Scalp necrosis following preoperative endovascular embolisation of the superficial temporal artery for meningioma

A woman in her late 50s with a left frontal lobe convexity meningioma underwent an elective endovascular embolisation of the left middle meningeal artery and distal branches of the left superficial temporal artery prior to surgical resection of the tumour. On postoperative day 46, she developed scalp necrosis, leading to poor wound healing requiring wound debridement and a complex plastic surgery reconstruction with a rotational flap. Endovascular embolisation of vascular tumours prior to surgical resection does not come without risks. The lack of consistency in the literature regarding indication, technique and outcomes makes it difficult to define the exact role of preoperative meningioma embolisation.

Unusual case of intraosseous primary intracranial malignant melanoma

Primary intracranial malignant melanoma (PIMM) represents 0.07% of central nervous system tumours; clinical behaviour and prognosis are not well documented. Preoperative diagnosis of PIMM is complex and it could be easily misdiagnosed, especially with malignant meningioma.We are reporting a case of a man with a history of rapidly arising motor slowing associated with urinary incontinence, presenting with mild convergent strabismus caused by paralysis in abduction in the right eye. A brain CT showed a lesion compatible with malignant spheno-orbital meningioma, and the patient underwent gross total resection. Intraoperatively, the blackish lesion infiltrated and eroded the bone; it was placed externally on the dura mater with a mild reaction and without attachment. Histological examination confirmed PIMM.Intraosseous localisation of PIMM has been observed in the basic bone structure of the oral cavity. We report the first intraosseous spheno-orbital PIMM case and present an embryological theory about how this unusual tumour can develop.

Intracranial ependymoma in an adult patient with multiple primary malignancies

The incidence of multiple primary malignancies (MPM) is increasing, and therefore, it has become highly important for clinicians to consider the concept of MPM when treating oncology patients. In this case report, we follow the clinical course of a patient diagnosed with a new intracranial lesion, an ependymoma, on a background of MPM. We explore the barriers implicating the delay in her diagnosis, dissect the challenges in managing her disease and emphasise the importance of social determinants in optimising her care.

Euvolaemic hyponatraemia as a rare first presentation of chronic hypopituitarism

A man in his late 40s with no significant medical history presented with 2 weeks of lethargy, nausea and dizziness, alongside worsening headaches. Initial assessment revealed severe hyponatraemia and secondary hypothyroidism; urgent MRI pituitary was requested with a clinical suspicion of pituitary apoplexy. This demonstrated a likely cystic pituitary adenoma, with further testing revealing pituitary gland suppression, leading to a diagnosis of chronic secondary hypopituitarism. Initiating hormone replacement allowed substantial reported improvements in this patient's quality of life.A review of the patient's work-up revealed areas in which best practice was not followed. Cortisol measurements and paired urinary and serum osmolalities were initially not sent, nor results appropriately chased. A subsequent literature review identified that conformation with national and local guidelines on hyponatraemia management is poor. This patient's case, when combined with the literature review, provides evidence to support methods to increase educational awareness of an appropriate work-up of hyponatraemia among clinicians.

Fertility Preservation Techniques in Neuro-Oncology Patients: Protocol for a Systematic Review

BACKGROUND

Advancements in cancer treatments have successfully improved central nervous system (CNS) cancer survivorship and overall quality of life. As a result, the awareness of the importance of fertility preservation techniques is increasing. Currently, a range of established techniques, such as oocyte cryopreservation and sperm cryopreservation, are available. However, oncologists may be hesitant to refer patients to a reproductive specialist.

OBJECTIVE

The primary aim of the proposed systematic review is to assess the best evidence for fertility preservation techniques used in patients with CNS cancers. It also aims to evaluate outcomes related to their success and complications.

METHODS

This protocol was produced in adherence with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols). Electronic databases will be systematically searched to identify studies that meet our eligibility criteria. Studies will be included if they report at least one type of fertility preserving or sparing technique in male patients of any age and female patients aged <35 years. Animal studies, non-English studies, editorials, and guidelines will be excluded from the review. From the included studies, data will be extracted and synthesized by using a narrative approach and summarized in tables. The primary outcome will be the number of patients successfully undergoing a fertility preservation technique. The secondary outcomes will include the number of retrieved oocytes, the number of oocytes or embryos vitrified for cryopreservation, clinical pregnancy, and live birth. The quality of the included studies will be assessed by using the National Heart, Lung, and Blood Institute risk-of-bias tool for any type of study.

RESULTS

The systematic review is expected to be completed by the end of 2023, and results will be published in a peer-reviewed journal and on PROSPERO.

CONCLUSIONS

The proposed systematic review will summarize the fertility preservation techniques available for patients with CNS cancers. Given the improvement in cancer survivorship, it is becoming increasingly important to educate patients about fertility preservation techniques. There are likely to be several limitations to this systematic review. Current literature is likely to be of low quality due to insufficient numbers, and there may be difficulty in accessing data sets. However, it is our hope that the results from the systematic review provide an evidence base to help inform the referral of patients with CNS cancers for fertility preservation treatments.

TRIAL REGISTRATION

PROSPERO CRD42022352810; https://tinyurl.com/69xd9add.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/44825.

The Role of Neuro-Inflammation and Innate Immunity in Pathophysiology of Brain and Spinal Cord Tumors

Inflammation and innate immune system play a central role in cancers, including those affecting the central nervous system (CNS). Currently, classification of neoplasms, especially regarding gliomas, is established on molecular mutations in isocitrate dehydrogenase (IDH) genes and the presence of co-deletion 1p/19q. Treatment, in most of brain and spinal cord tumors, is centered on surgery, radiotherapy and pharmacological approaches with chemotherapeutic agents. However, the results of the treatments, after several decades, are not completely satisfactory. Cytokines and angiogenic factors are closely linked to the brain cancer behavior. Moreover, recent studies suggest a link between inflammation and tumorigenesis, underlying the complex nature of this topic, especially the anti- and pro-tumoral activities of inflammation and the two-way interactions between immune and tumor cells. The current understanding of the mechanisms by which CNS cancer cells modulate the immune system, especially how bi-directional communications between immune cells and tumor cells create an immunosuppressed microenvironment, gives important information about the promotion of tumor survival and growth. Here, we have briefly reviewed the current literature on this topic, focusing on the possible role of inflammation and innate immunity involved in the origin and in the development of CNS tumors.

The hsa-miR-516a-5p and hsa-miR-516b-5p microRNAs reduce the migration and invasion on T98G glioblastoma cell line

microRNAs (miRNAs) are involved in numerous functions and processes in the brain and other organs through the regulation of gene and protein expression. miRNA dysregulation is associated with the development of several diseases, including the brain and Central Nervous System cancer (CNS). The hsa-miR-516a-5p and hsa-miR-516b-5p are involved in proliferation, migration, and invasion in different tumor models, but their antitumor effect has not been evaluated in cancer of CNS. Therefore, we aimed to assess the effect of the miRNAs hsa-miR-516a-5p and miRNA hsa-miR-516b-5p on the Glioblastoma cell line (T98G). We used synthetic miRNA mimics to induce the overexpression of both miRNAs in the cell line, which was corroborated by RT-qPCR. Next, we evaluated the effect on proliferation, migration, and invasion using the CyQuant direct kit, ThinCert ™ inserts and invasion BioCoat ™ Matrigel® Invasion Chambers. We found upregulation of these miRNAs induced significant changes on the migration and invasion processes of T98G cells, but not affected the proliferation rate. These results suggest that both microRNAs could be playing an important role in the control of tumor progression towards metastasis. The bioinformatics analysis showed that target genes for these miRNAs are involved in different biological processes such as in cell adhesion molecule binding and cell junction disassembly, which are important for cancer progression. Further studies and experimental validation are needed to identify the genes regulated by microRNAs.

SMART syndrome: two cases highlighting a complex and rare complication of brain irradiation

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare complication of radiotherapy with complex neurological impairment. Patients present with neurological symptoms and signs such as migraine, hemianopsia, hemiplegia, aphasia and/or seizures-without recurrence of neoplastic disease. In this report, we describe SMART syndrome in two adult patients 4 and 14 years following brain irradiation, respectively.

GABP couples oncogene signaling to telomere regulation in TERT promoter mutant cancer

Telomerase activation counteracts senescence and telomere erosion caused by uncontrolled proliferation. Epidermal growth factor receptor (EGFR) amplification drives proliferation while telomerase reverse transcriptase promoter (TERTp) mutations underlie telomerase reactivation through recruitment of GA-binding protein (GABP). EGFR amplification and TERTp mutations typically co-occur in glioblastoma, the most common and aggressive primary brain tumor. To determine if these two frequent alterations driving proliferation and immortality are functionally connected, we combine analyses of copy number, mRNA, and protein data from tumor tissue with pharmacologic and genetic perturbations. We demonstrate that proliferation arrest decreases TERT expression in a GABP-dependent manner and elucidate a critical proliferation-to-immortality pathway from EGFR to TERT expression selectively from the mutant TERTp through activation of AMP-mediated kinase (AMPK) and GABP upregulation. EGFR-AMPK signaling promotes telomerase activity and maintains telomere length. These results define how the tumor cell immortality mechanism keeps pace with persistent oncogene signaling and cell cycling.

TERT promoter mutations are common in human cancer and confer cellular immortality. McKinney et al. describe the interaction between TERT promoter mutations, EGFR amplification, and the cell cycle in glioblastoma. The results demonstrate how proliferation drivers cooperate with telomere maintenance mechanisms to counteract telomere shortening caused by unlimited cell division.

Diagnosis and management of leptomeningeal disease secondary to grade IV astrocytic glioma

A man in his mid-40s presented to hospital with confusion, headache and feeling generally unwell. He had had a total resection of a grade IV astrocytic glioma 1 year prior. Initial observations, blood tests and CT head scan were unremarkable for acute features to explain the patient's presentation. However, an MRI head scan on this admission demonstrated a clear communicating hydrocephalus with new abnormal leptomeningeal enhancement, consistent with leptomeningeal metastatic infiltration by glioma. Lumbar puncture cytology and biochemistry supported this interpretation. As a small district general hospital in rural Wales, we discuss the experience of diagnosis and coordination of specialist input from a multidisciplinary team. We share the challenges of managing leptomeningeal disease in the COVID-19 pandemic, in the context of the additional risks this presents with chemotherapy-induced immunosuppression.

Gamma Knife radiosurgery for a recurrent craniocervical junction solitary fibrous tumour

Spinal solitary fibrous tumour (SFT) is an uncommon tumour with few cases reported in the literature. It rarely originates at the craniocervical junction. To our knowledge, only eight cases of spinal SFT located at the craniocervical junction have been reported in the literature. We presented a patient with a craniocervical junction SFT and discussed its clinical presentation, radiological features, pathology, management and outcome. This was the first patient reported in the literature with a recurrent craniocervical junction SFT treated with Gamma Knife radiosurgery. The treatment reduced the tumour volume by more than 85% within 12 months.

Spinal leptomeningeal hemangioblastomatosis occurring without craniospinal surgery in von Hippel-Lindau disease

Hemangioblastomatosis represents an unusual and malignant leptomeningeal dissemination of hemangioblastoma (HB). It has been reported in patients with sporadic HB or von Hippel-Lindau (VHL) disease. Hemangioblastomatosis had been reported following resection of a primary HB lesion in all cases except one patient with a sporadic HB. We present a patient with VHL with several HBs at the brainstem, cerebellum, pituitary stalk and retina who developed spinal hemangioblastomatosis without previous craniospinal surgery. A whole spine MRI showed the spinal dissemination from the primary lesions. The patient received craniospinal radiotherapy due to the extensive spinal leptomeningeal dissemination and multiple HBs. MRI performed 12 months after the radiotherapy showed stability of the lesions.

Primary bone destruction and extracranial metastases in an atypical glioblastoma with sarcomatoid features

A man in his early 40s was referred to the neurology department with headache, hemianopsia and a palpable fluctuating mass on the back of his head. Investigations revealed a right-sided parieto-occipital mass with involvement of dura, bone and subcutaneous tissue. After debulking, pathological examination revealed a primary high-grade glioma with sarcomatoid features and a small-cell component. Concurrent chemoradiation was initiated. 10 weeks postoperatively, symptomatic bone metastases were diagnosed. During the clinical course, local and systemic treatment was consecutively administered, in order to control both primary tumour site and metastatic lesions. Due to progression of both intracranial and extracranial tumour load treatment was eventually discontinued; the patient passed away 28 months after initial presentation. The combination of a high-grade glioma with local destruction of the skull and subsequent metastasis is extremely rare and, when these features do occur, warrant a tailored approach to control both intracranial and extracranial tumour load.

Extremely delayed-onset post-transplant lymphoproliferative disorder in a renal transplant patient

Post-transplant lymphoproliferative disorder (PTLD) is a rare condition that occurs in patients who have undergone solid organ transplantation. Symptoms at presentation depend on the organs involved. PTLD most commonly occurs in the first year after transplant (early onset) or around 5 years after transplant (late onset). Herein, we report a rare presentation of central nervous system PTLD in an adult who presented with seizures 17 years after renal transplantation. After extensive infectious and transplant-related workup, brain biopsy confirmed the diagnosis of PTLD. The patient was treated with rituximab and high-dose methotrexate. Eighteen months later, the patient had no signs of recurrence. Very late-onset (>10 years) PTLD is rare, but is likely to become more common with more long-term survivors of solid organ transplant. Data are limited but show that the factors associated with very late-onset PTLD are different from early or late-onset PTLD.

Leptomeningeal disease in BRIP1-mutated pancreatic adenocarcinoma

Leptomeningeal disease is rare in pancreatic cancer and prognosis remains poor. Mutation profiles are now directing therapy to improve survival. We describe a case of leptomeningeal and brain metastasis in BRCA1 interacting protein 1, or BRIP1-mutated pancreatic adenocarcinoma with progression through several lines of chemotherapy and immunotherapy. A woman in her late 50s presented with metastatic pancreatic adenocarcinoma on liver biopsy. She achieved complete response after modified FOLFIRINOX and started a poly (ADP-ribose) polymerase (PARP) inhibitor for a BRIP1 mutation. She had recurrence at 9 months and started pembrolizumab (programmed cell death protein 1, or PD-1receptor antibody) for tumour mutational burden of 10 muts/Mb. At 10 months, she presented with lower extremity weakness and back pain. MRI revealed leptomeningeal metastases from T11 to cauda equina roots and right occipital metastasis. Cerebrospinal fluid studies revealed elevated pressure (290 mm H2O) and protein (73 mg/dL) with negative cytology. Leptomeningeal carcinomatosis was diagnosed. She began palliative radiation but died at 11 months from initial diagnosis.

Symptomatic leptomeningeal carcinomatosis: a rare presentation of chronic lymphocytic leukaemia relapse

Central nervous system (CNS) involvement in patients with chronic lymphocytic leukaemia (CLL) is very rare and, when present, it is frequently asymptomatic. Rather, CNS involvement is more common in other haematological malignancies such as mantle cell lymphoma or diffuse large B cell lymphoma. The paucity of literature on CNS involvement in CLL underscores the importance of increasing awareness about its presentation, diagnosis and optimal management. We describe a case of symptomatic leptomeningeal leukaemic involvement as an atypical presentation of CLL relapse. A favourable clinical response was observed following systemic monotherapy with venetoclax.

Stereotactic radiosurgery for hypoglossal schwannoma

Hypoglossal schwannomas (HS) are extremely rare neoplasms. Surgical resection has historically been the treatment of choice but carries a significant risk of postoperative neurological deficits and mortality. Stereotactic radiosurgery (SRS) is a minimally invasive approach that may afford long-term tumour growth. However, literature to determine the safety and effectiveness of SRS in the treatment of HS is scarce. We report on a patient who presented with progressive headache and dysphagia as well as tongue deviation to the left, due to a space-occupying lesion, consistent on brain MRI with a left HS. Primary SRS using a prescription dose of 12 Gy in a single fraction was used to treat the tumour without complications. By last follow-up, the tumour regressed, and the patient's symptoms improved. Our case shows that radiosurgery can be safe and effective for the management of HS.

Adenoid cystic carcinoma with a leptomeningeal dissemination in a 'wash' pattern

A 39-year-old woman was referred to the neurology department due to headache, instability and difficulty walking for 5 months. Several ancillary tests were performed. The blood test showed leucocytosis and the cerebrospinal fluid revealed an increased total protein and glucose consumption. Other infections or autoimmune causes were excluded. The MRI showed non-specific brain and spinal cord lesions. Given the findings described, a differential diagnosis between granulomatous meningoencephalitis and primary tumour or metastasis was proposed. Empirical treatment with tuberculostatic agents and corticosteroids was started. The neurological state of the patient worsened, she fell into a non-responsive coma and died in few days. The clinical autopsy performed revealed an adenoid cystic carcinoma with involvement of the central nervous system that developed leptomeningeal dissemination along the spinal cord in a fluid 'wash' pattern.

Multimodality durable salvage of recurrent brain metastases refractory to LITT, SRS and immunotherapy with resection and cesium-131 brachytherapy: case report and literature review

Brain metastases (BrM) are treated with multimodality therapy, however the optimal combination and timing of modalities in the setting of recurrent tumours that have failed prior treatments remain poorly defined. We present a case of a patient with biopsy-confirmed renal cell carcinoma BrM with good performance status initially treated with laser interstitial thermal ablation therapy (LITT) followed by stereotactic radiosurgery and dual checkpoint inhibitor immunotherapy. He subsequently developed rapid in-field recurrence which was treated with salvage surgical resection and implantation of intracavitary cesium-131 brachytherapy. The patient's disease remained stable through 18 months postoperatively. This case illustrates the range of options available and provides a combination salvage therapy strategy in a select group of locally recurrent patients who have exhausted conventional treatment options.

Primary leptomeningeal low-grade Schwann cell neoplasm

We discuss an extremely rare case of low-grade Schwann cell leptomeningeal neoplasm with no evident intradural primary, presenting with rapid neurological decline leading to death reflecting the aggressive biological behaviour of this entity despite its low-grade morphology. Notwithstanding extensive investigations, the diagnosis was only established on autopsy as clinical presentation is non-specific making diagnosis challenging. This condition could be considered in patients presenting with leptomeningeal disease if initial workup of more common causes is non-revealing.

Malignant peripheral nerve sheath tumour transformation of histological benign vestibular schwannoma after stereotactic radiosurgery in patients without neurofibromatosis

Stereotactic radiosurgery (SRS) poses a minimal but important risk for tumour transformation, typically occurring 8-10 years after the treatment. Malignant peripheral nerve sheath tumour (MPNST) is the most common tumour arising from a vestibular schwannoma treated with SRS, with only 14 cases previously reported. We present the fifteenth case and describe its evolution and clinical course. A 56-year-old man without a history of neurofibromatosis was diagnosed 9 years prior with a vestibular schwannoma. SRS to the residual tumour was given 3 months later. During the current hospitalisation, he was reoperated where histology confirmed a MPNST. All 15 MPNST cases were analysed, showing a 77% female predominance presenting a malignant transformation at a mean age of 51. The diagnosis was made at a mean time of 74 months after SRS. The mean survival time after diagnosis was 16 months. MPNST arising from benign vestibular schwannoma after SRS treatment is an uncommon but devastating complication.

Rare sacral extradural grade II ependymoma: a comprehensive review of literature

Sacral spinal cord ependymoma is an uncommon pathology. Most of the reported cases are consistent with a myxopapillary ependymoma histopathologic subtype. Non-myxopapillary ependymomas rarely occur in the sacral region. Most lesions are intradural; however, rare extradural cases can occur. We present the case of a 46-year-old female patient diagnosed with a grade II sacral extradural ependymoma, emphasising the importance of an interdepartmental case approach for diagnosis and management. Even though grade II ependymomas are considered low grade, the potential for recurrence and metastatic disease has been reported. There are no treatment guidelines for these rare tumours besides gross total resection.

New model for an epoxy-based brachytherapy source to be used in spinal cancer treatment

The present work described the cold fabrication of a P-32 radioactive source to be used in CNS cancer using epoxy resin. The epoxy plaque fabricated with Teflon mold presented better agreement. MCNP simulation evaluated the radiation dose. Special attention was given to factors that can impact dose distribution. Average dose was 16.44 ± 2.89% cGy/s. Differences of less than 0.01 cm in thickness within the plaque lead to differences of up to 12% in the dose rate.

Near-Infrared MAO A Inhibitor (NMI) Outperformed FDA-Approved Chemotherapeutic Agents in Brain and Other Cancers: A Bioinformatic Analysis of NCI60 Screening Data

Our previous work has shown that monoamine oxidase A (MAO A) is overexpressed in glioma and prostate cancer. Near-infrared dye conjugate MAO A Inhibitor (NMI) inhibited the growth of these cancers. This study investigated the effects of NMI on other cancers by NCI60 screening. Our results showed that 48 out of 59 screened cell lines from nine types of cancer had 100% growth inhibition at 10 μM NMI treatment. The in vitro efficacy of NMI determined by growth inhibition (GI₅₀ and TGI) and lethal doses (LC₅₀) has been further studied in various cell lines of CNS cancer, prostate cancer, and non-small cell lung cancer (NSCLC), these three cancers showed increased MAO A expression in tumors compared to normal tissues. Based on the waterfall plots and the 3D scatter plot of GI₅₀, TGI, and LC₅₀ data, NMI showed higher potency to several CNS cancer and NSCLC cell lines than prostate cancer cell lines. In vitro efficacy of NMI outperformed FDA-approved drugs for CNS cancer, prostate cancer, and NSCLC, respectively. The Pairwise Pearson Correlation Coefficient (PCC) showed that NMI has a unique mechanism compared to the existing anticancer drugs. This study shows that NMI is a novel theragnostic drug with high potency and unique mechanisms for brain, prostate, NSCLC, and other cancers.

Primary leptomeningeal lymphoma masquerading as infectious tubercular meningitis

Primary central nervous system lymphoma (PCNSL) is infrequent and often poses diagnostic conundrums due to its protean manifestations. We present the case of a South Asian young man presenting with raised intracranial pressure and a lymphocytic cerebrospinal fluid (CSF) with pronounced hypoglycorrhachia. Progression of the neuro-ophthalmic signs while on early stages of antitubercular treatment led to additional investigations that produced a final diagnosis of primary leptomeningeal lymphoma. Treatment with chemoimmunotherapy (methotrexate, cytarabine, thiotepa and rituximab (MATRix)) achieved full radiological remission followed by successful autologous transplant. This case highlights the difficulties and diagnostic dilemmas when PCNSL presents as a chronic meningeal infiltrative process. While contextually this CSF is most often indicative of central nervous system tuberculosis and justifies empirical treatment initiation alone, it is essential to include differential diagnoses in the investigation work-up, which also carry poor prognosis without timely treatment. High suspicion, multidisciplinary collaboration and appropriate CSF analysis were the key for a correct diagnosis.

Olfactory groove meningioma with a 10-year history of smell loss and olfactory recovery after surgery

A rare cause of olfactory impairment is olfactory groove meningiomas with insidious onset of non-specific symptoms like headache, olfactory dysfunction, psychiatric symptoms such as depression, personality changes, declining cognitive function, visual disturbances or seizures. A common complication of surgery is loss of olfactory function. Still, the preservation of olfactory function should be attempted as olfactory loss often has a severe negative impact on quality of life. This report describes a woman with an olfactory groove meningioma and a 10-year history of olfactory impairment. It includes preoperatively and postoperatively extended olfactory testing, a neurosurgical approach to preserve the olfactory function and postoperative olfactory rehabilitation. After rehabilitation, the patient regained a normal olfactory function, even though the right-sided olfactory nerve could not be preserved during surgery. The case demonstrates the importance of performing neuroimaging in selected patients with olfactory loss and a method for preserving and potentially improving postoperative olfactory function.

Successful treatment of central nervous system lymphoproliferative disorder in a kidney-pancreas and stem cell transplanted patient using intrathecal rituximab

Central nervous system lymphoproliferative disorder (CNS-PTLD) after organ transplant is a unique clinicopathological entity and is associated with poor survival rates. When the CNS is involved, intravenous rituximab might not be the treatment of choice, due to its poor CNS penetration. However, intrathecal (IT) administration of rituximab has shown to be safe and efficient in small studies and in case series. We report here the case of a patient with late development of CNS-PTLD after kidney-pancreas transplantation who achieved complete remission after surgical resection and four cycles of IT rituximab and we provide a review of the literature for this treatment option.

Primary diffuse large B cell lymphoma of the optic chiasm in an immunocompetent patient

Primary lymphoma of the visual pathway is rare, especially at the chiasm. Very few cases have been reported. The lesion is frequently confused with an optic-hypothalamic glioma. A 55-year-old man was found disoriented at his home by a friend and evaluated with a brain MRI which demonstrated an expansile mass located at the optic chiasm and hypothalamus level. The principal differential was a high-grade hypothalamic glioma due to the contrast enhancement. A biopsy of the chiasmal lesion was performed. Histological diagnosis of the lesion was compatible with a diffuse large B cell lymphoma. He was started on methotrexate and rituximab; however, his clinical course kept deteriorating, and he died 64 days after his presentation. All prior cases of primary lymphoma of the chiasm are reviewed.

Bilateral facial nerve palsies due to leptomeningeal progression of lung adenocarcinoma and response to osimertinib

A 39-year-old female Chinese non-smoker was diagnosed with epidermal growth factor receptor mutation-positive lung adenocarcinoma with cerebral metastases and commenced erlotinib. After 5 weeks, she presented with a 3-day history of severe bilateral facial weakness (House-Brackmann grade V/VI) and hypogeusia consistent with bilateral facial nerve palsies. MRI demonstrated new, symmetrical contrast-enhancing foci at the expected location of the facial nerves, consistent with leptomeningeal progression. Erlotinib was ceased and osimertinib was commenced. Facial nerve motor and sensory function began to improve within 1 week and by 2 weeks had returned to near normal. Review at 2 and 6 months demonstrated normal facial nerve function and progressive resolution of the facial nerve lesions on MRI. While rare, leptomeningeal malignancy may present as simultaneous bilateral facial nerve palsies. Osimertinib has superior central nervous system penetration and in this case was associated with rapid and sustained clinical and radiographical resolution of the facial nerve lesions.

Nivolumab with radiation therapy in a glioblastoma patient with Lynch syndrome

Lynch syndrome is an autosomal dominant disorder leading to cancer predisposition caused by mutations in mismatch repair genes. There is minimal published experience treating glioblastoma in patients with Lynch syndrome. We report a patient with Lynch syndrome who was initially diagnosed with a left occipital isocitrate dehydrogenase (IDH) wild-type glioblastoma. After resection, she was treated with chemoradiation, followed by tumour treating fields. Three years after diagnosis, recurrence was resected. After refusing cytotoxic chemotherapy, decision was made to treat with off-label nivolumab concurrently with radiation. She has been maintained on nivolumab without recurrence of her glioblastoma now over 5 years out from her initial diagnosis. This case provides the first report of glioblastoma in a patient with Lynch syndrome responding to nivolumab and concurrent radiation. In patients with Lynch syndrome and glioblastoma, immunotherapy in the form of nivolumab may be an alternative option to standard cytotoxic chemotherapy.

Anaesthetic challenges for a patient with huge superior mediastinal mass in prone position

Anaesthesia for patients with huge mediastinal mass is very challenging due to the cardiorespiratory embarrassment that may occur. We present a patient with this condition, which was complicated by total airway obstruction, intraoperatively. We discuss the importance of patient positioning and the role of spontaneous ventilation.

Alveolar rhabdomyosarcoma metastatic to the brain

Alveolar rhabdomyosarcoma (ARMS) has a predilection for the peripheral extremities, and brain metastases are rare, with only a few cases reported after the initial diagnosis. We present a 22-year-old male patient with a right orbital-ethmoidal ARMS who presented with a recurrence to the brain 1 year after the initial diagnosis. He was referred to our institution due to acute neurological deterioration. A brain MRI was performed, showing an enhancing bilateral parafalcine lesion centred about the bilateral cingulate gyri with extension into the corpus callosum. The patient was taken to the operating room for a stereotactic biopsy under general anaesthesia, which was compatible with metastatic ARMS. Our case is exceedingly rare, considering the initial diagnosis of an orbital/ethmoidal ARMS, its subsequent metastasis to the brain and its clinical sequelae after a biopsy. Prognosis after cerebral metastatic ARMS is dismal, with most patients expiring due to central nervous system metastatic disease.

Work Personality, Core Self-evaluation and Perceived Career Barriers in Young Adult Central Nervous System Cancer Survivors

PURPOSE

The purpose of this study is to examine the relationship between work personality, core self-evaluation (CSE), and perceived internal and external barriers to employment in a group of young adult CNS survivors.

METHODS

The participants consisted of 110 young adult survivors of pediatric central nervous system (CNS) tumors aged between 18 and 30 years old (M = 23.05, SD = 3.36). Mediation analysis with structural equational modeling (SEM) technique was used to correlate a number of different measures (Work Personality [WP], Perceived Employment Barriers [PEB], and Core-Self Evaluation [CSE]).

RESULTS

Results revealed an exceptionally well-fitting model to our data with work personality predicting CSE positively: β = 0.34, SE = 0.07, 95% CI (0.18, 0.47) while CSE inversely predicts Perceived Barriers to Employment, β = - 0.60, SE = 0.06, 95% CI (- 0.70, - 0.49). There is a direct pathway from WP to PEB once CSE was accounted for β = - 0.20, SE = 0.07, 95% CI (- 0.33, - 0.06). The presence of both significant direct and indirect effects of WP on PEB implied that there was a partial mediating effect of CSE on the association between WP and PEB.

CONCLUSIONS

Work personality is a robust construct that can be applied to young adult CNS survivors in effort to gain more insight into the personality and psychological factors that impact career development and employment in this group. The major finding of this study was that work personality and CSE had a significant direct effect on perceived career barriers and that there was a significant indirect effect with CSE acting as a mediator between developmental work personality and perceived career barriers.

CAPE and Neuroprotection: A Review

Propolis, a product of the honey bee, has been used in traditional medicine for many years. A hydrophobic bioactive polyphenolic ester, caffeic acid phenethyl ester (CAPE), is one of the most extensively investigated active components of propolis. Several studies have indicated that CAPE has a broad spectrum of pharmacological activities as anti-oxidant, anti-inflammatory, anti-viral, anti-fungal, anti-proliferative, and anti-neoplastic properties. This review largely describes CAPE neuroprotective effects in many different conditions and summarizes its molecular mechanisms of action. CAPE was found to have a neuroprotective effect on different neurodegenerative disorders. At the basis of these effects, CAPE has the ability to protect neurons from several underlying causes of various human neurologic diseases, such as oxidative stress, apoptosis dysregulation, and brain inflammation. CAPE can also protect the nervous system from some diseases which negatively affect it, such as diabetes, septic shock, and hepatic encephalopathy, while numerous studies have demonstrated the neuroprotective effects of CAPE against adverse reactions induced by different neurotoxic substances. The potential role of CAPE in protecting the central nervous system (CNS) from secondary injury following various CNS ischemic conditions and CAPE anti-cancer activity in CNS is also reviewed. The structure–activity relationship of CAPE synthetic derivatives is discussed as well.