P14.24 Estimating survival outcomes in elderly (70+ years) patients with primary glioblastoma

BACKGROUND

Elderly patients with glioblastoma are perceived to face a poor prognosis, with perceptions around older age and a relative lack of randomized data raising a concern about their undertreatment. The EANO guidelines recommend >70-year-old patients with good performance status to undergo maximal safe resection followed by hypofractionated (40 Gy in 15 fractions, i.e. RT40/15) radiotherapy with or without concurrent and adjuvant Temozolomide (TMZ), depending on MGMT promoter methylation. This study evaluated the relative survival impact of biological, histological, surgical and oncological factors and aimed to devise a scoring system to estimate the survival of elderly glioblastoma patients, with an aim to more accurately guide treatment in this cohort.

METHODS

The records of 169 elderly (≥70 years) patients with a new diagnosis of IDH-wild type glioblastoma were retrospectively examined for gender, age, WHO performance status (PS), comorbidities, MGMT methylation, surgical intervention and chemoradiation regime. The adjusted survival impact of these factors was determined using Cox proportional hazards model and used to devise a two-stage scoring system to estimate survival of patients at the stage of surgical (Elderly Glioblastoma Surgical Score, EGSS) and oncological management (Elderly Glioblastoma Oncological Score, EGOS).

RESULTS

The overall median survival (MS) of the cohort was 28.8 weeks. Subtotal resection (MS=27.7 weeks, 95%CI 24.1–31.6 weeks, HR=0.58) and gross-total resection (MS=77.8 weeks, 95%CI 67.0–88.6 weeks, HR=0.36) were associated with significant overall survival benefit compared to biopsy alone (MS=18.2 weeks, 95%CI 15.7–20.7 weeks, HR=5.23), p<0.05. Hypofractionated radiation with Temozolomide (RT40/15+TMZ, MS=60.9 weeks, 95%CI 49.9–71.8 weeks, HR=0.13) was non-inferior to the Stupp protocol (RT60/30+TMZ, MS=50.6 weeks, 95%CI 32.4–66.7 weeks, HR=0.11), p=0.72. Negative prognosticators included age above 75 years, biopsy alone and no chemoradiotherapy. Subgroup analysis revealed that MGMT unmethylated 70–75 year old patients who received the Stupp protocol had significantly improved overall survival (MS=57.6 weeks, 95%CI 27.7–88.1 weeks) compared to standard of care RT40/15 alone (MS=29.7 weeks, 95%CI 7.1–51.6 weeks), p=0.002. EGSS and EGOS scores estimated survival with 65% and 73% accuracy, respectively.

CONCLUSION

When appropriate and safe, a subgroup of elderly glioblastoma patients may benefit from more aggressive surgical and oncological management. The proposed EGSS and EGOS scores takes into account important prognostic factors to help guide which patients should receive such treatment.

Resting connectivity predicts task activation in pre-surgical populations

Injury and disease affect neural processing and increase individual variations in patients when compared with healthy controls. Understanding this increased variability is critical for identifying the anatomical location of eloquent brain areas for pre-surgical planning. Here we show that precise and reliable language maps can be inferred in patient populations from resting scans of idle brain activity. We trained a predictive model on pairs of resting-state and task-evoked data and tested it to predict activation of unseen patients and healthy controls based on their resting-state data alone. A well-validated language task (category fluency) was used in acquiring the task-evoked fMRI data. Although patients showed greater variation in their actual language maps, our models successfully learned variations in both patient and control responses from the individual resting-connectivity features. Importantly, we further demonstrate that a model trained exclusively on the more-homogenous control group can be used to predict task activations in patients. These results are the first to show that resting connectivity robustly predicts individual differences in neural response in cases of pathological variability.

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A method for identifying eloquent areas in the brain from resting fMRI is proposed.

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It uses supervised learning to predict task contrasts from resting connectivity.

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Good predictions were obtained in controls and in pre-surgical patient populations.

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Patient diagnoses included epilepsy, tumours, and vascular lesions.

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Language maps in patients could be predicted from models trained on controls.

Primary intraosseous meningioma: an osteosclerotic bone tumour mimicking malignancy

BACKGROUND

Sclerotic tumours of the calvarial bones are rare and may be due to primary and secondary bone tumours as well as extradural tumours of meningeal origin.

CASE PRESENTATION

We report a case of primary intraosseous meningioma (PIM) which arose in the frontal bone of a 63 year old woman who complained of progressive pain and thickening of the right skull. Radiology showed a large osteosclerotic lesion in the right frontal bone. Histology showed an intraosseous lesion containing dense fibrous tissue in which there were scattered cells that expressed epithelial membrane antigen and progesterone receptor. The tumour was partially resected and 3 years after operation has not recurred.

CONCLUSIONS

PIM is a rare tumour which needs to be distinguished from primary/secondary osteosclerotic calvarial bone tumours.

Asphaltene detection using surface enhanced Raman scattering (SERS)

Surface enhanced Raman spectroscopy using a gold substrate and excitation at 514 nm can detect sub parts per million quantities of asphaltene and thereby petroleum.

Diagnostic and prognostic markers in gliomas - an update

Gliomas are the most common primary central nervous system tumour seen in adults. There have been many advances over the last two decades as we widen our search for a molecular basis of gliomagenesis. Many biomarkers have been discovered to be important in the management of gliomas, including 1p19q co-deletion, MGMT promoter methylation, BRAF and IDH1 mutations. In this review, we attempt to summarise the available literature on these biomarkers and their use in the diagnosis and management of gliomas. We pay special attention to the recently discovered IDH1 mutation, which is already proving to be a valuable new marker for favourable prognosis and may also indicate a greater response to therapy. 1p19q co-deletions have been shown to delineate a clinically distinct tumour type and are now routinely tested for in certain situations and can help direct treatment. MGMT promoter methylation is one of the most commonly studied biomarkers in gliomas. It has been shown to be a strong positive prognostic marker in gliomas, with positive tumours being more sensitive to chemotherapy. However, a lack of alternatives means that it is not yet a routine mutation tested for clinically. BRAF mutations are new markers found in pilocytic astrocytomas. Although the prognostic value of such mutations is not yet known, they may play a significant role in the diagnosis and treatment of such tumours. IDH1 mutations are 'the new kid on the block' and seem to play a central role in the pathogenesis of gliomas. They represent an independent and favourable prognostic marker and are a new molecular marker for disease diagnosis. Its role in determining response to chemotherapy is still controversial but with further study, IDH1 mutations may prove to be an invaluable marker in the management of gliomas.

Progressive tension pneumocephalus as a delayed postoperative complication in the absence of any obvious CSF leak

Tension pneumocephalus is a rare neurosurgical emergency usually causing rapid deterioration. Slowly-progressive postoperative tension pneumocephalus is very rare. We present a case that came to our attention 5 weeks after a craniotomy with gradual development of symptoms, and in the absence of any obvious CSF leak. A dural defect causing a one-way valve system was found at explorative craniotomy.

The high-frequency description of scatter of a plane compressional wave by an elliptic crack

High-frequency approximations that can be interpreted in terms of the Uniform Geometrical Theory of Diffraction (UGTD) and Uniform Kirchhoff Approximation (UKA) are used to develop a code for modeling ultrasonic scatter of a plane compressional wave by an elliptic crack in the radiating near field. The approximations are intercompared and partially validated against a direct numerical code based on an FD (Finite-Difference) scheme. At present, in many realistic situations the approximate codes of the type described here offer the only viable simulation tool; purely numeric codes are not only much slower, they still require too much computer memory to simulate the complex structure of the radiating near fields.

Transcallosal resection of hypothalamic hamartoma for gelastic epilepsy

INTRODUCTION

Hypothalamic hamartomas (HHs) are commonly associated with severe epilepsy resistant to anticonvulsant therapy. Historically, surgical resection of HHs resulted in considerable morbidity.

DISCUSSION

Two series of patients who successfully underwent resection using a transcallosal approach have now been published; we report the first UK experience of this technique in a series of five patients with HHs and gelastic epilepsy resistant to anticonvulsant therapy. Patients were assessed pre- and postoperatively for seizure activity, endocrine function, ophthalmology, and neurocognitive function. Two patients had precocious puberty and all had evidence of developmental delay and behavioral problems. Postoperatively, all children experienced at least a 50% reduction in seizure frequency with abolition of major seizure types; one child remains seizure-free. One child developed a mild postoperative right hemiparesis and one developed transient diabetes insipidus.

CONCLUSION

There were no adverse developmental effects of surgery. Transcallosal resection of HHs ameliorates resistant epilepsy syndromes associated with HH.

Long term survival in a patient with variant Creutzfeldt-Jakob disease treated with intraventricular pentosan polysulphate

Variant Creutzfeldt-Jakob disease (vCJD) is a neurodegenerative disease that principally affects young people and has a median duration of illness of 13 (range 6-39) months. vCJD is incurable and there are currently no treatments that conclusively slow the rate of disease progression. However, recent animal studies and isolated case reports have suggested that treatment with intraventricular pentosan polysulphate (PPS) may be beneficial in the treatment of patients with vCJD. We report a case of a 22-year-old male with vCJD treated 19 months after the onset of clinical symptoms with continuous intraventricular PPS (32 microg/kg/day) over a period of 31 months. Treatment with PPS appeared to be safe and well tolerated and was associated with prolonged survival (51 months) when compared to natural history studies. However, PPS treatment did not appear to arrest the progression of the disease.

Characterization and removal of DNAPL from sand and clay layered media

Important characterization and remediation techniques (e.g. partitioning tracer tests (PTT), cosolvent and surfactant flushing) have been developed over the years to deal with dense nonaqueous phase liquid (DNAPL) sources in the saturated zone. Unfortunately, subsurface media layering and heterogeneity pose a major challenge to the efficiency of these and other techniques that rely on flushing fluids through porous media. Using laboratory column experiments with both single media and layered-media columns and computer modeling of tracer breakthrough results, we examined the difficulty that layering poses to subsurface remediation and characterization techniques. Quantifying tetrachloroethylene (PCE) saturation in layered media was determined using PTT and effluent mass determinations. Conservative tracer breakthrough curves were used to determine permeability and the flow through layers before and after PCE contamination. The removal efficiency of alcohol flushing in the layered systems was also determined. Results showed that even a relatively simple layering with less than an order magnitude difference in permeability leads to difficulty in characterization and remediation using flushing technologies. These results suggest that much greater volumes of flushing solutions will be needed in heterogeneous environments to ensure adequate flushing of lower permeable lenses and layers.

Distinct right frontal lobe activation in language processing following left hemisphere injury

Right hemisphere activation during functional imaging studies of language has frequently been reported following left hemisphere injury. Few studies have anatomically characterized the specific right hemisphere structures engaged. We used functional MRI (fMRI) with verbal fluency tasks in 12 right-handed patients with left temporal lobe epilepsy (LTLE) and 12 right-handed healthy controls to localize language-related activity in the right inferior frontal gyrus (RIFG). During the phonemic task, LTLE patients activated a significantly more posterior region of the right anterior insula/frontal operculum than healthy controls (P = 0.02). Activation of the left inferior frontal gyrus (LIFG) did not differ significantly between the two groups. This suggests that, following left hemisphere injury, language-related processing in the right hemisphere differs from that with a functionally normal left hemisphere. The localization of activation in the left and right inferior frontal gyri was determined with respect to the anatomical sub-regions pars opercularis (Pop), pars triangularis (Ptr) and pars orbitalis (Por). In the LIFG, both healthy controls (8 out of 12) and LTLE patients (9 out of 12) engaged primarily Pop during phonemic fluency. Activations in the RIFG, however, were located mostly in the anterior insula/frontal operculum in both healthy controls (8 out of 12) and LTLE patients (8 out of 12), albeit in distinct regions. Mapping the locations of peak voxels in relation to previously obtained cytoarchitectonic maps of Broca's area confirmed lack of homology between activation regions in the left and right IFG. Verbal fluency-related activation in the RIFG was not anatomically homologous to LIFG activation in either patients or controls. To test more directly whether RIFG activation shifts in a potentially adaptive manner after left hemisphere injury, fMRI studies were performed in a patient prior to and following anatomical left hemispherectomy for the treatment of Rasmussen's encephalitis. An increase in activation magnitude and posterior shift in location were found in the RIFG after hemispherectomy for both phonemic and semantic tasks. Together, these results suggest that left temporal lobe injury is associated with potentially adaptive changes in right inferior frontal lobe functions in processing related to expressive language.

Secondary contamination in organophosphate poisoning: analysis of an incident

BACKGROUND

Acute organophosphate poisoning is rare in the UK, and the risks to attending staff are seldom appreciated.

STUDY DESIGN

Report of an incident.

RESULTS

In May 2001, a 45-year-old man attempted suicide by drinking organophosphate insecticide, and was brought to an urban general hospital in a collapsed state. Twenty-five hospital workers and paramedics sought medical advice after coming into contact with the poisoned patient, of whom ten complained of symptoms related to toxin exposure. Provision of emergency services by the hospital was compromised, and the emergency department was closed until the area was decontaminated and staffing levels could be restored.

DISCUSSION

Ingestion of OP compounds can present a significant risk to health professionals as well as patients. Problems with the management of this patient included late recognition of the need for decontamination, large numbers of non-essential staff coming into contact with the patient, and the difficulty of carrying out medical procedures while wearing protective equipment. Decontamination should always be considered early, and the possibility of an ingested poison being vomited and causing a chemical spill should not be overlooked.

Posterior spinal ligament rupture associated with laryngeal mask insertion in a patient with undisclosed unstable cervical spine

A case of posterior spinal ligament rupture associated with a general anaesthetic for a laparoscopic cholecystectomy is reported. The role of the general anaesthetic in this case is discussed and a review of the literature is presented.

3-Anilino-4-arylmaleimides: potent and selective inhibitors of glycogen synthase kinase-3 (GSK-3)

Potent 3-anilino-4-arylmaleimide glycogen synthase kinase-3 (GSK-3) inhibitors have been prepared using automated array methodology. A number of these are highly selective, having little inhibitory potency against more than 20 other protein kinases.

High-dose intrathecal diamorphine for analgesia after Caesarean section

Forty women undergoing elective Caesarean section under spinal anaesthesia using hyperbaric 0.5% bupivacaine were randomly allocated to receive either 0.5 mg or 1 mg intrathecal diamorphine. All women received diclofenac 100 mg at the end of surgery and morphine via a patient-controlled analgesia system. Oral analgesics were not used. Postoperative analgesia was more prolonged and more reliable in the 1-mg group. Mean time to first analgesia was 10.2 h in the 1-mg group and 6.9 h in the 0.5-mg group, and 45% in the 1-mg group used no morphine, compared with 10% in the 0.5-mg group. Mean morphine consumption over 24 h was 5.2 mg in the 1-mg group and 10.6 mg in the 0.5-mg group. Pain scores all tended to be lower in the 1-mg group but this was only significant at 4 h. There were no serious side-effects. Minor side-effects were common but well tolerated, and the incidence did not differ between the groups. If intrathecal diamorphine is used in combination with rectal diclofenac and without oral analgesia, then 1 mg provides superior analgesia to 0.5 mg without any worsening of the side-effects.

The inhibition of human cytomegalovirus (hCMV) protease by hydroxylamine derivatives

Aryl hydroxylamine derivatives have been synthesised that are some of the most potent inhibitors of hCMV protease prepared to date (IC50 14-60 nM). Mass spectrometry studies indicate that oxazinone derived hydroxylamines inhibit the enzyme by acylation of Ser132 whereas non-oxazinone derived hydroxylamines appear to inhibit via formation of a sulfinanilide at Cys138.

Artefact on MRA following aneurysm clipping: an in vitro study and prospective comparison with conventional angiography

Using both an experimental model and clinical cases, we looked at the artefact produced by Aesculap titanium-alloy aneurysm clips on MRA. Experimentally, the volume affected by artefact was 50 % less when the clip was imaged lying parallel to the main ferromagnetic field than when lying perpendicular to it. Clinically, MRA was prospectively compared with digital subtraction angiography (DSA) in nine patients who had undergone aneurysm clipping. One patient with a non-diagnostic MRA due to movement artefact was excluded. In all other cases there was an area of signal loss surrounding the clips, obscuring the immediately adjacent vessel segments. There was good demonstration of the adjacent bifurcations in five cases and the contralateral circulation was seen well in all patients. In three cases in which the adjacent bifurcations were not seen, considerable vasospasm was suggested by MRA and confirmed with DSA. In one patient an unclipped contralateral ophthalmic artery aneurysm was identified using both modalities. In this series there were no adverse events relating to clips in either static or time-varying magnetic fields.

Fused aminotetralins: novel antagonists with high selectivity for the dopamine D3 receptor

Starting from a series of 2-aminotetralins 1, a novel series of N-[4-(4-phenylbenzoylamino)butyl]-octahydrobenzoquinolines and hexahydrobenzoindoles with high potency and selectivity for the dopamine D3 receptor has been designed. The effect of ligand chirality on binding affinity has been established. Selected derivatives (e.g. 2o, 2p) show high functional selectivity and enhanced in vivo properties compared to 1.

The intradural cervical plexus. An absent cervical nerve root

Whilst dissecting the intradural and peripheral pathways of the spinal accessory n. (Sp. XI) as part of a larger study into its microsurgical anatomy, we have discovered an unusual and previously unreported anatomical variant. In one cadaver the intradural C2 dorsal n. root was completely absent on the left side. Considerable speculation surrounds the function of the spinal accessory n. in human subjects. Recent anatomical and clinical studies have drawn attention to the intradural plexus-like morphology of the Sp. XI and raised the possibility of integration of pro-prioception and motor control of the neck musculature at this level. The general anatomy of the Sp. XI is reviewed along with current ideas from recent studies.

A review of 560 Hickman catheter insertions

Indwelling, cuffed, tunnelled, central venous (Hickman) catheters are increasingly being used for venous access and the administration of chemotherapy for oncological patients. This paper reviews the technical problems associated with the percutaneous insertion of these catheters and the complications arising from their use. Five hundred and sixty catheters were inserted; 31.3% had complications at insertion, most commonly precipitation of an arrhythmia (13.9%). Arterial puncture occurred in 3.8% and pneumothorax in 1.6%. Catheters remained in place for a median period of 91 days. Forty percent of catheters were removed electively on completion of treatment; 30.2% required removal because of complications, which included sepsis, migration, thrombosis and blockage. Twenty percent of patients died with their catheter in place, 8.5% were still in situ and 1.6% were removed because of patient non compliance. Sepsis remains the commonest, long term complication, with staphylococcus epidermidis being the organism isolated most frequently. There were no catheter-related deaths.

ECMO in newborn infants: the New South Wales experience

Extracorporeal membrane oxygenation (ECMO) has been used at the Prince of Wales Children's Hospital, Sydney for the treatment of newborn infants with life-threatening respiratory or cardiac failure since August 1989. The main indications are that the disease is reversible, the surviving infant is likely to be normal and there is an 80% likelihood of death without ECMO. Eighteen of 19 newborn infants have survived at least 2 months after ECMO. The 15 infants receiving ECMO (nine with meconium aspiration, six with persisting pulmonary hypertension) who did not have a congenital diaphragmatic hernia were normal survivors. One death occurred at 5 months of age from chronic lung disease. Three of four infants with congenital diaphragmatic hernia were discharged following ECMO and appeared normal at 6, 9 and 18 months of age. These results are similar to results from other centres internationally. It appears that ECMO is a useful therapy for near-term newborn infants with otherwise fatal cardiorespiratory failure.

Aortic xenograft valve performance at eight years. A comparative study

The medium-term performance of commercially available xenograft prostheses in the aortic position, was evaluated in 198 patients operated upon since 1975. No associated procedures were performed in these patients in whom a variety of prostheses was employed. The valve behaviour has been compared with other xenograft series, homografts and synthetic prostheses. There was a 5.5% hospital death rate and a 7.5% late mortality. Five late deaths were valve related, five were unrelated to the valve and four were of unknown cause but in elderly patients. At eight years, 86.1% of patients were alive, the majority functionally improved. Thromboembolic events were considerably fewer than those experienced with most non-biological prostheses, all but three events being transient. Re-operation for primary valve dysfunction was a safe procedure but re-operation for infected prostheses carried a high mortality. In comparing the aortic xenograft with other prostheses, severe dysfunction was found to occur with similar frequency in all prostheses up to eight years and was rare. Mild prosthetic dysfunction (asymptomatic diastolic murmur) occurs in about 25% of all tissue valves at eight years, including the homograft. The progression, or otherwise, of mild dysfunction has yet to be evaluated in currently available xenograft prostheses.

Why do protease inhibitors enhance leucocyte migration inhibition to the antigen PPD?

Epsilon amino caproic acid (EACA) and Aprotinin significantly increase the inhibition to PPD in the leucocyte migration test (Burden, Stacey, Wood & Bell, 1978). This is not due to increased leucocyte inhibition factor (LIF) generation. The proteolytic inhibitors prevent the loss of activity of LIF due to prolonged incubation in the presence of serum. Both have a significant effect on the target cells (Polymorphonuclear leucocytes) used in the assay to exaggerate the migration inhibition to LIF. These actions can be explained by decreased proteolytic breakdown of LIF.

Tracheal stenosis associated with a low pressure cuffed endotracheal tube

A case of tracheal stenosis following a short period of intubation with a low pressure cuffed portex tube is described. The possible factors responsible for the tracheal damage are discussed.

Mitochondrial isocitrate dehydrogenase and isocitrate oxidation of rat ventral prostate

Mitochondrial preparations isolated from rat ventral prostate were capable of oxidizing isocitrate by way of NADP isocitrate dehydrogenase (NADP-IDH) and NAD-IDH. NAD-IDH activity required ADP for activation. The pH responses for NAD-IDH and NADP-IDH were quite different. The results indicated that two different enzymes were involved in the NAD- and NADP-IDH activities. Indirect evidence indicated that NADPH-NAD transhydrogenase activity might also be involved in the mitochondrial pathway for isocitrate oxidation. NADP-IDH activity was significantly greater than NAD-IDH activity. The oxidation of isocitrate through IDH activity was coupled to the cytochrome system by NADPH- and NADH-cytochrome c reductase activities. Citrate, via isocitrate, oxidation proceeded at a much slower rate suggesting that aconitase activity could be limiting in the oxidation of citrate. In comparison to other tissues, the prostate oxidative enzyme activities are considerably lower. The results suggest that the accumulation of high prostate citrate levels is not due to a limitation imposed by a lack of IDH activity in prostate mitochondria.