5-Aminolevulinic acid a biomarker for worse prognosis in IDH-wildtype brain tumors? Evolution of a Fluorescence-Positive Diffuse Astrocytoma: Case Report

Introduction  In 2017, the U.S. Food and Drug Administration (FDA) approved 5-aminolevulinic acid (5-ALA) as an intraoperative optical imaging agent in patients with suspected high-grade gliomas (HGGs). However, the application of 5-ALA for low-grade gliomas is still less accepted. Astrocytoma, isocitrate dehydrogenase (IDH) mutant tumors are diffuse infiltrating astrocytic tumors where there is no identifiable border between the tumor and normal brain tissue, even though the borders may appear relatively well-marginated on imaging. Generally, it is considered that 5-ALA cannot pass through a normal blood–brain barrier (BBB). Thus, 5-ALA fluorescence may mean disruption of BBB in grade II glioma.

Case Report  A 74-year-old male patient was diagnosed with a right parietal lesion suggestive of a low-grade brain tumor in a surgical resection using 5-ALA, which led to the detection of tiny fluorescence spots during the surgery. The frozen section was consistent with diffuse astrocytoma, IDH-wildtype (World Health Organization [WHO] grade II). The patient's postoperative magnetic resonance imaging (MRI) showed complete resection. Eight months after surgery, he began experiencing symptoms again and was admitted with a brain MRI finding consistent with recurrent infiltrating astrocytomas. This required reoperation of the brain tumor resection with 5-ALA. Unlike the first surgery, they observed a high fluorescence intensity; the pathological finding was glioblastoma, IDH-wildtype (WHO grade IV). Postsurgical brain MRI showed total resection of the tumor. The patient was discharged 4 weeks after surgery and continued with specialized clinical follow-up.

Conclusion  The use of 5-ALA continues to be a great contributor to the improvement in complete resection of primary brain tumors, especially HGG. Besides, fluorescence is increasingly approaching its use as a prognostic tool for aggressive clinical course, regardless of the initial grade of the tumor. This case report is an effort to expand knowledge for potentially using 5-ALA to help prognosticate brain tumors. Nevertheless, more clinical prospective studies must be conducted.

Gamma knife stereotactic radiosurgery as an effective tool in primary CNS lymphoma: Evaluation of stereotactic radiosurgery and methotrexate treatment in a prospective and observational clinical research study

OBJECTIVE

The purpose of this study was to compare the progression of Primary Central Nervous System Lymphoma (PCNSL) in patients treated with methotrexate (MTX) versus those treated with a combination of Stereotactic Radiosurgery (SRS) and MTX. Progression was measured via brain lesion count and tumor volume.

METHODS

This observational and prospective cohort study evaluated the outcome of SRS treatment of PCNSL in one hundred twenty-eight subjects. We analyzed baseline, prospective, and retrospective data of patients enrolled in the brain tumor registry between June 2010 and August 2017. Seventy-three patients were treated exclusively with MTX while the remaining fifty-five patients received a combination of SRS and MTX. Strict inclusion and exclusion criteria were established.

RESULTS

Mean survival rate for patients receiving combined SRS and MTX treatment was significantly higher (52.6 months) compared to the MTX group (19.8 months); p = 0.0029. At the 36 months follow-up, patients treated with SRS and MTX also had a lower rate of tumor progression (32.7 %) than the MTX group (95.9 %); p = 0.00192. Local tumor control was achieved in all patients treated with SRS. No clinical toxicity was observed in this group.

CONCLUSIONS

Clinical results obtained from this observational study highlight the potential effectiveness of SRS in the treatment of PCNSL. Although treatment outcomes have improved in the past years, additional evidence in the clinical design of randomized trials is needed to evaluate the strength of this treatment in specific situations.

Highly Active Antiretroviral Therapy and Gamma Knife Radiosurgery for the Treatment of AIDS-Related Primary Central Nervous System Lymphoma

BACKGROUND

The criterion standard for the treatment of newly diagnosed primary central nervous system lymphoma (PCNSL) remains high-dose chemotherapy in conjunction with palliative whole-brain radiotherapy; however, there may be a role for novel combined approaches in immunocompromised patients.

CASE DESCRIPTION

A 66-year-old man presented with acute cephalalgia, disorientation, and lethargy. His condition was evaluated in the emergency department, and he was admitted with probable hydrocephalus. Magnetic resonance imaging (MRI) of the brain revealed multiple nonspecific brain lesions, predominantly involving the right temporal lobe, which on biopsy led to a diagnosis of PCNSL. Subsequent laboratory studies demonstrated active human immunodeficiency virus (HIV) infection, with a CD4 count of 21 cells/μL and an HIV viral load (VL) of >400,000 copies/mL. The patient was eventually given highly active antiretroviral therapy (HAART). He declined palliative whole-brain radiotherapy but was amenable to gamma knife radiosurgery (GKRS) for treatment of the right temporal brain lesions. Three months later, the patient's neurologic symptoms had improved; similarly, his CD4 count increased to 176 cells/mL, and his HIV viral load was <90 copies/mL. By the 12-month follow-up visit, the patient was asymptomatic, and at 36 months, MRI of the brain demonstrated total remission without new brain lesions.

CONCLUSIONS

The criterion standard for treatment of newly diagnosed PCNSL remains high-dose chemotherapy in conjunction with palliative whole-brain radiotherapy; however, there may be a role for novel combined approaches using chemotherapy, HAART, and GKRS to have a positive impact on survival rates of PCNSL related to AIDS.

Primary Central Nervous System Lymphoma (PCNSL): Analysis of Treatment by Gamma Knife Radiosurgery and Chemotherapy in a Prospective, Observational Study

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is a rare cancer accounting for less than 3% of primary brain and central nervous system (CNS) tumors. Tissues involved include the brain parenchyma, leptomeninges, eyes, and spinal cord. High-dose methotrexate (MTX) is the gold standard for newly diagnosed PCNSL. However, Gamma Knife radiosurgery (GKRS) may be efficacious as a co-adjuvant treatment. The purpose of this prospective observational cohort study is to determine the effectiveness of MTX in combination with GKRS in the treatment of PCNSL.

METHODS

This is a prospective, observational cohort study evaluating the treatment of histologically confirmed PCNSL with MTX as a single agent in a dose of 8 g/m2 (control) and treatment with MTX, plus GKRS. Strict inclusion and exclusion criteria were employed. Primary outcomes were measured by survival rate. Secondary outcomes were assessed by the tumor's responsiveness to treatment and reduction in size as noted on imaging.

RESULTS

Between January 2007 and January 2012, 128 charts were evaluated. Included in this evaluation were 73 chemotherapy (control) and 55 chemotherapy, plus GKRS, patients (variable). The follow-up period was 24 to 49 months (mean: 36.9 months). There were no statistically significant differences in patient demographics or histology diagnosis. Patients were treated with GK doses ranging from 11 Gy to 16 Gy (median: 11 Gy). The median survival rate from initial diagnosis was 26.8 months in the chemotherapy group and 47.6 in the chemotherapy, plus GKRS, group (p-value: 0.0034). All lesions showed a complete response after GKRS when evaluated using magnetic resonance imaging after three to eight weeks (mean range: 6.3 weeks).

CONCLUSIONS

The use of GKRS is non-invasive, safe, and shows rapid success, improving the prognosis of the patient. This noninvasive treatment modality should be considered as an option for patients with PCNSL. In our study, GKRS as a co-adjuvant therapy to high-dose methotrexate was statistically significant for greater tumor control, enhanced overall survival period, and a lesser number of complications.

Is Subdural Peritoneal Shunt Placement an Effective Tool for the Management of Recurrent/Chronic Subdural Hematoma?

OBJECTIVE : To describe a surgical technique and to report using a retrospective study the efficacy of peritoneal shunts for the treatment of recurrent/chronic subdural hematoma (CSDH). We describe the considerations, complications, and outcomes related to this technique. METHODS : In a retrospective cohort study, 125 charts with a diagnosis of subacute/chronic subdural hematoma were assigned for evaluation. Of the charts reviewed, 18 charts were found from subjects with a diagnosis of recurrent sub-acute or chronic subdural hematoma. All patients had undergone initial surgical treatment of their condition followed by peritoneal shunt placement to help alleviate intracranial pressure. Factors including the age, size of subdural hematoma, number of previous events, BMI, complications, survival, and clinical course were analyzed. RESULTS : After subdural peritoneal shunt placement all patients had full neurological recovery with no complaints of headaches, lethargy, weakness, confusion or seizures. None of the cases had new subdural hematoma episodes after placement for a minimum of a two-year period (mean 26.1 months) (range 24.3-48.6 months). No postoperative complications were reported. The rates of postoperative hemorrhage, infection, distal catheter revision, and perioperative seizures was found to be zero percent. Shunt drainage was successful in all cases, draining 85% of the blood in the first 48 hours. There was no significant relationship between complications and the use of anticoagulants four weeks after surgery.

CONCLUSIONS

Peritoneal shunts, though rarely used, are a viable option in the treatment of sub-acute/chronic subdural hematomas. When pursuing this treatment, this technique is recommended to mitigate the risks of repeat surgical intervention and lessen perioperative time in high-risk patients.