Bujung Hong

Multiple microsurgical resections for repeated recurrence of glioblastoma multiforme.

Objectives:There has been little evidence so far supporting further surgical intervention in case of repeated recurrence of glioblastoma multiforme (GBM). Thus, the efficacy and utility of repeated resection remains unclear but worthy of consideration. The aim of this study was to review the efficacy of multiple repeated resections in patients with recurrent GBM. Methods:Forty-two patients underwent repeated surgical resections for recurrent GBM. All patients who underwent >2 surgical interventions were clustered in group A. Group B were patients treated nonsurgically after resection of the first recurrence. Patients’ treatment history, including surgical interventions, radiotherapy, chemotherapy regimens, postoperative complications, Karnofsky Performance Score, and survival rate were reviewed. Results:Group A consisted of 10 patients (median age, 60.5 y) and group B of 32 patients (median age, 56.5 y). Histopathologic findings revealed typical GBM in 8 patients of group A and in 23 patients of group B. An oligodendroglial component was detected in 2 patients of group A and in 7 patients of group B. The median Karnofsky Performance Score after the first surgery for tumor recurrence was 80 in both groups (P=0.084). The median overall survival time was 26 months in patients of group A and 16 months in patients of group B (P=0.052). The 2-year survival rate of group A was 58.3% and significantly higher than in group B (29.0%; P=0.036). The 3-year survival rate of group A was 31.1% and 12.4% of group B (P=0.038). Conclusions:Microsurgical resection of repeatedly recurring GBM is likely to prolong survival. Repeated surgical resection may be considered as an effective treatment option in addition to radiochemotherapy in repeated GBM recurrence.

Common molecular cytogenetic pathway in papillary tumors of the pineal region (PTPR).

Primary papillary tumors of the central nervous system and particularly the pineal region are rare. Papillary tumor of the pineal region (PTPR) is a recently described neoplasm that has been formally recognized in the 2007 World Health Organization Classification of Tumors of the Nervous System. Because of their rarity, further pheno‐ and genotypical observations as well as therapeutic experience are necessary to differentiate PTPR from other primary or secondary papillary tumors of this region. We herein present three cases of PTPR characterized by local recurrence in two of them. Primary and recurrent tumors were analyzed by immunohistochemistry and comparative genomic hybridization (CGH). From our results clonal chromosomal aberrations can be postulated which seem to be a feasible tool to differentiate PTPRs from other primary or secondary papillary tumors of this region.

Cyclooxygenase-2 Supports Tumor Proliferation in Vestibular Schwannomas

BACKGROUND:Recent studies have shown that cyclooxygenase-2 (COX-2) plays an important role in tumor growth and neovascularization. However, COX-2 expression in vestibular schwannomas (VSs) has not been investigated. OBJECTIVE:To analyze the pattern of COX-2 expression in sporadic and neurofibromatosis type 2 (NF2)–associated VSs and its relationship with tumor proliferation and microvessel density. METHODS:Fifteen sporadic and 15 NF2-associated VSs were examined for COX-2 expression, microvessel density, and proliferation rate by immunohistochemical methods. Immunohistochemical scores were used to interpret the extent and intensity of COX-2 staining. Microvessel density (MVD) was determined using von Willebrand factor (vWf). Proliferation rate was quantified using Ki-67. The relationship among COX-2 expression, MVD, and proliferation rate was statistically analyzed. RESULTS:COX-2 expression was detected in 29 (96.67%) of 30 VSs, with no significant difference between sporadic and NF2-associated VSs (P = .722). In 6 (20%) VSs, COX-2 expression was graded as strong, in 12 (40%) as moderate, and in 11 (36.7%) as weak. VSs with high proliferation showed significantly higher COX-2 expression (P = .015) than VSs with low proliferation. COX-2 expression and MVD did not show specific biological correlations (P = .035). CONCLUSION:Our data demonstrate that COX-2 is expressed in VSs. High COX-2 expression in VSs with high proliferation rates suggests that the COX-2 pathway may be involved in the development and growth of VSs.

Surgical resection of osteolytic calvarial lesions: Clinicopathological features

OBJECTIVE Osteolytic calvarial lesions are infrequent findings. Some cases are found incidentally during cancer staging or subsequent to unspecific symptoms. There are no standardized algorithms for the treatment of such lesions. Thus, the aim of this study was to describe the clinicopathological features and surgical outcome in various osteolytic calvarial lesions. MATERIAL AND METHODS The clinical presentation, radiological imaging findings, surgical treatment and histopathological findings of 36 patients who underwent surgery for an osteolytic calvarial lesion at our institution between 1998 and 2008 were reviewed. RESULTS Thirty-six osteolytic calvarial lesions were identified in 20 men and 16 women. Mean age at diagnosis was 37 years. Ten patients were children younger than 15 years. Five lesions were detected during cancer staging. Complete removal of the calvarial lesions was achieved in all patients without complications. The most common histopathological diagnosis was metastasis (n=9), Langerhans-cell histiocytosis (n=9), and intraosseous hemangioma (n=5). In two asymptomatic patients, histopathological findings revealed metastases of a previously unknown tumor. In two other patients known to suffer from cancer, histopathological findings indicated intraosseous hemangioma and intraosseous meningioma, respectively. Reconstruction of the calvarial defect was performed in 24 cases with poly-methyl-methacrylate and with titanium mesh in 1 case. CONCLUSIONS Osteolytic calvarial lesions can be found in any age group. The histopathological examination reveals various entities, and in some instances it was not concurrent with a primary malignancy. Because surgical morbidity is low, we recommend complete resection of osteolytic calvarial lesions with reconstruction when feasible.

Vestibular schwannoma microsurgery for recurrent tumors after radiation therapy or previous surgical resection.

Objective The purpose of this study is to compare the outcomes in patients who underwent microsurgical resection for recurrent vestibular schwannoma after microsurgical resection and previous radiation therapy. Study Design Retrospective study. Setting University hospital. Patients Fifteen patients, who underwent microsurgical resection for recurrent vestibular schwannoma after previous surgery (group A), and 5 patients, who underwent microsurgical resection after previous radiation therapy (group B) were included. Intervention Surgical resection after radiation therapy or previous surgical resection. Main Outcome Measures Intraoperative findings and postoperative facial nerve function were investigated in groups A and B. Results Mean tumor volumes were 18.4 ± 2.44 cm3 in group A and 19.0 ± 1.53 cm3 in group B. Total resection was achieved in 10 patients (67%) of group A and in 3 patients (60.0%) of group B. The tumor was more difficult to resect because of severe adhesions to the facial nerve. Anatomic facial nerve preservation could be achieved in 19 patients. Mean follow-up time was 80 months for group A and 28 months for group B. At last follow-up, 7 patients (53.8%) of group A had a good facial nerve function. In 3 patients (75.0%) of group B, the preoperative facial nerve function was preserved postoperatively. Preexistent facial paresis, large tumor with extrameatal growth and brainstem compression correlated with poor postoperative facial nerve function. Conclusion Surgical outcome of recurrent vestibular schwannoma is more unsatisfactory than after primary surgery. It remains to be clarified whether previous surgery may implicate a higher risk for postoperative facial nerve function than previous radiation therapy upon surgery for tumor recurrence.

Normobaric Hyperoxia for Treatment of Pneumocephalus after Posterior Fossa Surgery in the Semisitting Position: A Prospective Randomized Controlled Trial

Background Supratentorial pneumocephalus after posterior fossa surgery in the semisitting position may lead to decreased alertness and other symptoms. We here aimed to prove the efficacy of normobaric hyperoxia on the absorption of postoperative pneumocephalus according to a standardized treatment protocol. Methods and Findings We enrolled 44 patients with postoperative supratentorial pneumocephalus (> 30 ml) after posterior fossa surgery in a semisitting position. After randomisation procedure, patients received either normobaric hyperoxia at FiO2 100% over an endotracheal tube for 3 hours (treatment arm) or room air (control arm). Routine cranial CT scans were performed immediately (CT1) and 24 hours (CT2) after completion of surgery and were rated without knowledge of the therapy arm. Two co-primary endpoints were assessed: (i) mean change of pneumocephalus volume, and (ii) air resorption rate in 24 hours. Secondary endpoints were subjective alertness (Stanford Sleepiness Scale) postoperatively and attention (Stroop test), which were evaluated preoperatively and 24 hours after surgery. The mean change in pneumocephalus volume was higher in patients in the treatment arm as compared to patients in the control arm (p = 0.001). The air resorption rate was higher in patients in the treatment arm as compared to patients in the control arm (p = 0.0015). Differences were more pronounced in patients aged 52 years and older. No difference between patients in treatment arm and control arm was observed for the Stroop test. The distribution of scores in the Stanford Sleepiness Scale differed in the treatment arm as compared to the control arm, and there was a difference in mean values (p = 0.015). Conclusions Administration of normobaric hyperoxia at FiO2 100% via an endotracheal tube for 3 hours is safe and efficacious in the treatment of pneumocephalus after posterior fossa surgery in the semisitting position. Largest benefit was found in elderly patients and particularly in older men. Trial Registration German Clinical Trials Register DRKS00006273

Complex wound-healing problems in neurosurgical patients: risk factors, grading and treatment strategy

BackgroundWound-healing problems in the neurosurgical patient can be particularly bothersome, owing to various specific risk factors involved. These may vary from simple wound dehiscence to complex multi-layer defects with cerebrospinal fluid (CSF) leakage and contamination. The latter is quite rare in practice and requires an individually titrated reconstruction strategy. The objective is to retrospectively analyze neurosurgical patients with complex, recalcitrant wound-healing problems we had treated in our department, attempt to develop a grading system based on the risk factors specific to our specialty and adapt a surgical reconstruction algorithm.MethodsDuring an 11-year period, 49 patients were identified to have had complex, recalcitrant wound-healing problems involving the cranial vault (n = 43) and the skull base (n = 6) that required an adapted surgical wound-management strategy. The etiologies of wound healing problems were aftermaths of surgical treatment of: (1) brain tumors (nine cases), (2) aneurysm clipping (ten cases), (3) trauma (27 patients), and (4) congenital malformations (three patients). Local rotational advancement flaps were performed in 18 patients and free microvascular tissue transfer was performed in 37 cases.ResultsMajor risk factors leading to recalcitrant wound healing problems in the presented group were: prolonged angiographic interventions (20%), ongoing chemotherapy or radiotherapy (47%), prolonged cortisone application (51%), CSF leak (76%) and, above all, multiple failed attempts at wound closure (94%). Stable long-term wound healing was achieved in all patients using vascularized tissue coverage. A ternary grading system was developed based on various risk factors in the presented cohort. Accordingly, the algorithm for reconstruction in neurosurgical patients was adapted.ConclusionsPrimary disease, treatment history, and distorted anatomical structures are major concerns in the management of complex wound-healing problems in neurosurgical patients. The higher the risk factors involved, the more complex is the surgical strategy. Free microvascular tissue transfer offers stable long-term results in recalcitrant cases. However, this may be indicated only in patients with a good prognosis of the underlying disease.

Spinal metastasis of papillary tumor of the pineal region

Papillary tumor of the pineal region (PTPR) has recently been lassified as a new entity according to the 2007World Health Orgaization (WHO) “Classification of Tumors of the Nervous System” 1]. Since the first report described by Jouvet et al. [2], only few ases have been published. We report a case of a spinal metasasis from a PTPR detected by neuraxis staging. This is the first ncidence of a spinal metastasis of a PTPR verified by histological xamination.

Delayed distant spinal metastasis in thymomas.

Study Design. A case report. Objective. To demonstrate 2 cases of delayed distant spinal metastasis from a thymoma with comprehensive immunohisto-chemical analysis. Summary of Background Data. Thymoma is a rare slow-growing cancer arising in the mediastinum. Thymomas usually grow invasively into surrounding structures. Distal spinal metastasis is uncommon. To date, only 4 cases with histological verification have been described. Methods. Patient 1: A 42-year-old female complained about back pain for 4 years. She underwent gross-total resection of a type B2 thymoma 8 years earlier without adjuvant therapy. Neurological examination revealed no deficits. Magnetic resonance imaging demonstrated an intraspinal extradural tumor at the level of L4–S1 with infiltration of vertebral body L5. A nearly total resection was performed via a partial L4 and L5 hemilaminectomy. Patient 2: A 62-year-old female was referred with segmental thoracic pain. She underwent a total of 6 surgical procedures for resection of a thymic carcinoma during a period of 13 years with a subsequently local radiation therapy and various chemotherapy cycles. Magnetic resonance imaging revealed an intraspinal extradural tumor at the level of T9–T10 with infiltration of vertebral body T9–T10. A gross-total tumor resection was performed via a costotransversectomy and facetectomy T9–T10. Results. Patient 1: The tumor cells were strongly positive for AE1/3- and CK5/14-specific antibodies. Most of the immature T-cells expressed CD3. CD1a, CD5, and TdT expression was observed in a smaller portion. The findings were consistent with the diagnosis of a spinal metastasis of the known type B2 thymoma. Patient 2: The tumor cells were CK5/14 and CK19/20 positive. Only the infiltrating lymphocytes were labeled with CD3-specific antibodies. Histopathological findings revealed a metastasis of a previously resected well-differentiated thymus carcinoma. Conclusion. We recommend surgical resection because metastasis of thymoma may infiltrate nerve roots and compress the spinal cord. A multidisciplinary approach is required to manage long-term sequelae.

Outcome of surgical decompression of spinal mass lesions in non-Hodgkin's lymphoma and plasmacytoma.

OBJECTIVE Surgical treatment for spinal mass lesions due to non-Hodgkins lymphoma (NHL) or plasmacytoma is necessary only in rare instances. The purpose of this study was to investigate long-term outcome and quality of life of surgery combined with postoperative chemotherapy or radiochemotherapy. METHODS The data of patients, who underwent spinal surgery for mass lesions in a 10-year periods were reviewed, identifying 10 patients with a histopathological diagnosis of NHL or plasmacytoma. Functional outcome were assessed by the Karnofsky Performance Score (KPS), quality of life by the Short Form-36 (SF-36) Health Survey Questionnaire, and pain by the Visual Analog Scale (VAS). RESULTS Clinical presentations included pain (n=10), paresis (n=5), and sensory deficits (n=5). Surgical treatment included removal of the mass lesion (total, n=5; subtotal, n=5) for decompression, interbody fusion (n=3), and corporectomy followed by stabilization (n=1). Histopathological findings revealed NHL in five patients and plasmacytoma/multiple myeloma in five other patients. Postoperatively, all patients underwent chemotherapy or radiochemotherapy. Mean follow-up time was 38 months. At the last follow-up, 2 patients had succumbed to progression of disease. Pain intensity remained significantly reduced as compared to preoperatively (p=0.049). The KPS was 90-100% in five patients still alive, 70% in two, and 60% in one. SF-36 subscores were lower as compared to age-matched healthy controls. CONCLUSIONS This retrospective study shows that surgical decompression of spinal mass lesions is a valuable option in selected patients with NHL or plasmacytoma to improve neurological deficits and control pain. Long-term outcome after postoperative adjuvant therapy confirms prolonged stability of quality of life.