, Münster North Rhine-Westphalia, Germany
| | - Andrea Wagner
- Institute of Neuropathology University Hospital Münster, Münster North Rhine-Westphalia, Germany
| | - Walter Stummer
- Department of Neurosurgery University Hospital Münster, Münster North Rhine-Westphalia, Germany
| | - Werner Paulus
- Institute of Neuropathology University Hospital Münster, Münster North Rhine-Westphalia, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery University Hospital Münster, Münster North Rhine-Westphalia, Germany
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