Arcangelo Giamundo

Cerebral gliosarcomas: correlation of computed tomographic findings, surgical aspect, pathological features, and prognosis.

The cases of 5 patients with cerebral gliosarcomas examined by computed tomography are reported and the correlations among the computed tomographic (CT) findings, the surgical and histological aspects, and the prognosis are discussed. In some patients, these tumors appear on CT scan as intracerebral lesions, with large necrotic areas and peripheral contrast enhancement; this CT aspect, similar to that of glioblastomas, corresponds to a diffusely infiltrating growth of the tumor and the prevalence of a gliomatous component. In other patients, the tumor appears on the CT scan as a hyperdense mass with well-defined margins and homogenous contrast enhancement; this CT finding, which may mimic that of a meningioma, corresponds to a rather well-demarcated surgical aspect and the prevalence of sarcomatous component. In our series, we have also noticed a more prolonged survival in a patient with a CT aspect that suggested a meningioma and prevalence of the sarcomatous component.

Cerebral edema associated with meningiomas.

Fifty patients with intracranial meningiomas have been retrospectively examined, and the cerebral edema on computed tomography scan has been correlated with the clinical evolution, size, location, and histological features of the tumor. The degree of brain edema was found to be related to the clinical evolution and the size of the tumor, whereas the histological features were less significant. These results are discussed after reviewing the data of five other series in the literature of this subject. A correlation between the tumor steroid receptors and edema is suggested.

Early clinical and neuroradiological worsening after radiotherapy and concomitant temozolomide in patients with glioblastoma: Tumour progression or radionecrosis?

OBJECTIVES This study investigates the diagnosis and management of patients with resected brain glioblastomas who presented early clinical and neuroradiological worsening after the completion of the Stupp protocol. Its aim is to discuss the occurrence of early radionecrosis. METHODS Fifty patients with brain glioblastoma treated by surgical resection and Stupp protocol were reviewed; 15 among them (30%) had early clinical and neuroradiological worsening at the 6-month follow-up. The MR spectroscopy and surgical findings of these patients are reviewed. RESULTS MR spectroscopy was in favour of tumour recurrence in 14 among 15 patients and showed radionecrosis in one. Among 10 patients who were reoperated on, 7 had histologically verified tumour recurrence or regrowth, whereas in 3 histopathology showed necrosis without evidence of tumour. The 7 patients with tumour progression had prevalence of focal neuroradiological signs (6/7) and a survival of 7.5-12 months (median survival 10 months). The 4 patients with early radionecrosis (including one patient who was not reoperated on) had clinical worsening with mental deterioration, confusion and ataxia, and MR spectroscopy positive for tumour recurrence in 3. Three were alive 24-30 months after the end of the radiotherapy, whereas one died at 40 months. CONCLUSION Early radionecrosis after the Stupp protocol is not a rare event due to the radiosensitization effect of temozolomide. This phenomenon may predict a durable response to radiotherapy. MR spectroscopy may simulate tumour recurrence. A correct diagnosis is necessary to avoid useless reoperations and incorrect withdrawal of temozolomide.

Intracranial Plasma Cell Granuloma

An exceptional case of intracranial plasma cell granuloma, located in the right frontoparietal convexity in a 16-year-old boy is reported. Reports of these rare inflammatory lesions locate them primarily in the lungs and in other regions of the body, and only exceptionally in the nervous system; indeed, only three intracranial cases and one other arising from the spinal meninges have been reported. The computed tomographic and surgical aspects suggested a falx meningioma in our case. The pathological diagnosis differentiating these from other intracranial lesions with a plasma cell component, including meningioma with plasma cell infiltration and plasmacytoma, is discussed.

Cystic lesions associated with meningiomas

Three cases of meningiomas associated with large cysts are reported, and 58 other cases from the literature are reviewed. The etiology of these cysts is analyzed on the basis of surgical and pathological findings. The preoperative diagnosis of large computed tomographic hypodensities associated with meningiomas and the differential features from other cystic tumors are discussed. The surgical aspect of the solid tumor and particularly the absence of a capsule separating the tumor from the cyst are usually decisive in confirming the intratumoral nature of the cyst. In questionable cases a histologic evaluation of the cyst walls may be necessary.

Ewing's Sarcoma Arising Primarily in the Spinal Epidural Space: Fifth Case Report

Ewings sarcoma is found exceptionally as a primary epidural tumor of the spine. Four cases have been described in the literature. We describe the fifth case: a 10-year-old boy who underwent operation followed by radiotherapy and chemotherapy. For 1 year he then had a complete remission with no local recurrence and his neurological condition was satisfactory, although metastases developed later. Comparison with the cases described previously shows all five to possess interesting features in common.

Primary intraventricular oligodendroglioma

Abstract This article reports a case of primary intraventricular oligodendroglioma that was successfully treated by ventriculoatrial shunting and radical removal by a transventricular approach. Oligodendrogliomas very rarely occur in the ventricles. The computed tomographic findings are pointed out.

Craniopharyngioma of the cranial base and nasopharynx

A rare case of craniopharyngioma extending to the cranial base and nasopharynx is reported and eight other cases in the literature are reviewed. The embryology and the clinical features of these tumors are discussed. Tomograms of the skull and computed tomography are the most useful radiological tools of investigation. A nasoseptal or transpalatal approach to surgery, which has been performed in reported cases of cystic nasopharyngeal craniopharyngiomas, was not performed on our patient because of the hard consistency and the diffusely infiltrating aspect of the tumor.

MRI Features of Spinal Solitary Fibrous Tumors A Report of Two Cases and Literature Review

Spinal solitary fibrous tumors (SFT) are very rare neoplasms occurring in the spinal canal, with only 38 cases reported in ten years since the first description. We describe two cases of SFT of the spine and review 33 well-documented cases in the literature to define distinctive radiological and surgical features raising the suspicion of a spinal SFT before histological verification. A 67-year-old man with cervical myeloradiculopathy had a large extramedullary tumor of the cervical spinal canal extending from C4 to C7. On MRI the tumor was isointense on T1-sequences and hypointense on T2-sequences, and had marked contrast enhancement. At surgery, the tumor was intradural extramedullary, with no dural or root attachment, but it was adherent to the cord. Complete tumor removal was achieved with good outcome. A 75-year-old man with progressive thoracic myelopathy had an intramedullary tumor at C6 and C7 level, which was hypointense on T1- and T2-weighted images of MRI. At surgery, the tumor was intramedullary and strongly adherent to the cord; it was successfully removed. Both tumors were composed of elongated cells with a collagen-matrix background. Immunohistochemical staining was positive for vimentin, CD34, and bcl-2, and negative for EMA and S-100 protein. A careful analysis of our own and the other reported cases of spinal SFTs may disclose some peculiar features of this rare tumor. A spinal intramedullary or extramedullary tumor, hypointense on T2-weighted images of MRI, which intraoperatively shows hard consistency, scarce vascularization, no nerve root involvement, no or weak dural attachment, absence of arachnoidal interface, and adherence to the spinal cord may suggest the diagnosis of SFT.

Glioblastoma in the Elderly: The Impact of Advanced Age on Treatment and Survival

OBJECTIVE To evaluate the effects of combined treatments on the outcome and survival of elderly (≥ 65 years) patients with glioblastoma as compared with younger ones. MATERIAL AND METHODS Fifty consecutive elderly (≥ 65 years) patients (group A) who underwent complete or subtotal (> 80%) resection of brain glioblastoma followed by irradiation and chemotherapy with temozolomide between 2004 and 2009 were retrospectively reviewed and compared with 50 glioblastoma patients aged < 65 years, treated in the same period (group B). Patient sex, tumor location, size and side, combined treatments, reoperation, progression-free survival, and overall survival were compared in the two groups by using the Kaplan-Meyer method. RESULTS There were no significant differences between the two groups for tumor location, size and side, and Ki-67 Li. Forty-four of 50 group B patients were treated by the Stupp protocol, whereas all group A patients underwent irradiation and adjuvant temozolomide. Second-line chemotherapy was administrated in 32% of group A and 76% of group B cases, and reoperation was performed in 16% and 36%, respectively. The median survival of the overall series of 100 patients was 15.6 months. Group A patients (≥ 65 years) had a median survival of 14.5 months, significantly lower than group B cases (17 months) (p = 0.02). CONCLUSION Elderly patients with glioblastoma may benefit from combined treatments, including surgery, radiotherapy, and chemotherapy. Although younger patients do survive longer than older ones, the difference of survival is less significant if several criteria of selection to surgery, such as good Karnofsky performance status (KPS), largely resectable tumor, and no significant comorbidity, are respected.