B. Anandh

Expression of p53, EGFR, pRb and bcl-2 proteins in pediatric glioblastoma multiforme: a study of 54 patients.

Pediatric glioblastoma multiforme (GBM) tumors, which have been established as ‘de novo’ neoplasms, are known to differ from their adult counterparts in terms of biology, genetics and ultimately survival of patients. In order to evaluate the utility of markers of tumor biology for refining prognostic assessment, we retrospectively analyzed 54 pediatric GBMs (age range 9 months to 15 years) occurring at different anatomical sites in the brain, operated at our institute between 1995 and 2001. The expression of p53, epidermal growth factor receptor (EGFR), bcl-2 and retinoblastoma proteins (pRb) was analyzed by immunohistochemistry and the results were compared with the clinical profile, MIB-1 labeling index (LI) and patient survival. p53 immunoreactivity was noted in 53.7% of cases, predominantly in thalamic (75%) and cerebral lobar (62.2%), followed by brainstem tumors (30%). It was absent in cerebellar tumors. p53-positive tumors had a higher MIB-1 LI, compared to p53-negative tumors (p = 0.003). EGFR and bcl-2 overex pression was observed in 25.9% and 33.3% of cases, respectively, and loss of pRb expression was evident in only 7.4% of cases, indicating that loss of this gene function is not significantly involved in pediatric GBMs. p53 and bcl-2 expression were maximally noted in patients with poorer outcome. Our results indicate that p53 expression status is noted in a significant number of pediatric supratentorial neoplasms. p53 with bcl-2 overexpression is more often associated with ominous prognosis. Further molecular characterization would provide newer insights into the biology of these neoplasms and form a basis for future therapeutic decision making.

Pyruvate: an in vivo marker of cestodal infestation of the human brain on proton MR spectroscopy.

To study intracranial cestodal cysts using in vivo proton magnetic resonance spectroscopy (1H MRS) in an effort to identify metabolite(s) that may help in recognizing the parasitic etiology and, perhaps, viability of such tapeworm cysts. Cestodal infestations of the human central nervous system (CNS)—cysticercosis and hydatidosis—are not rare. Identification of a scolex is considered diagnostic of cysticercosis on imaging. In its absence, however, the features are non‐specific.

Diagnostic efficacy of stereotactic biopsies in intracranial tuberculomas

BACKGROUND Stereotactic biopsies for diagnosing intracranial tuberculomas are often reported to be inconclusive, being confirmatory in only 28% of cases. We analyzed the role and diagnostic efficacy of stereotactic biopsies in the management of intracranial tuberculomas. METHODS Twenty patients diagnosed with intracranial tuberculomas based on neuroimaging procedures underwent computerized tomography (CT) guided stereotactic biopsies for histological confirmation. In 10 patients (Group A), biopsies were obtained from the center of the lesion; in the other 10 (Group B), biopsies were obtained from both the enhancing rim and the isodense center and examined separately. The tissues were processed for paraffin sections and hematoxylin eosin staining. In addition, in the first five patients a squash smear from a small portion of the biopsy was prepared, and the cytological features of the cells were examined. All the patients received antitubercular medication and CT scans were repeated 4 months posttreatment. RESULTS Histopathological features of the paraffin sections in 17 patients (Group A: 8, Group B: 9) were diagnostic of tuberculoma, whereas the other three revealed only chronic nonspecific inflammation. Based on the cytological features in squash smears, diagnosis could be made in one of five. In two, although the smear was not diagnostic, the histological section from the same specimen confirmed the tuberculous pathology. There was no procedural morbidity or mortality. One patient had a small asymptomatic hematoma at the biopsy site. Three patients died during the follow-up period, due to secondary complications of tuberculosis. Repeat CT scans during follow-up after antituberculous treatment confirmed the reduction in the size of the lesion in 15/17 patients. CONCLUSION The high positive yield of stereotactic biopsies in diagnosing tuberculomas argues for their inclusion in the management protocol for tuberculous mass lesions.

Role of stereotactic aspiration in the management of tuberculous brain abscess.

BACKGROUND Intracranial tuberculous abscesses are uncommon clinical entities, even in countries where tuberculosis is endemic. Surgical excision and antituberculous treatment is the treatment of choice. The role of stereotactic aspiration in the management of these lesions is highlighted in this communication. METHODS Three patients, all receiving treatment for pulmonary tuberculosis, presented with symptoms of raised intracranial pressure and neurological deficits. Computed tomography (CT) scans revealed cystic lesions with enhancing rim in the thalamus in two patients and multiple coalescing cystic lesions in the deep temporal region in another. RESULTS Stereotactic aspiration of the cyst and biopsy of the cyst wall were performed in all. In two, the pus revealed acid fast bacilli (AFB). In another, though the pus did not reveal any AFB, the wall showed tuberculous granuloma. Antituberculous treatment was continued in all the patients. Follow-up CT revealed resolution of the lesions in all patients. CONCLUSION Stereotactic aspiration is an useful alternative modality of management of tuberculous abscesses in a selected group of patients.

Visceral larva migrans presenting as multiple intracranial and intraspinal abscesses

Involvement of nervous system by toxocariasis is rare and can produce a spectrum of pathology that includes eosinophillic meningoencephalitis, meningomyelitis, space occupying lesions, vasculitis causing seizures or behavioral abnormalities posing diagnostic dilemmas. We describe a 38‐year‐old man who presented with multiple intracranial and intramedullary abscesses caused by visceral larva migrans. Neurohelminthiasis as a cause of multiple abscesses, though rare, should be entertained as a differential diagnosis particularly in tropical South‐east Asian countries where helminthiasis is still an epidemiological concern prevalent in the pediatric age group.

An unusual etiology of recurrent cerebral abscesses—a report of 3 cases

BACKGROUND Cerebral abscess commonly occurs secondary to trauma, hematogenous spread from distant infection, or otitis media. Pulmonary AVF is an uncommon cause of recurrent cerebral abscess and is often overlooked. We report 3 cases of cerebral abscesses secondary to pulmonary AVF. CASE DESCRIPTION A 20-year-old man who presented with fever, headache, and vomiting of short duration was diagnosed as having right parietal abscess and underwent burr hole and tapping and antibiotic treatment. He later presented with many episodes of cerebral abscess at various locations involving both sides and required multiple surgical procedures. The routine workup for the source did not reveal any etiology. His hematological examination revealed polycythemia. A pulmonary angiogram was performed, which revealed pulmonary AVF. He underwent embolization of the fistula and had no further recurrence. Two other adult men were treated surgically for cerebral abscess. One patient had polycythemia and hypoxemia, and another had clubbing. Both patients were investigated with CT of the chest and were diagnosed as having pulmonary AVF. None of them had features of HHT. CONCLUSIONS Pulmonary AVF is an unusual cause of cerebral abscess. Patients with multiple recurrences of cerebral abscess, signs of pulmonary disease, and hypoxia should be investigated for pulmonary AVF.

A 30-year-old male with diffuse white matter lesions.

A 30-year-old male presented with fever and cough withexpectoration of 3-month duration. He was diagnosed to havepulmonary tuberculosis and antituberculous therapy was ini-tiated. He developed progressive lower limb weakness over1 month. He was detected to be HIV seropositive. At the timeof admission to the hospital, he was dull, withdrawn, and hadspastic paraparesis (Grade 4/5 power). Cerebrospinal fluid(CSF) studies revealed 120 cells/mm

Factors predicting progression of low-grade diffusely infiltrating astrocytoma

BACKGROUND Low-grade diffuse astrocytoma (DA) is considered benign tumor (World Health Organization [WHO] grade II), but it has an inherent tendency for malignant progression, which is quite variable. AIM To identify malignant progression in an individual case of DA, we studied the clinico-radiological and immunohistochemical factors and correlated with progression of DA at a dedicated tertiary level neurosciences centre NIMHANS, Bangalore, India. PATIENTS AND METHODS Consecutive adult patients who had undergone tumor decompression for lobar supratentorial DA at our institute from 1994 to 1998 were retrospectively selected and followed up for clinico-radiological progression. The clinico-radiological and histomorphological features were studied. With the use of immunohistochemistry, proliferation index [MIB-1 labeling index (LI)], p53 protein expression, microvessel density (MVD) count [assessed using anti-CD34 antibody] were analyzed and correlated with progression-free survival (PFS) Results: There were 13 patients. Mean age was 34 years. The most common presenting symptom was seizures. The median follow-up was 54 months. There were four recurrences, with median interval of 75 months. Eight patients received radiotherapy. Younger patients (<40 years), seizure as the presenting symptom and postoperative radiotherapy were associated with longer PFS, while gemistocytic morphology (>20% gemistocytic cells), MVD value >20 correlated with shorter PFS, albeit statistically insignificant. MIB1 LI did not correlate with recurrence pattern. Moreover, p53 LI > 10% correlated with early progression (P = 0.04). CONCLUSION Our study highlights some of the clinical, histological and immunohistochemical parameters that predict progression on DA. Validation on a larger sample may be useful to plan appropriate treatment in an individual case.