Giada Pauletto

Low-grade glioma surgery in eloquent areas: Volumetric analysis of extent of resection and its impact on overall survival. A single-institution experience in 190 patients - Clinical article

OBJECT A growing number of published studies have recently demonstrated the role of resection in overall survival (OS) for patients with gliomas. In this retrospective study, the authors objectively investigated the role of the extent of resection (EOR) in OS in patients with low-grade gliomas (LGGs). METHODS Between 1998 and 2011, 190 patients underwent surgery for LGGs. All surgical procedures were conducted under corticosubcortical stimulation. The EOR was established by analyzing the pre- and postoperative volumes of the gliomas on T2-weighted MRI studies. The difference between the preoperative tumor volumes was also investigated by measuring the volumetric difference between the T2- and T1-weighted MRI images (ΔVT2T1) to evaluate how the diffusive tumor-growing pattern affected the EOR achieved. RESULTS The median preoperative tumor volume was 55 cm(3), and in almost half of the patients the EOR was greater than 90%. In this study, patients with an EOR of 90% or greater had an estimated 5-year OS rate of 93%, those with EOR between 70% and 89% had a 5-year OS rate of 84%, and those with EOR less than 70% had a 5-year OS rate of 41% (p < 0.001). New postoperative deficits were noted in 43.7% of cases, while permanent deficits occurred in 3.16% of cases. There were 41 deaths (21.6%), and the median follow-up was 4.7 years. A further volumetric analysis was also conducted to compare 2 different intraoperative protocols (Series 1 [intraoperative electrical stimulation alone] vs Series 2 [intraoperative stimulation plus overlap of functional MRI/fiber tracking diffusion tensor imaging data on a neuronavigation system]). Patients in Series 1 had a median EOR of 77%, while those in Series 2 had a median EOR of 90% (p = 0.0001). Multivariate analysis showed that OS is influenced not only by EOR (p = 0.001) but also by age (p = 0.003), histological subtype (p = 0.005), and the ΔVT2T1 value (p < 0.0001). Progression-free survival is similarly influenced by histological subtype (fibrillary astrocytoma, p = 0.003), EOR (p < 0.0001), and ΔVT2T1 value (p < 0.0001), as is malignant progression-free survival (p = 0.003, p < 0.0001, and p < 0.0001, respectively). Finally, the study shows that the higher the ΔVT2T1 value, the less extensive the currently possible resection, highlighting an apparent correlation between the ΔVT2T1 value itself and EOR (p < 0.0001). CONCLUSIONS The EOR and the ΔVT2T1 values are the strongest independent predictors in improving OS as well as in delaying tumor progression and malignant transformation. Furthermore, the ΔVT2T1 value may be useful as a predictive index for EOR. Finally, due to intraoperative corticosubcortical mapping and the overlap of functional data on the neuronavigation system, major resection is possible with an acceptable risk and a significant increase in expected OS.

Surgery of insular nonenhancing gliomas: volumetric analysis of tumoral resection, clinical outcome, and survival in a consecutive series of 66 cases.

BACKGROUND Despite intraoperative technical improvements, the insula remains a challenging area for surgery because of its critical relationships with vascular and neurophysiological functional structures. OBJECTIVE To retrospectively investigate the morbidity profile in insular nonenhancing gliomas, with special emphasis on volumetric analysis of tumoral resection. METHODS From 2000 to 2010, 66 patients underwent surgery. All surgical procedures were conducted under cortical-subcortical stimulation and neurophysiological monitoring. Volumetric scan analysis was applied on T2-weighted magnetic resonance images (MRIs) to establish preoperative and postoperative tumoral volume. RESULTS The median preoperative tumor volume was 108 cm. The median extent of resection was 80%. The median follow-up was 4.3 years. An immediate postoperative worsening was detected in 33.4% of cases; a definitive worsening resulted in 6% of cases. Patients with extent of resection of > 90% had an estimated 5-year overall survival rate of 92%, whereas those with extent of resection between 70% and 90% had a 5-year overall survival rate of 82% (P < .001). The difference between preoperative tumoral volumes on T2-weighted MRI and on postcontrast T1-weighted MRI ([T2 - T1] MRI volume) was computed to evaluate the role of the diffusive tumoral growing pattern on overall survival. Patients with preoperative volumetric difference < 30 cm demonstrated a 5-year overall survival rate of 92%, whereas those with a difference of > 30 cm had a 5-year overall survival rate of 57% (P = .02). CONCLUSION With intraoperative cortico-subcortical mapping and neurophysiological monitoring, a major resection is possible with an acceptable risk and a significant result in the follow-up.

Surgery for insular low-grade glioma: predictors of postoperative seizure outcome.

OBJECT Although a number of recent studies on the surgical treatment of insular low-grade glioma (LGG) have demonstrated that aggressive resection leads to increased overall patient survival and decreased malignant progression, less attention has been given to the results with respect to tumor-related epilepsy. The aim of this investigation was to evaluate the impact of volumetric, histological, and intraoperative neurophysiological factors on seizure outcome in patients with insular LGG. METHODS The authors evaluated predictors of seizure outcome with special emphasis on both the extent of tumor resection (EOR) and the tumors infiltrative pattern quantified by computing the difference between the preoperative T2- and T1-weighted MR images (ΔVT2T1) in 52 patients with preoperative drug-resistant epilepsy. RESULTS The 12-month postoperative seizure outcome (Engel class) was as follows: seizure free (Class I), 67.31%; rare seizures (Class II), 7.69%; meaningful seizure improvement (Class III), 15.38%; and no improvement or worsening (Class IV), 9.62%. Poor seizure control was more common in patients with a longer preoperative seizure history (p < 0.002) and higher frequency of seizures (p = 0.008). Better seizure control was achieved in cases with EOR ≥ 90% (p < 0.001) and ΔVT2T1 < 30 cm(3) (p < 0.001). In the final model, ΔVT2T1 proved to be the strongest independent predictor of seizure outcome in insular LGG patients (p < 0.0001). CONCLUSIONS No or little postoperative seizure improvement occurs mainly in cases with a prevalent infiltrative tumor growth pattern, expressed by high ΔVT2T1 values, which consequently reflects a smaller EOR.

Anticancer drugs and central nervous system: Clinical issues for patients and physicians

Anticancer drugs may cause neurological toxicity involving the central nervous system. Patients receiving anticancer treatment may develop encephalopathy, extrapyramidal reactions, seizures, cerebellar dysfunction, retinopathy, cerebral venous thrombosis, myelopathy, cognitive impairment, and psychiatric symptoms. Physician should carefully evaluate neurological signs and symptoms in order to recognize these drug-related adverse reactions. In this review we aimed at presenting different neurological complications of anticancer drugs and their management. PUBMED search was performed in order to retrieve all articles and case reports dealing with central nervous system toxicity related to anticancer treatments.

Second Surgery in Insular Low-Grade Gliomas

Background. Given the technical difficulties, a limited number of works have been published on insular gliomas surgery and risk factors for tumor recurrence (TR) are poorly documented. Objective. The aim of the study was to determine TR in adult patients with initial diagnosis of insular Low-Grade Gliomas (LGGs) that subsequently underwent second surgery. Methods. A consecutive series of 53 patients with insular LGGs was retrospectively reviewed; 23 patients had two operations for TR. Results. At the time of second surgery, almost half of the patients had experienced progression into high-grade gliomas (HGGs). Univariate analysis showed that TR is influenced by the following: extent of resection (EOR) (P < 0.002), ΔVT2T1 value (P < 0.001), histological diagnosis of oligodendroglioma (P = 0.017), and mutation of IDH1 (P = 0.022). The multivariate analysis showed that EOR at first surgery was the independent predictor for TR (P < 0.001). Conclusions. In patients with insular LGG the EOR at first surgery represents the major predictive factor for TR. At time of TR, more than 50% of cases had progressed in HGG, raising the question of the oncological management after the first surgery.

Quantitative Diffusion Tensor Imaging Analysis of Low-Grade Gliomas: From Preclinical Application to Patient Care

BACKGROUND Preoperative diffusion tensor tractography (DTT) has recently been used to aid in the mapping of functional pathways to limit damage associated with resection of low-grade gliomas (LGGs). OBJECTIVE To assess the predictive capacity of DTT as a biomarker of postoperative motor outcomes in patients with LGGs involving the corticospinal tract (CST). CST parameters obtained using a quantitative fiber tracking approach were used to investigate the reliability of the DTT biomarker by comparing their values in the tumoral (Tcst) and healthy (Hcst) hemispheres. METHODS Thirty-seven patients with LGGs involving the CST were enrolled. Quantification of structural differences between the Tcst and Hcst were analyzed according to the novel biomarker (NF index), defined as follows: (Hcst NF - Tcst NF)/Hcst NF, where NF represents the number of fibers in each region. Logistic regression analysis was used to examine associations among clinical postoperative outcomes and NF index values, tumoral patterns, and premotor/motor evoked potentials. RESULTS NF values significantly differed between the Tcst and Hcst. Analysis of the NF index showed that patients with a preoperative NF index <0.22 had a significantly lower risk of developing transient postoperative deficits (area under the curve, 0.92; 95% binomial confidence interval, 0.834-1). Patients with less pronounced differences in NF between the Tcst and Hcst also experienced better clinical outcomes. CONCLUSIONS The NF index may be a useful biomarker for predicting clinical outcomes in patients with LGGs. Furthermore, the NF index may provide a preoperative estimate of the patients potential for recovery from possible postsurgical neurologic deficits.

Supratentorial Cavernous Malformations Involving the Corticospinal Tract and Sensory Motor Cortex: Treatment Strategies, Surgical Considerations, and Outcomes

BACKGROUND Cavernous malformations (CMs) are congenital malformations and may be located anywhere in the brain. We present a series of CMs located close to or inside of the motor-sensory cortex or corticospinal tract (CST) with clinical onset due to hemorrhage or mass effect. In such cases, surgery becomes an acceptable option. OBJECTIVE To evaluate the role of diffusion tensor imaging (DTI), functional-magnetic-resonance imaging (fMRI), intraoperative neurophysiological monitoring, neuronavigation, and brain-mapping and the clinical results of surgical treatment of CMs in this critical location. METHODS The study included 54 patients harboring 22 cortical and 32 deep locations. This series was distinct because in group I, where the DTI was not obtained, and in the group II, where this evaluation was performed. RESULTS The postoperative permanent morbidity rate was 4% in the historical group for the deeper CMs, and there was no morbidity in the second group. DTI and fMRI permitted us to estimate the distance between the CMs and both the cortical activation cluster and the pyramidal tract. These data, in addition to intraoperative mapping and monitoring, made it necessary for us to perform a partial resection in 2 cases in the second series. CONCLUSION CMs are congenital lesions and CST fibers can run directly on their surface. Integration of fMRI and DTI data with intraoperative functional monitoring and direct cortical and subcortical mapping are mandatory to accomplish an optimal resection, tailoring the best surgical approach to the acceptable morbidity. A subtotal resection could be considered an option for deep locations.

Effect of thymectomy on refractory autoimmune status epilepticus

Refractory status epilepticus (RSE) is an increasingly recognized manifestation of autoimmune encephalitis, which can occur either as a paraneoplastic or non-paraneoplastic disorder. The effect of tumor removal in paraneoplastic status epilepticus has never been explored systematically, although early tumor treatment is usually recommended. In this study, we report clinical, pathological and EEG findings of a patient who developed RSE as one of multiple paraneoplastic manifestations of thymoma and the effect of thymectomy on seizure outcome. To our knowledge, this is the first report of successful treatment of RSE with tumor removal in paraneoplastic encephalitis.

P11.7 Effects of “dissociative” anaesthesia on subthalamic nucleus activity in Parkinsonian patients who underwent deep brain stimulation

Introduction: During cerebral aneurysms surgery, could appear isquemic complications because of an artery occlusion. The changes depend of the cerebrovascular auto regulation, collateral perfusion and systemic homeostasis parameters. Objective: Assess intraoperative neurophysiologic monitoring outcomes of patients whom were operated or cerebral aneurysms. Methods: We present a total of 17 patients with intracranial aneurysms, that was intraoperative monitored with somatosensory evoked potentials (SEP) and motor evoked potentials (MEP). Results: Isquemic time during temporal clip collocation was 4 minutes in 11 cases, and in 6 cases between 1 second and 25 minutes. In 3 patients there was a change in SEP and MEP during the clipping. Patient 1: absence of SEP after 30 seconds aneurysm clipping without posterior recover and postoperative left hemiplegic. MEP with no changes. Patient 2: 50% amplitude reduction of SEP and MEP, when the aneurysm clipping with posterior recover and not postquirugic neurological sequel. Patient 3: 50% amplitude reduction of SEP after 6.86 minutes aneurysm clipping and a second amplitude SEP reduction alter 1.10 minutes, both of them with posterior recover and not postoperative neurological sequel. No changes in MEP. Conclusions: In our knowledge, the most sensitive parameter to detect isquemia was the SEP. MEP is not reliable, probably because it can bypass isquemic site by distal stimulation. The clipping duration was not related with the changes on SEP and MEP, maybe because of the presence of collateral arteries. Nevertheless it would be required more number of cases to determine the time of clipping and sensitive parameters to define isquemic complications.