Prognostic scoring system for surgical treatment of intramedullary spinal cord metastases

Although rare, intramedullary spinal cord metastases (ISCMs) are on the rise, most likely due to prolonged survival and improved outcomes as a result of the advances in cancer treatment for cancer patients. While the management of these lesions remains controversial, surgery for ISCM has recently been advocated for selected patients. We performed a retrospective analysis on 30 patients who were surgically treated for intramedullary spinal cord metastases in order to determine a preoperative prognostic scoring system to guide patient selection for surgical interventions. The scoring system was designed to decide between surgery or other therapeutic procedures. The five parameters selected and employed in the assessment system were: 1) patient's general condition, 2) age, 3) primary site of the cancer, 4) number of other extramedullary metastases and 5) severity of neurologic symptoms. Prognosis could not be predicted from a single parameter. These five factors were added together to give a prognostic score between 1 and 10. The average survival period of patients with a prognostic score between 1 and 3 points was 3 months; 11 patients with a score of 4 and 5 points had a mean survival of 7.63 months, while patients with a prognostic score between 6 and 10 was 14.8 months. According to our prognostic scoring system for surgical treatment of ISCM, surgery should be performed in those patients who score above 6 points, while radiotherapy/chemotherapy or palliative care is recommended for those who score between 1 and 3 points. A prognostic score of 4 and 5 represents a grey area where surgeons must use their judgment on whether to intervene either medically or surgically. This scoring system could facilitate decision-making in the management of patients with intramedullary spinal cord metastases.

The Glioma-IRE project − Molecular profiling in patients with glioma: steps toward an individualized diagnostic and therapeutic approach

Background

This study aimed to characterize the genetic profile of patients with glioma and discuss the impact of next-generation sequencing in glioma diagnosis and treatment.

Methods

Between 2019 and 2022, we analyzed the genetic profile of 99 patients with glioma through the Oncomine Focus Assay. The assay enables the detection of mutations in 52 driver genes, including single nucleotide variants (SNVs), copy number variants (CNVs), and gene fusions. We also collected and analyzed patients’ clinic characteristics and treatment outcomes.

Results

Over a period of 35 months, 700 patients with glioma followed by our neuro-oncology unit were screened, and 99 were enrolled in the study; most of the patients were excluded for inadequate non-morphological MRI or lack/inadequacy of the tissue samples. Based on our findings, most patients with glioma present mutations, such as SNVs, CNVs or gene fusions. Our data were similar to those reported by The Cancer Genome Atlas Program in terms of frequency of SNVs and CNVs, while we observed more cases of gene fusions. Median overall survival, progression-free survival, and time to progression were significantly lower for patients with grade VI glioblastoma than those with other gliomas. Only four patients were offered a targeted treatment based on the mutation detected; however, only one received treatment, the others could not receive the selected treatment because of worsening clinical status.

Conclusion

Routine timely molecular profiling in patients with glioma should be implemented to offer patients an individualized diagnostic approach and provide them with advanced targeted therapy options if available.

Surgical treatment of cerebellar metastases in elderly patients: A threshold that moves forward?

The impact of surgery for cerebellar brain metastases in elderly population has been the object of limited studies in literature. Given the increasing burden of their chronic illnesses, the decision to recommend surgery remains difficult. All patients aged ≥65 years, who underwent surgical resection of a cerebellar brain metastasis from May 2000 and May 2021 at IRCCS National Cancer Institute "Regina Elena", were analyzed. The study cohort includes 48 patients with a mean age of 70.8 years. 7 patients belonged to the II Class according to the RPA classification, 41 to the III Class; the median GPA classification was 1.5. Median pre-operative and post-operative KPS was 60. Median Charlson Comorbidity Index (CCI) was 11; median 5-variable modified Frailty Index was 2. Overall, 14 patients (29%) presented perioperative neurologic and systemic complications. 34 patients (71%) were able to perform adjuvant therapies as RT and/or CHT after surgery. A higher CCI predicted complications occurrence (p = 0.044), while significant factors for a post-operative KPS ≥70, were i) hemispheric location of the metastasis, ii) higher pre-operative KPS, iii) RPA II classification. Median Overall Survival was 7 months. A post-operative KPS <70 (p = 0.004) and a short time interval between diagnosis of the primary tumor and cerebellar metastasis appearance, were predictive for a worse outcome (p = 0.012). Our study suggests that selected elderly patients with cerebellar metastases may benefit from microsurgery to continue their adjuvant therapies, although a high complications rate should be taken in account.

Breast cancer metastasis: is it a matter of OMICS and proper ex-vivo models?

Genomics has greatly increased the understanding of the study of breast cancer (BC) and has shaped the concept of intra-tumor heterogeneity, currently recognized as a propelling force for cancer progression. In this context, knowledge and understanding of metastatic breast cancer (mBC) has somehow lagged behind that of primary breast cancer. This may be explained by the relative scarcity of matched mBC samples, however it is possible that the mutation spectrum obtained from primary BC does not capture the full complexity of the metastatic disease. Here, we provide a few examples supporting this possibility, from public databases. We evoke the need to perform an integrated multi-OMICS characterization of mBC, to obtain a broad understanding of this complex disease, whose evolution cannot be explained solely by genomics. Pertinent to this, we suggest that rather an infrequent use of Patient-Derived –Tumor-Organoids (PDTOs) may be influenced by assuming that the metastatic conditions of PDTOs growth (mPDTOs) should be similar to those of the tissue of origin. We challenge this view by suggesting that the use of “target-organ inspired” growth conditions for mPDTOs, may better fit the emerging knowledge of metastatic disease. Thus, the integrated use of multi-OMICS and of clinically relevant mPDTOs may allow a further understanding of such disease and foster therapeutically relevant advances. We believe that our points may be valid for other solid cancers.

Multidomain and long-term cognitive evaluation in malignant glioma patients

Aim: We performed longitudinal evaluations of the neurocognitive status in glioma patients to describe possible variations over the course of illness. Materials and methods: Glioma patients underwent a complete battery of standardized neuropsychological tests pre-radiotherapy at 6, 12 and 24 months. Results: We enrolled 130 patients, 67.7% of whom had a deficit in at least one cognitive domain. The most affected domains included executive function (n = 68, 52.3%), long-term memory (n = 46, 35.3%) and short-term memory (n = 39, 30%). At follow-up, cognitive status worsened in 31.5%, remained unchanged in 38.4% and improved in 30.1% of patients. Conclusion: This is one of few studies investigating longitudinal neurocognitive status in a wide sample of patients to monitor neuropsychological changes due to tumor progression and treatment administration.

Surgical treatment of solitary intradural extramedullary spinal cord metastases from solid cancers of non-neurogenic origin. A multicenter study

PURPOSE

Intradural extramedullary spinal metastases (IESM) represent an extremely rare manifestation of systemic cancer. We evaluated the surgical indications, complications and outcome in a series of 43 patients with solitary intradural extramedullary metastases originating from solid cancer of non-neurogenic origin.

METHODS

Patients' age, histopathological diagnoses of primary cancer, tumor size, spinal location, and extramedullary tumor dissemination were collected. Preoperative functional status, pre- and post-operative neurological status, extent of the tumor resection were also analyzed.

RESULTS

The majority of IEMS occurred in the thoracic area, with the most common presenting symptoms ranging from motor (76.7%) to sensory (72%) deficits. Gross total resection was achieved in 55.8% of cases, while In 44.2% of patients a subtotal resection was performed due to strong adherence between the tumor and neural tissue. After surgery, 72.1% of patients exhibited improvement of symptoms in terms of pain relief and partial recovery of motor and/or sensory deficits, while neurologic functional status was severely affected postoperatively in 3 patients.

CONCLUSION

Although there was no statistical significance between the different parameters and overall survival, KPS and the presence of other metastases were the strongest prognostic factors for overall survival and postoperative neurologic outcome.

Major Differences in Lymphocyte Subpopulations Between Cerebrospinal Fluid and Peripheral Blood in Non-Hodgkin Lymphoma Without Leptomeningeal Involvement: Flow Cytometry Evidence of a Cerebral Lymphatic System

Cerebrospinal fluid (CSF) flow cytometry has a crucial role in the diagnosis of leptomeningeal disease in onco-hematology. This report describes the flow cytometry characterization of 138 CSF samples from patients affected by non-Hodgkin lymphoma, negative for disease infiltration. The aim was to focus on the CSF non-neoplastic population, to compare the cellular composition of the CSF with paired peripheral blood samples and to document the feasibility of flow cytometry in hypocellular samples. Despite the extremely low cell count (1 cell/µl, range 1.0-35) the study was successfully conducted in 95% of the samples. T lymphocytes were the most abundant subset in CSF (77%; range 20-100%) with a predominance of CD4-positive over CD8-positive T cells (CD4/CD8 ratio = 2) together with a minority of monocytes (15%; range 0-70%). No B cells were identified in 90% of samples. Of relevance, a normal, non-clonal B-cell population was documented in 5/7 (71%) patients with primary central nervous system lymphoma at diagnosis (p<0.0001), suggesting a possible involvement of blood-brain barrier cell permeability in the pathogenesis of cerebral B-cell lymphomas. The highly significant differences between CSF and paired peripheral blood lymphoid phenotype (p<0.0001) confirms the existence of an active mechanism of lymphoid migration through the meninges.

Eribulin in brain metastases of breast cancer: outcomes of the EBRAIM prospective observational trial

Background: Eribulin shows some activity in controlling brain metastasis in breast cancer. Methods: This observational, multicenter study evaluated brain disease control rates, survival and safety in patients with brain metastatic breast cancer treated with eribulin in clinical practice. Results: A total of 34 patients were enrolled (mean age 49 years, 91% with visceral metastases) and 29 were evaluable for brain disease. Fourteen achieved disease control and showed a longer time without progression: 10 months (95% CI: 2.3-17.7) versus 4 months (95% CI: 3.3-4.7) in the control group (p = 0.029). Patients with clinical benefits at 6 months had longer survival. Leukopenia and neutropenia were the most frequent grade 3-4 toxicities. Conclusion: Eribulin confirms its effectiveness in patients with brain metastatic breast cancer. Further studies on larger cohorts are needed to confirm the results.

Surgical treatment of intramedullary spinal cord metastases: functional outcome and complications-a multicenter study

Intramedullary spinal cord metastasis (ISCM) is a rare event in the course of advanced malignancy. Management of these lesions remains controversial. Recently, surgery for ISCM has been advocated for selected patients. We performed a retrospective analysis of the clinical course, complications, and outcome of 30 patients surgically treated for ISCM. Patients' age, histopathological diagnoses of primary cancer, tumor size, spinal location, and extramedullary tumor dissemination were collected. Preoperative functional status, pre- and postoperative neurological status, and extent of the tumor resection were also analyzed. Predominant tumor location was thoracic, followed by cervical and conus medullaris. Lung cancer constituted the majority of primary malignancies. In 9 cases, one of the indications for spinal surgery was to obtain a histopathological diagnosis. On admission, all patients presented with neurological symptoms suggestive of myelopathy. After surgery, 18 patients exhibited improvement of symptoms in terms of pain relief and partial recovery of motor and/or sensory deficits; 6 patients were unchanged, while 6 patients exhibited postoperative deterioration. Median survival time after surgery was 9.9 months. Age > 70 years old, presence of systemic metastases, preoperative neurological non functional status, and lung cancer as primary tumor were all factors associated with a worse survival prognosis. This study did not show a clear survival difference between gross total and subtotal ISCM tumor resection. Patients who underwent gross total resection had a worse functional outcome with respect to patients with only partial resection. Gross total resection with low morbidity must be the surgical target, but when not possible, subtotal resection and adjuvant therapy are a valid therapeutic option.

Hemorrhagic Attitude in Frameless and Frame-Based Stereotactic Biopsy for Deep-Seated Primary Central Nervous System Lymphomas in Immunocompetent Patients: A Multicentric Analysis of the Last Twenty Years

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is a rare manifestation of aggressive extranodal non-Hodgkin lymphoma. In patients with deep-seated lesions, stereotactic brain biopsy (SBB) is an accepted diagnostic procedure to obtain histopathologic confirmation.

OBJECTIVE

The aim of this study was to assess the feasibility, diagnostic yield, safety, and complications of stereotactic procedures in midline and deep-seated PCNSLs.

METHODS

Patients selected had received a histopathologic diagnosis of PCNSL localized in deep-seated midline structures, obtained by SBB. The intraoperative frozen section was executed as an integral part of the procedure. Computed tomography scan was performed after surgery.

RESULTS

A total of 476 SBBs were performed between January 2000 and December 2019 . Of these SBBs, 91 deep-seated lesions had a histologic diagnosis of PCNSL. A significant increase of the incidence of PCNSL compared with all other diseases was observed (P < 0.0001). Eight patients (8.7%) showed a symptomatic hemorrhage, 4 of whom required craniotomy. There were 4 deaths and 2 cases of permanent morbidity. The hemorrhage risk in the PCNSL group was statistically significant (P = 0.0003) compared with other histotypes.

CONCLUSIONS

In suspected cases of PCNSL, a histopathologic diagnosis is necessary to distinguish it from glioblastoma or other, nonmalignant conditions. Deep-seated PCNSLs present a higher risk of biopsy-related morbidity and mortality. Intraoperative frozen section increases the diagnostic yield and reduces the number of sampling procedures. Postoperative computed tomography seems to be warranted in patients with suspected PCNSL.

Oblique Lateral Retroperitoneal Lumbar Pre-Psoas Approach for Vertebrectomy in Cancer Patients: Surgical Technique

Due to the longer survival of cancer patients secondary to improved systemic treatments, there has been a recent increase in the incidence of spinal metastases. Metastatic disease involves the anterior vertebral body in 80% of cases. Progressive osseous invasion may result in pathologic vertebral fractures and neural structure compression. Surgical indications are spinal cord and cauda equina compression or spinal instability in patients with an expected survival of at least 6 months. Tumor resection and spine reconstruction in the lumbar region are technically demanding. Several approaches have recently been developed to access the lumbar spine: anterior lumbar approach (ALIF), lateral and extreme lateral transpsoas lumbar approach (LLIF, XLIF, DLIF), and oblique retroperitoneal lumbar pre-psoas approach (OLIF). Each technique has its advantages and drawbacks. OLIF is an emerging procedure that has progressively been used by spine surgeons. The retroperitoneal space allows direct access to the vertebra, thus avoiding injury to the paraspinal muscles, psoas muscle, and lumbar plexus. Between 2005 and 2017, 14 patients underwent somatectomy and spinal reconstruction using an oblique retroperitoneal lumbar pre-psoas approach at our institution. All were affected by lumbar vertebral metastases from solid and hematological tumors, and all presented a Tokuhashi score ≥ 12. L3 vertebral body was involved in 7 cases, L1 was involved in 3, L2 was involved in 2, and L4 was involved in 2. All patients underwent a lateral retroperitoneal approach to achieve vertebrectomy and spinal reconstruction with a cage. Spinal fixation was completed with pedicle screws and rods in 4 cases. No neurological worsening was noted except in one patient who presented a transitory deficit of the left ileopsoas muscle. The oblique retroperitoneal lumbar pre-psoas approach may be a valuable and feasible technique that is potentially able to significantly reduce tissue trauma in patients while still making it possible to achieve corpectomy and solid reconstruction of lumbar vertebral bodies. To our knowledge, this is the first reported series of patients with lumbar spinal metastases treated with the oblique retroperitoneal lumbar pre-psoas approach.

Schwannomas of the sciatic nerve: A rare and neglected diagnosis. A review of the literature with two illustrative cases

OBJECTIVE

Schwannomas of the sciatic nerve, which is the largest nerve of the human body, are very rare accounting for ≤ 1% of all schwannomas. They often may raise confusion with other more common causes of sciatica, such as lumbar degenerative and inflammatory diseases or spinal tumors, which may often lead to a late correct diagnosis.

PATIENTS AND METHODS

We present two cases of sciatic nerve schwannomas that were recently treated at our Institution, and we review the pertinent English literature on this topic over the last 15 years, yielding twenty three cases to analyze.

RESULTS

Even if sciatic nerve schwannomas are a rare occurrence, a thorough clinical and radiological evaluation of the sciatic nerve should be considered whenever a sciatic pain is not otherwise explained. A positive Tinel sign and a palpable mass along the course of the sciatic nerve may be strong clues to achieve the diagnosis. Combined morphological and advanced functional MRI imaging may help to differentiate benign from malignant peripheral nerve sheath tumors, avoiding unnecessary preoperative biopsy.

CONCLUSIONS

A standard microsurgical technique guided by ultrasound and neurophysiologic monitoring, allows in most of the cases a safe removal of the tumor and very satisfactory post-operative results for the patients.

Neurocognitive evaluation in older adult patients affected by glioma

BACKGROUND

Glioblastoma (GBM) has an increasing incidence and dismal prognosis in older adults. This study evaluated neurocognitive status of an older adult population with GBM and its correlation with clinical and demographical variables.

METHODS

Each patient underwent an extended neuropsychological evaluation by means of a battery of standardized tests describing eight cognitive domains: global function; verbal learning; short- and long-term memory (LTM); executive functions (EFs); abstract reasoning (AR); attention; and visuo-constructional abilities (CA).

RESULTS

We assessed 79 patients with GBM (median age: 74 years). Out of this initial sample, a subgroup of seventeen patients with six-month median time underwent a follow-up test session. 46 out of the 79 patients (58.2%) presented multi-domain cognitive impairment, 24 patients (30.3%) showed single-domain cognitive impairment and only seven (9%) showed no cognitive impairment. Kaplan Meier estimator showed that patients with AR deficit had a poorer prognosis in terms of progression-free survival and overall survival (p < .001). At the multivariate analysis AR (deficit vs non; hazard ratio (HR) = 5.07, 95%; confidence interval (CI): 1.91-13.46; p < .001) was correlated with disease progression and overall survival, AR (deficit vs non; HR = 7.24, 95% CI: 2.58-20.32; p < .001). Eight out of seventeen patients who underwent follow-up test session showed cognitive improvement, five resulted in further deterioration, and four patients remained stable. LTM, EF, and CA were the most affected functions at follow-up, while verbal learning was the most improved one in patients with cognitive improvement.

CONCLUSIONS

Cognitive functioning evaluation should be included among the standard clinical endpoints in the treatment of older adult neuro-oncology patients.

How is stereotactic brain biopsy evolving? A multicentric analysis of a series of 421 cases treated in Rome over the last sixteen years

OBJECTIVE

In recent decades, frame-based (FBB) and frame-less stereotactic brain biopsy (FLB) have played a crucial role in defining the diagnosis and management of expanding intracranial lesions in critical areas. During the same period, there have been significant advances in diagnostic imaging, a shift in surgical strategies towards extensive resection in gliomas and new molecular classification of brain tumors. Taking these advances into account, we have evaluated whether significant changes have occurred over the last sixteen years of our clinical practice in terms of frequency, indications, target selection, and the histologic results of stereotactic brain biopsy (SBB) procedures.

PATIENTS AND METHODS

We analyzed a series of 421 SBB cases treated between January 2002 and June 2017 in three major neurosurgical institutes in Rome, serving a total of 1.5 million people. Within this series, 94.8% of patients underwent FBB, while, more recently, FLB was performed in 5.2% of cases. The entire period under consideration, running from 2002 to 2017, has been further stratified into four-year time-frames (2002-2005, 2006-2009, 2010-2013, 2014-2017) for the purpose of analysis.

RESULTS

The diagnostic yield was 97%. Final diagnoses revealed tumors in 90% of cases and non-neoplastic masses in 7%, while 3% of cases were not conclusive. The morbidity rate was 3% (12 cases) and mortality was 0.7% (3 cases). Intra-operative frozen sections were made in 78% of biopsies. In our three institutes, the number of SBBs decreased steadily throughout the time-frames under consideration. We have also observed a statistically significant reduction in biopsy procedures in lobar lesions, while those performed on the basal ganglia increased and the number of SBBs of multiple masses and lesions of the corpus callosum remained stable. Primary central nervous system diagnosis of lymphomas (PCNSL) was the sole diagnosis whose incidence increased significantly.

CONCLUSIONS

Over the last sixteen years, we have witnessed a significant decrease in SBB procedures and a modification in target selection and histologic results. Despite the significant evolution of neuroimaging, an accurate non-invasive diagnosis of intracranial expanding lesions has not yet been achieved. Furthermore, the most recent WHO classification of brain tumors (2016), which incorporates molecular and morphological features, has boosted the need for molecular processing of tissue samples in all expanding brain lesions. For these reasons, it is likely that SBBs will continue to be performed in specific cases, playing a significant role in diagnostic confirmation by providing tissue samples, so as to better assess the biology and the prognosis of cerebral lesions, as well as their sensitivity to standard radio-chemotherapy or to new molecular target therapies.

Epigenetic silencing of miR-145-5p contributes to brain metastasis

Brain metastasis is a major cause of morbidity and mortality of lung cancer patients. We assessed whether aberrant expression of specific microRNAs could contribute to brain metastasis. Comparison of primary lung tumors and their matched metastatic brain disseminations identified shared patterns of several microRNAs, including common down-regulation of miR-145-5p. Down-regulation was attributed to methylation of miR-145's promoter and affiliated elevation of several protein targets, such as EGFR, OCT-4, MUC-1, c-MYC and, interestingly, tumor protein D52 (TPD52). In line with these observations, restored expression of miR-145-5p and selective depletion of individual targets markedly reduced in vitro and in vivo cancer cell migration. In aggregate, our results attribute to miR-145-5p and its direct targets pivotal roles in malignancy progression and in metastasis.

Brain stereotactic biopsy flow cytometry for central nervous system lymphoma characterization: advantages and pitfalls

BACKGROUND

Brain stereotactic biopsy (SB) followed by conventional histopathology and immunohistochemistry (IHC) is the gold standard approach for primary central nervous system lymphoma (PCNSL) diagnosis. Flow cytometry (FCM) characterization of fine-needle aspiration cytology and core needle biopsies are increasingly utilized to diagnose lymphomas however, no biological data have been published on FCM characterization of fresh single cell suspension from PCNSL SB. The aim of this study was to establish the feasibility and utility of FCM for the diagnosis and characterization of brain lymphomas from a tissue samples obtained by a single SB disaggregation.

METHODS

Twenty-nine patients with a magnetic resonance suggestive for PCNSL entered the study. A median of 6 SB were performed for each patient. A cell suspension generated from manual tissue disaggregation of a single, unfixed, brain SB, was characterized by FCM. The FCM versus standard approach was prospectively compared.

RESULTS

FCM and IHC showed an high degree of agreement (89 %) in brain lymphoma identification. By FCM, 16 out of 18 PCNSL were identified within 2 h from biopsy. All were of B cell type, with a heterogeneous CD20 mean fluorescence intensity (MFI), CD10 positive in 3 cases (19 %) with surface Ig light chain restriction documented in 11 cases (69 %). No false positive lymphomas cases were observed. Up to 38 % of the brain leukocyte population consisted of CD8 reactive T cells, in contrast with the CD4 positive lymphocytes of the peripheral blood samples (P < 0.001). By histopathology, 18 B-PCNSL, only one CD10 positive (5 %), 1 primitive neuroectodermal tumor (PNET) and 10 gliomas were diagnosed. A median of 6 days was required for IHC diagnosis.

CONCLUSION

Complementary to histopathology FCM can contribute to a better characterization of PCNSL, although necrosis and previous steroid treatment can represent a pitfall of this approach. A single brain SB is a valid source for accurate FCM characterization of both lymphoma and reactive lymphocyte population, routinely applicable for antigen intensity quantification and consistently documenting an active mechanism of reactive CD8 T-lymphocytes migration in brain lymphomas. Moreover, FCM confirmed to be more sensitive than IHC for the identification of selected markers.

Intraoperative radiation therapy as adjuvant treatment in locally advanced stage tumours involving the middle ear: a hypothesis-generating retrospective study

The objective of this study was to evaluate the safety, effectiveness and functional outcomes of intraoperative radiotherapy (IORT) followed by intensity-modulated radiation therapy (IMRT) in locally advanced stage tumours involving the middle ear. Data on 13 consecutive patients treated for malignant tumor of external auditory canal involving the middle ear were retrospectively reviewed. Median follow-up was 33 months (range 6-133). Five (38%) patients were stage III and 8 (62%) were Stage IV according to the University of Pittsburgh staging system. Lateral temporal bone resection (LTBR) was performed in all cases. LTBR was associated with parotidectomy in 5 (38%) cases, and with neck dissection and parotidectomy in 6 (46%) cases. No patients had gross residual tumour. Surgical treatment was followed by IORT (12 Gy) and IMRT (50 Gy). Adjuvant chemotherapy was used in 4 (30%) cases. Preoperative and postoperative audiometric tests were performed to assess hearing loss. 5-year local-control (LC), 5-year distant-metastasis (DM), 5-year disease-free-survival (DFS) and 5-year overall-survival (OS) were calculated with Kaplan-Meyer method. Significant changes in bone conduction were reported after treatment. Partial flap necrosis was the only early complication observed in three (23%) cases, while meningeal fistula was seen in one (7.6%) case as a late complication. The 5-year LC-rate was 68%. The 5-year DM-rate was 90%. The 5-year DFS-rate was 61%. The 5-year OS-rate was 69%. IORT followed by IMRT for the treatment of advanced external auditory canal and middle ear tumours seems to be safe. No intraoperative death was reported. IORT may reduce the postoperative irradiation of remnant tissue obtaining the same full dose on the tumour bed. No complications of the residual external ear were observed. Detriment of neurosensory hearing may be expected. Future studies are required to confirm the benefit of this procedure in the ear.

Home palliative care and end of life issues in glioblastoma multiforme: results and comments from a homogeneous cohort of patients

OBJECT

Glioblastoma multiforme (GBM) is a rare tumor whose prognosis has remained poor over the years despite innovative radio- and chemotherapies, and important technical advances in neurosurgery such as intraoperative imaging, fluorescence, Cavitron ultrasonic surgical aspirator, and neuronavigation. Particular attention has been dedicated in the last years to the end of life (EOL) period in cancer patients for both ethical and socioeconomic issues. Good palliative care at home avoids improper and expensive hospitalizations, and helps and trains families, caregivers, and patients in facing a difficult situation.

METHODS

In 2012-2013 the authors' group cared for 197 patients with brain tumors. Of these there were 122 with GBMs: 64 died and 58 are still receiving assistance. The clinical conditions are periodically evaluated with the following scales: Barthel Index, Karnofsky Performance Scale, and Mini-Mental State Examination. Home care staff includes 2 neurologists, 5 nurses, 2 psychologists, 3 rehabilitation therapists, and 1 social worker. The intensity of care changes at the different stages of disease, ranging from low to medium levels of intensity at the progression stage (more than 1 access weekly) to high levels of intensity at the EOL stage (at least 3 accesses weekly). Control MRI studies are obtained every 3 months before terminal progression.

RESULTS

Overall in this sample of patients there were 2838 home visits and 11,714 days of assistance. Thirty-four patients (14 female and 20 male) died at home (53.1%); 22 (13 female and 9 male) at the hospice (34.4%); and 8 (4 female and 4 male) at the hospital (12.5%). A positive impact on caregivers for home assistance was recorded in 97% of cases, for nursing in 95%, communication in 90%, rehabilitation at home in 92%, and social work help in 85%. Also, 72% had an improvement in their quality of life scores due to rehabilitation. End of life palliative sedation with midazolam was necessary in 11% of cases to obtain good control of symptoms such as uncontrolled delirium, agitation, death rattle, or refractory seizures. Intramuscular phenobarbital is the authors' drug of choice for the severe seizures that occurred in 30% of cases. The reduction of steroid dosage is also used to decrease wakefulness. Steroids were withdrawn in 45% of patients dying at home, mild hydration was done in 87%, and tube feeding in 13%. The decision-making process at the EOL stage is time consuming, but the degree of distress of the family is inversely proportional to the extent of the preparatory period.

CONCLUSIONS

A previous paper showed the positive cost-effectiveness of home assistance for a larger group of patients dealing with any kind of malignant brain tumors. The same is enhanced for patients with GBM. This requires a well-trained neuro-oncology team that manages neurological deterioration, clinical complications, rehabilitation, and psychosocial problems with a multidisciplinary approach.

Radionecrosis induced by stereotactic radiosurgery of brain metastases: results of surgery and outcome of disease

Sterotactic radiosurgery (SRS) is an effective and commonly employed therapy for metastatic brain tumors. Among complication of this treatment, symptomatic focal cerebral radionecrosis (RN) occurs in 2-10 % of cases. The large diffusion of combined therapies as SRS followed by WBRT and/or CHT, has significantly amplified the number of patients who potentially might be affected by this pathology and neurosurgeons are increasingly called to treat suspected area of RN. Results of surgery of RN in patients with brain metastases are rarely reported in literature, a standardization of diagnostic work-up to correctly identify RN is still lacking and the timing and indications in favour of surgical therapy over medical treatments are not clear as well. In this retrospective study, we review current concept related to RN and analyze the outcome of surgical treatment in a series of 15 patients previously submitted to SRS for brain metastases and affected by suspected radionecrotic lesions. After surgery, all patients except one neurologically improved. No intra-operative complications occurred. Brain edema improved in all patients allowing a reduction or even suspension of corticosteroid therapy. Pure RN was histologically determined in 7 cases; RN and tumor recurrence in the other 8. Overall median survival was 19 months. An aggressive surgical attitude may be advisable in symptomatic patients with suspected cerebral RN, to have histologic confirmation of the lesion, to obtain a long-lasting relief from the mass effect and brain edema and to improve the overall quality of life, sparing a prolonged corticosteroid therapy.

Brain metastases from solid tumors: disease outcome according to type of treatment and therapeutic resources of the treating center

Background

To evaluate the therapeutic strategies commonly employed in the clinic for the management of brain metastases (BMs) and to correlate disease outcome with type of treatment and therapeutic resources available at the treating center.

Methods

Four Cancer centres participated to the survey. Data were collected through a questionnaire filled in by one physician for each centre.

Results

Clinical data regarding 290 cancer patients with BMs from solid tumors were collected. Median age was 59 and 59% of patients had ≤ 3 brain metastases. A local approach (surgery and stereotactic radiosurgery) was adopted in 31% of patients. The local approach demonstrated to be superior in terms of survival compared to the regional/systemic approach (whole brain radiotherapy and chemotherapy, p = <.0001 for survival at 2 years). In the multivariate analysis local treatment was an independent prognostic factor for survival. When patients were divided into 2 groups whether they were treated in centers where local approaches were available or not (group A vs group B respectively, 58% of patients with ≤ 3 BMs in both cohorts), more patients in group A received local strategies although no difference in time to brain progression at 1 year was observed between the two groups of patients.

Conclusions

In clinical practice, local strategies should be integrated in the management of brain metastases. Proper selection of patients who are candidate to local treatments is of crucial importance.

Low-dose fotemustine for recurrent malignant glioma: a multicenter phase II study

Fotemustine at the conventional dose of 100 mg/m(2) is an active treatment for recurrent malignant gliomas (RMGs). However, it is associated with a relevant incidence of severe myelotoxicity, which is not justified in the palliative setting of this disease. This study was conducted to address whether administration of fotemustine at 60 mg/m(2) (induction) followed by 75 mg/m(2) (maintenance) would preserve clinical activity with the advantage of improved tolerance. Forty patients with RMGs pretreated with ≤2 lines of chemotherapy were enrolled. Median age was 57 years (26-80) and median Karnofsky performance status was 80 (60-100). Thirty-one patients (77.5%) had tissue available for analysis of the O(6)-methylguanine methyltransferase (MGMT) gene promoter which was found to be methylated in 14 cases (45%). Overall, 8 partial responses (20%) and 13 disease stabilizations (32.5%) were observed for a disease-control rate of 52.5%. At 6 months, 21% of patients were free from progression. Grades 3 and 4 platelet and white blood cell toxicity occurred in ≤10% of patients, and no patients discontinued treatment because of toxicity. No significant difference was observed for disease control rate between methylated and unmethylated patients, although a trend toward improved progression-free survival was reported for methylated patients. Low-dose fotemustine has activity comparable with that of the full-dose regimen, therefore it should be preferred for its greater tolerability. The role of MGMT gene promoter methylation status in relation to sensitivity to fotemustine is still unclear and needs further evaluation in future clinical trials.

Spontaneous cerebrospinal fluid rhinorrhea as the presenting symptom of sellar pathologies: three demonstrative cases

Spontaneous rhinorrhea due to sellar pathologies is a rare and insidious disease that may represent a diagnostic challenge. Since the precipitating cause is not apparent in most patients, delayed diagnosis and/or improper treatments are not uncommon and may be detrimental for the patients. The precise mechanisms of such rhinorrhea are still incompletely understood. Proposed etiological factors include constant cerebrospinal fluid pulsations against the anterior skull base transmitted by primitive or acquired arachnoid invaginations in combination with either elevated ICP or congenital/pathologic erosions of sellar and parasellar bone structures. Advances in the diagnosis and surgical techniques have recently modified the decision-making approach to this pathology. The present paper reports three unusual cases of sellar pathologies revealed by rhinorrhea as the first symptom discussing controversial issues on pathogenesis, complications and current management of this kind of fistula.

Unilateral limited laminectomy as the approach of choice for the removal of thoracolumbar neurofibromas

STUDY DESIGN

The paper reports a minimally invasive approach to the dorsolumbar spine for the removal of neurofibromas.

OBJECTIVES

Demonstrating that a limited unilateral approach is the one of choice for this kind of tumors.

SUMMARY OF BACKGROUND DATA

Spinal intradural extramedullary tumors are generally removed by single-level or multilevel laminectomy with midline dural incision. Cases of delayed postoperative kyphosis and spinal instability (6%) may be reduced by unilateral microsurgery, causing minimum damage to ligaments and joints.

METHODS

Ten patients with dorsolumbar neurofibroma were operated on between June 2000 and June 2002. There were 5 males (all with lumbar) and 5 females (2 with lumbar and 3 with inferior dorsal neurofibromas). One female had 3 lumbar tumors and required two operations. Surgery was performed in the prone position with a unilateral approach, sparing the joint and the ligamentum interspinosum. The dura was opened paramedially and the tumor dissected from the root and removed in one piece when possible. Water-tight dural closure was done with 5-0 or 6-0 stitches.

RESULTS

All the patients were mobilized on day 2 and discharged on day 4 or day 5. No complications resulting from the technique were observed. Static and dynamic plain radiograph films showed that none of them had kyphosis and/or instability 6 months postoperatively. Neurologic results were good.

CONCLUSIONS

Hospital stay may be reduced and stability may be preserved with an appropriate microsurgical technique. The technique reported in the paper should thus become the one of choice and extended to other spinal intradural extramedullary tumors.

Tanycytic ependymoma of the spinal cord. Case report and review of the literature

OBJECTIVE AND IMPORTANCE

We report a rare case of the tanycytic variant of intramedullary ependymoma. Tanycytes are the common progenitor cells of both ependymal cells and astrocytes. These particular elongate unipolar and bipolar ependymal cells extend from the ventricular lumen to the surface of the nervous system. It is extremely important, in terms of both management and prognosis, to distinguish intramedullary tanycytic ependymomas from intramedullary astrocytomas although a correct histological diagnosis may be difficult since tanycytes resemble astrocytes.

CASE REPORT

A 39-year-old woman underwent surgical treatment for a cervical intramedullary tumor in our department. Although pathological examination of frozen sections was suggestive of low-grade astrocytoma, the definitive histological diagnosis was "tanycytic" ependymoma, a tumor characterized by poor cellularity, elongated elements mixed with fibrillary components, rare pseudo-rosettes and mixed astro-ependymal aspects. Since a complete resection was performed at surgery, no further treatment was proposed. After a follow-up period of two years the patient is free from recurrence.

CONCLUSION

Tanycytic ependymomas should be managed in the same way as "ordinary" ependymomas, since there is no current evidence suggesting that these morphologically distinct tumors differ in terms of biological behavior. Increased awareness of this transitional form of intramedullary ependymoma among neurosurgeons and pathologists may avoid incorrect surgical approaches and postoperative treatment.

Temozolomide chemotherapy for progressive low-grade glioma: clinical benefits and radiological response

BACKGROUND

The optimal treatment for low-grade glioma (LGG) is still controversial. Recent data indicate a potential influence of chemotherapy on the natural evolution of these tumors, allowing for the deferral of more aggressive therapies.

PATIENTS AND METHODS

Forty-three patients affected with LGG (29 astrocytoma, four oligodendroglioma and 10 mixed oligo-astrocytoma) were treated with temozolomide (TMZ) at the time of documented clinical and radiological progression. McDonald's response criteria were utilized to evaluate TMZ activity. Thirty patients (69.7%) had previously received radiotherapy; 16 (37.2%) had received prior chemotherapy. Clinical benefit was evaluated measuring seizure control, reduction in steroid dose and modification of Karnofsky performance status and Barthel index. Quality of life was assessed with the QLQ-C30 questionnaire.

RESULTS

We observed a complete response in four patients, 16 partial responses, 17 stable disease (with four minor response) and six progressive disease. Median duration of response was 10 months [95% confidence interval (CI) 8-12], with a 76% rate of progression free survival (PFS) at 6 months, and a 39% rate of PFS at 12 months. A relevant clinical benefit was observed particularly in patients presenting epilepsy.

CONCLUSIONS

The high response rate of 47% (95% CI 31% to 61%) confirms that TMZ chemotherapy is a valid option in the treatment of progressive LGG. The present preliminary results seem interesting and warrant further evaluation of TMZ clinical activity in a larger series of progressive LGG.

Sphenoidal metastasis from prostate carcinoma. Case report and review of the literature

A case of an uncommon sphenoidal metastasis from prostate carcinoma with cranial nerve involvement is described. Current concepts of metastatic spread of this tumor to the skull base, clinical signs and therapeutic approaches are reviewed in the light of the available literature.

Pharmacologic reversal of cortical hyperexcitability in patients with ALS

OBJECTIVE

To reverse the profile of abnormal intracortical excitability in patients with ALS by administering drugs that promote GABAergic transmission.

BACKGROUND

Transcranial magnetic stimulation (TMS) has revealed abnormalities of cortical inhibition in ALS, a reduction of the silent period, and the absence of intracortical inhibition normally occurring in response to paired TMS. Impaired inhibitory transmission could play a role in the physiopathology of this illness.

METHODS

Using paired TMS with conditioning stimuli from 1-to-6-msec-interstimulus intervals, we investigated 16 patients with ALS. The protocol included: (1) the "drug-free" profile of paired TMS; (2) paired TMS 30 minutes after the intake of diazepam (3.5 mg); (3) paired TMS after 3 weeks' treatment with gabapentin (GBP) (600 mg/day) or riluzole (50 mg/twice a day).

RESULTS

Intracortical inhibition is lost in patients with ALS, and this abnormal profile is reversed by diazepam or sustained treatment with GBP. We also noted that motor-evoked potential amplitudes to single stimuli increased (p<0.01) after diazepam and GBP.

CONCLUSIONS

The demonstration of pharmacologic reversal of hyperexcitability in patients with ALS makes a potentially significant contribution toward understanding the pathophysiology of a disease that has so far eluded an effective cure.

The effect of benzodiazepines and flumazenil on motor cortical excitability in the human brain

In the present study, the effects of benzodiazepines (diazepam) were evaluated in terms of cortical excitability changes, as tested with transcranial magnetic simulation (TMS). In particular, analyzed were drug-induced changes regarding two selected parameters of TMS: (1) the cortical excitability threshold and (2) the silent period duration (SP). For this purpose, we evaluated the effects of long-term therapy with diazepam in the patients affected by anxiety disorders and the changes induced by single oral doses of diazepam in both healthy controls and patients. In addition, we tested cortical excitability changes in two 'extreme conditions' where a considerable concentration of serum benzodiazepine-like activity was reached, as represented by diazepam overdose and idiopathic recurrent stupor (IRS). In both groups of patients, a significant increment of motor threshold was found, while in the overdose patients, the SP was also increased. The administration of flumazenil in these two conditions was followed by a prompt reversal effect, consisting of a return to normal cortical excitability parameters. The long-term usage of diazepam in patients with anxiety disorders is associated with significantly increased threshold; the increased value of these parameters was temporarily further enhanced by the administration of a single oral dose of diazepam, which, in normal control subjects, is not associated with changes of cortical excitability. The results of this study reveal that different physio-pathological conditions induced by the influence of benzodiazepine and its antagonist are reflected in excitability changes which attest to the involvement and modification of cortical GABAergic activity.

Ipsilateral motor activation in patients with cerebral gliomas

OBJECTIVE

The aim of this study is to provide neurophysiologic evidence of ipsilateral hemispheric activation in patients affected by intracerebral gliomas via the use of transcranial magnetic stimulation.

BACKGROUND

The mechanisms involved in such ipsilateral activation have yet to be established, but they may involve preexisting routes that either are suppressed or undetected in the normal brain. Ipsilateral pathways may act in reserve, activated by the impairment of contralateral control. This hypothesis is suggested by the fact that the considerable size of the tumors in our patients is not matched by a proportionate loss of motor performance in the limbs contralateral to the affected hemisphere. However, it remains possible that ipsilateral motor-evoked potentials (iMEPs) may reflect reorganizational changes without significant functional effects.

METHODS

The effects of such activation were investigated using both focal and nonfocal coils stimulating cortical motor areas, with MEPs recorded from both left and right thenar muscles. Fifteen healthy control subjects and seven patients were examined.

RESULTS

iMEPs were generally absent in normal subjects, but in contrast they were obtained in the patients by stimulating the healthy hemisphere using both round and figure-of-eight coils. Distinct from contralateral MEPs, iMEPs are obtained with higher thresholds (range, 60 to 80% of stimulator output) and display longer latencies (20.9 msec versus 19.4 msec).

CONCLUSIONS

Taken in conjunction with recent research using functional imaging brain exploration and a variety of clinical, anatomic, and neurophysiologic studies, our results reflect a growing awareness of ipsilateral motor control and its potential compensatory role when contralateral routes are damaged.