Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

OS08.4.A Analysis of melanoma brain metastasis immune microenvironment through multiplex gene expression profiling

Background

Novel immunotherapies based on targeting of specific immune checkpoints enabled a significant improvement of melanoma outcome, but melanoma brain metastases (BM) remain an unmet oncological need with an overall 2-year survival rate lower than 10%. Tumour immune microenvironment has been demonstrated to play a key role in BM establishment and development, but data regarding the specific milieu of melanoma BM is limited.

Material and Methods

Gene expression profiles of 55 samples of primary melanoma and BM were evaluated using the nCounter PanCancer IO 360 Panel (NanoString Technologies) targeting 770 mRNA involved in tumor immune microenvironment modulation. The case series consisted of 10 primary melanomas and their 10 matched BM, 25 unmatched BM, and 10 locally advanced control melanomas without evidence of BM after >5 year follow up.

Results

Among BM samples, most patients (25/45) were males and median age at BM diagnosis was 61,2 years with a median time to BM development of 2,1 years. Median OS from BM diagnosis was 1,3 years. Several genes resulted significantly downregulated in BM compared to primary melanomas, including SERPINB5 (p<0.001), ARG1 (p=0.0067), S100A8 (p<0.001), S100A9 (p<0.001), S100A12 (p=0.0037), IL1RN (p=0.0012), CCL21 (p=0.0012), CCL22 (p=0.0012) and CCL13 (p=0.037) and SELE (p=0.026); conversely, C7 was upregulated (p<0.001). Downregulated signatures in BM involved those associated with multiple immune cell populations, including neutrophils, dendritic cells, mast cells and Treg, as well as inflammatory chemokines, the CTLA4 immune checkpoint and ARG1 enzyme function; conversely, MAGEs-related signature was upregulated. Comparison between primary melanomas which developed BM and those which did not showed a significant overexpression of RRM2 (p=0.0247) and TNFRSF1A (p=0.032) genes in the latter group and an upregulation of the PD-1 pathway. Analysis according to tumour mutational status showed an upregulation of signatures associated with inflammatory chemokines, dendritic and myeloid cells and neutrophils. No differences were observed according to time to BM development and survival from BM diagnosis.

Conclusion

Our findings show that melanoma BM harbor distinct immunosuppressive mechanisms compared to primary tumors: this data elicits the importance of investigating the heterogeneity of BM microenvironment. Genes and pathways selectively overexpressed or downregulated in melanoma BM should be validated to be possibly considered as novel therapeutic targets.

The post-surgical era of GBM: How molecular biology has impacted on our clinical management. A review

Glioblastoma (GBM) is the most common glioma in adults, with incidence increasing by 3% per year. According to the World Health Organization Classification of Central Nervous System Tumors, GBM is considered a grade IV tumor due to its malignant behavior. The aim of this review is to summarize the main biological aspects of GBM. In particular, we focused our attention on those alterations which have been proven to have an impact on patients' outcome, mainly in terms of overall survival (OS), or on the tumor response to therapies. We have also analyzed the cellular biology and the interactions between GBM and the surrounding environment.

P14.85 Brain metastasis from Hodgkin’s Lymphoma: case report and literature review

BACKGROUND

Central nervous system (CNS) metastases from Hodgkin’s Lymphoma (HL) are very rare, occurring in 0.02–0.5% of cases. They are usually associated to systemic relapse of the disease. Treatment options for HL brain metastases include surgery, radiotherapy, and systemic chemotherapy.

CASE REPORT

A 54 year-old woman presented with thoracic pain and dyspnea. Chest CT showed a thoracic bulky mass larger than 10 cm. Biopsy confirmed HL stage IIA, nodular sclerosing variant. No typical B symptoms, such as fever, night sweats or weight loss, were observed. The patient underwent chemotherapy with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD scheme), followed by 30Gy mediastinic radiotherapy (RT), which led to complete remission in September 2017. After 3 months, she presented with headache and rapidly progressing gait disorder. MRI showed a contrast-enhanced lesion in the right occipital lobe, with central necrosis and massive edema. Total-body CT scan and FDG-PET ruled out either the presence of new solid tumors or systemic relapses of HL. Gross total resection of the brain lesion was carried out, and HL histology was confirmed. CSF analysis from lumbar puncture was normal. Afterwards, the patient underwent 2 cycles of high dose cytarabine, but she rapidly progressed, and received salvage RT (30 Gy). Nevertheless, further systemic progression occurred: the patient developed headache, diplopia and dysphagia and, unfortunately, she died 6 months after the diagnosis of brain metastasis.

DISCUSSION

Thus far, only 45 cases of CNS HL have been reported from 2000 to 2018. Whole brain radiotherapy, with or without chemotherapy, was the most common treatment. In our patient, we chose surgical resection for the solitary brain metastasis followed by chemotherapy, delaying RT at recurrence. In the literature, median overall survival of patients diagnosed with brain metastases from HL is 18 months (1–273): 17 patients (38%) showed a progression (local / systemic: 12/17 - 71%), while 28 (62%) showed complete remission after a median follow-up of 20 months (6–273).

CONCLUSION

Intracranial localisation of Hodgkin’s Lymphoma is a rare entity but still has to be taken into account. Advanced brain imaging could be of help in case of uncertain radiological presentation. A multidisciplinary approach is needed as there is no consensus on the best treatment to choose: surgery, radiotherapy and chemotherapy should be considered on individual basis.

OS1.4 Liquid biopsy of the CSF in a series of GBM patients: preliminary results

BACKGROUND

Liquid biopsy (LB) by cerebrospinal fluid (CSF) can be useful to identify circulating tumour DNA (ctDNA), thus offering information about the heterogeneity of the neoplastic genome. The aim of our study is to assess the effectiveness of LB of the CSF in detecting ctDNA which mirrors the genetic profile of the tumoural tissue, and to investigate the clinical and radiological aspects influencing the availability of ctDNA.

MATERIAL AND METHODS

Tumoral tissue and CSF samples of 13 GBM patients undergoing surgery was collected. CSF was withdrawn from the very proximity of the tumoural surface before the excision. DNA extracted from tissue samples was analysed by qPCR to identify typical genetic alterations such as copy number variations (EGFR, PDGFRA, CDK4, MDM2, CDKN2A), and point mutations (TP53, PTEN, IDH, NRAS, PI3K1, pTERT). CtDNA extracted from CSF was analysed by droplet digital PCR to assess the presence of the alterations found in the matching tissue. Both contrast-enhanced (CE) and FLAIR volumes of the lesions were measured in the pre-surgical MRI. Linear and logarithmic regressions were employed for the statistical analysis.

RESULTS

From June 2016 to February 2017 we prospectively collected 13 GBM patients. Median age was 73 years. All lesions showed CE at the MRI; other radiological findings included necrosis (84.6%), oedema (76.9%), cortical, ventricular or meningeal involvement (76.9%, 30.8%, and 15.4%). Median volumes of CE and FLAIR lesions were 28.6 and 25.5 cm3, with a median FLAIR/CE ratio of 72.9. Surgery was subtotal (<95%) in all patients. All GBM tissues were tested for the following alterations: EGFR, PDGFRA, CDK4, MDM2, CDKN2A; 76.9% were tested for TP53, PTEN, and IDH mutations; 38.5% for NRAS and pTERT mutations; 30.8% for PI3KR1 mutation. MGMT methylation was assessed in 12 cases (92.3%) and found in 7 (58.3%). Median CSF volume, ctDNA quantity and concentration were 0.45 mL, 59.64 ng, and 0.42 ng/μL. Processable DNA was found in 11 CSF specimens (84.6%), in 8 of which (61.5%) it carried the same alteration expressed by the tumoural cells of the matched tissue, while in 3 cases (23.1%) it seemed to have a different genetic profile; finally, in 2 cases it was not possible to detect any circulating DNA in the CSF. Preliminary data on 13 patients suggest that the ctDNA concentration in the CSF could be related to the FLAIR/CE ratio as measured in the MRI before surgery (p = 0.02). Other correlations between the molecular and the radiological features are still being exploring.

CONCLUSION

Our study confirms that LB of CSF can detect ctDNA carrying the same molecular profile harboured in the tumour. Therefore, it seems to be an accurate method to identify markers useful for the diagnosis and the monitoring of the disease. Additionally, our ongoing study is trying to demonstrate a potential correlation between radiological features of the tumour and availability of ctDNA in CSF.

High-frequency electrical stimulation of the subthalamic nucleus in Parkinson's disease: kinetic and kinematic gait analysis

In the advanced phase of Parkinson's disease (PD), gait disturbances represent one of the main causes of disability. Several studies demonstrated that high-frequency electrical stimulation (HFS) of the subthalamic nucleus (STN) significantly improves the motor symptoms of PD. This study was finalised to quantitatively analyze the effect of STN HFS on gait of PD patients, through a three-dimensional gait analysis system. Ten PD patients were studied, with and without STN HFS. The results demonstrated that STN HFS significantly improves all the main gait parameters in PD patients.

Deep brain stimulation of the subthalamic nucleus: anatomical, neurophysiological, and outcome correlations with the effects of stimulation

OBJECTIVES

Bilateral chronic high frequency stimulation of the subthalamic nucleus (STN), through the stereotactical placement of stimulating electrodes, effectively improves the motor symptoms of severe Parkinson's disease. Intraoperative neurophysiological and clinical monitoring techniques (neuronal electrical activity recording and intraoperative stimulation) may improve and refine the localisation of the nucleus. The objective of this work was to compare the preoperative CT and MRI localisation with the intraoperative neurophysiological identification of STN. The relation between the localisation of the STN and the position of the most effective contact of the permanent quadripolar electrode at a 3 month and 1 year follow up was also studied.

METHODS

Fourteen consecutive parkinsonian patients were submitted to bilateral implant for STN stimulation. All the patients underwent a standard MRI and stereotactic CT to obtain, by image fusion and localisation software, the stereotactical coordinates of STN. The STN extension and boundaries were identified by a semimicrorecording of the neuronal electrical activity. The definitive quadripolar electrode was positioned to locate at least two contacts within the STN recording area. Intraoperative macrostimulation was performed to confirm the correct position of the electrode. Postoperative clinical evaluation of the effects of stimulation was checked for each contact of the quadripolar electrode testing the improvement on contralateral rigidity to select the best contact. This evaluation was repeated at 3 months and 1 year after surgery.

RESULTS

In 35.7% of the procedures it was necessary to perform more than one track to get a recording of neuronal activity consistent with STN. The mean position of the central point of all the 28 STN recording areas in respect of the AC-PC line midpoint was 2.7 mm posterior (SD 0.7), 3.8 mm inferior (SD 1.1), and 11.6 mm lateral (SD 0.9), and the mean distance between the anatomical target and the central point of the STN as defined by intraoperative recording was 0.5 mm (SD 0.5) on the anteroposterior plane, 0.7 mm (SD 0.7) on the lateral plane, and 0.9 mm (SD 0.6) on the vertical plane. At 1 year the mean position of the central point of the most effective contact of the electrode in respect of the AC-PC line midpoint was 1.7 mm posterior (SD 0.9), 1.7 mm inferior (SD 1.5), and 12.3 mm lateral (SD 0.9).

CONCLUSION

The results highlight the role of the intraoperative recording to get a more accurate localisation of the STN in surgery for Parkinson's disease, allowing the identification of the boundaries and of the extension of the nucleus. The most effective contact of the quadripolar electrode was always in the upper part of the STN recording area or immediately above it, suggesting a role of this region in the clinical effectiveness of the STN electrical stimulation.

Deep brain stimulation of the subthalamic nucleus in Parkinson's disease: effects of variation in stimulation parameters

OBJECTIVE

To investigate the relation between the variation of the parameters of stimulation and the clinical effectiveness in parkinsonian patients treated with deep brain stimulation of the subthalamic nucleus (STN), to provide information on the electrical parameter setting and the mechanism of action of deep brain stimulation.

METHODS

Ten patients with Parkinson's disease bilaterally implanted in the STN were studied. For every patient the intensity of the stimulus necessary to obtain the disappearance of contralateral wrist rigidity (required clinical effect, RCE) and the side effect threshold in 20 different conditions of stimulation, coupling four pulse width values (60, 120, 210, 450 micros) with five rate values (10, 50, 90, 130, 170 Hz) were determined. All the patients were tested after a 12 hour withdrawal of antiparkinsonian drugs, and the clinical evaluation was double blind.

RESULTS

In all the patients it was impossible to obtain the RCE using 10 and 50 Hz stimulus rates. For all the other stimulus rate values, the intensity-pulse width curves (IPWCs) for the RCE and for the side effect threshold showed a hyperbolic trend. For every pulse width value, increasing the rate from 90 to 130 and to 170 Hz progressively decreased the intensity of the stimulus necessary to reach the RCE, but the differences were not significant. Within the same rate value, the progressive reduction of the stimulus intensity necessary to obtain the RCE, obtained with the lengthening of the pulse width was significant (p<0.05) only comparing 60 with 210 micros and 60 with 450 micros.

CONCLUSIONS

The findings give some useful indications for the electrical parameter setting in deep brain stimulation of the STN, and some information about the mechanism of action of deep brain stimulation.

Acute brain swelling during removal of supratentorial cystic lesion caused by contralateral extradural hematoma: case report

BACKGROUND

Protrusion of the cortex through a bone flap in the course of surgery is a very serious event and, if it persists, the procedure must be suspended, the cause sought, and the problem resolved.

CASE DESCRIPTION

We report the case of a 13-year-old boy whose brain underwent sudden swelling during removal of a supratentorial cystic lesion. The operation was suspended at once and an emergency CT scan was performed. It revealed a large contralateral extradural hematoma, which was removed immediately.

CONCLUSIONS

We considered the following possible mechanisms of the emergency: bleeding of bone at the site of the supposed piercing by the headrest pin and/or a vacuum mechanism consequent upon removal of the large cystic lesion. Our aims are to emphasize the importance of gauging the thickness of a child's skull before fixing the head in the headrest, especially when chronic intracranial hypertension is present, and the need to suspend the operation for CT scanning in the event of uncontrollable brain swelling.

Variations in regional cerebral blood flow investigated by single photon emission computed tomography with technetium-99m-d, l-hexamethylpropyleneamineoxime = l-h during temporary clipping in intracranial aneurysm surgery: preliminary results

Single photon emission computed tomography with technetium-99m-d, l-hexamethylpropyleneamineoxime was used to assess variations in regional cerebral blood flow during temporary clipping in the course of intracranial aneurysm surgery and during the postoperative period in 20 patients, 14 of whom underwent temporary clipping. Of these 14 patients (Group A), 9 had aneurysms of the anterior communicating artery, 2 had aneurysms of the middle cerebral artery, and 3 had aneurysms of the carotid siphon. Temporary clips were applied, according to the site of the lesion, on A1, on the trunk of the middle cerebral artery, or on the trunk of the internal carotid artery. The occlusion time ranged from 2 to 31 minutes. The six patients who did not undergo temporary clipping served as controls (Group B), as follows: three had aneurysms of the posterior communicating artery, one of the anterior communicating artery, one of the middle cerebral artery, and one of the internal carotid artery. All patients were investigated with cerebral single photon emission computed tomography preoperatively, perioperatively, and postoperatively. In all the patients of Group A, the preliminary results of the study show a sharp fall in the perfusion of the territories of the temporarily clipped parent vessel and practically a complete recovery within 2 to 7 days of surgery, with no significant neurological symptoms. No similar disturbance of perfusion was found in the patients of Group B.

Clinical and neuroradiological correlations in a patient with a wandering retained air gun pellet in the brain

The authors present the case of a patient with an air gun pellet that moved from the ventricular system into the subarachnoid space of C2-C3, from where it was successfully removed by interlaminotomy.

Neuralgia of the intermediate nerve combined with trigeminal neuralgia: case report

An unusual case of a combination of trigeminal and intermediate nerve neuralgia is presented, caused by vascular compression of both of the nerve roots by different vessels. Because the neuralgia of the intermediate nerve could be cured by a vascular decompression operation, it is suggested to include it among the hyperactive dysfunction syndromes of cranial nerves caused by vascular compression at the root entry zone of the nerves. Therefore also for treatment of this neuralgia the non-destructive vascular decompression operation should be taken into consideration.

Serial stereotactic biopsy of brain stem expanding lesions. Considerations on 45 consecutive cases

Fourty-five patients affected by brain stem expanding lesions underwent serial stereotactic biopsy between 1978 and 1986. The definitive histological diagnosis allowed the definitive treatment of extrinsic tumours and non-neoplastic lesions. In patients affected from glial tumours the serial stereotactic biopsy allowed the histological grading and the definition of the growth modalities at the superior boundaries of the tumours. These data have been utilized to guide the choice of treatment. The future perspectives of stereotactic biopsies are discussed in view of the therapeutic results obtained in this series and in other series reported in the literature.

Surgical approach to giant aneurysms of the anterior circulation

The surgical approach to cerebral giant aneurysms is still a source of great concern. We describe our experience with giant aneurysms of the anterior circulation and discuss the different surgical techniques adopted. During the period January 1972-December 1985, a total of 33 patients were operated upon at the Istituto Neurologico "C. Besta" of Milan for a giant aneurysm of the anterior circulation. Nineteen cases had suffered subarachnoid haemorrhage before admission; in 14 cases the hospitalization was due to evidence of mass effect on the surrounding neurovascular structures. All aneurysms were directly approached: in 24 cases the neck was occluded by a suitable clip, in 4 cases intramural thrombosis was attempted, in 3 cases the aneurysms were definitively trapped and in one case aneurysmorrhaphy was performed after resection of the sac. Operative mortality was 12%. Long-term follow-up shows good results whenever exclusion of the aneurysm from cerebral circulation had been achieved, either after removal of the sac or not; on the contrary, only fair or poor results were evident when other surgical techniques were adopted, either electively or out of necessity. The importance of intraoperative protection and monitoring of brain function is stressed.

Cell kinetics of neuroepithelial tumors in serial stereotactic biopsies. A new combined approach

33 consecutive patients with brain glial tumors underwent serial stereotactic biopsies and (3H)-thymidine in vitro investigation. The labeling index has been determined in each case and matched with the WHO histological classification. The feasibility and the accuracy of cell kinetics study applied to stereotactic biopsies are discussed in view of future application for prognostic purposes. Particular attention is given to the description of the method.