Gualtiero Innocenzi

Role of stereotactic radiosurgery and fractionated stereotactic radiotherapy for the treatment of recurrent glioblastoma multiforme

Glioblastoma multiforme (GBM) is a devastating malignant brain tumor characterized by resistance to available therapeutic approaches and relentless malignant progression that includes widespread intracranial invasion, destruction of normal brain tissue, progressive disability, and death. Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) are increasingly used in patients with recurrent GBM to complement traditional treatments such as resection, conventional external beam radiotherapy, and chemotherapy. Both SRS and fSRT are powerful noninvasive therapeutic modalities well suited to treat focal neoplastic lesions through the delivery of precise, highdose radiation. Although no randomized clinical trials have been performed, a variety of retrospective studies have been focused on the use of SRS and fSRT for recurrent GBMs. In addition, state-of-the-art neuroimaging techniques, such as MR spectroscopic imaging, diffusion tensor tractography, and nuclear medicine imaging, have enhanced treatment planning methods leading to potentially improved clinical outcomes. In this paper the authors reviewed the current applications and efficacy of SRS and fSRT in the treatment of GBM, highlighting the value of these therapies for recurrent focal disease.

Prognostic factors in intramedullary astrocytomas

This report presents a retrospective prognostic study of 65 patients with intramedullary astrocytoma surgically treated between 1953 and 1990. Median survival and statistical survival at 5 years were assessed in relation to clinical, histological and therapeutic factors for each patient. Results showed that factors positively influencing the prognosis are low histological grade of the tumour and good pre- and post-operative general conditions. Among the grade II astrocytomas, the fibrillary and protoplasmatic types presented longer survival times regardless of the type of removal performed. In anaplastic astrocytomas the simultaneous presence of certain morphological features indicative of higher malignancy negatively influenced survival. The degree of resection did not influence average survival within each histological grade.

Intramedullary astrocytomas and ependymonas in the pediatric age group: a retrospective study

A series of 45 pediatric patients underwent surgery for intramedullary astrocytoma or ependymoma at the Cook County Hospital or the Childrens Memorial Hospital of Chicago (Northwestern University) and the Neurosurgical Department of Rome “La Sapienza” University. Results showed that intramedullary astrocytomas and ependymomas in children differ from one another in terms of prognosis, and particularly as regards surgical strategy as an element of therapeutic management. Gross total removal of 70% of the ependymonas was achieved, in comparison to 33% of the astrocytomas. In astrocytomas the extent of resection did not significantly influence prognosis. Neurological condition on admission, regardless of oncotype, was found to be extremely influential: patients operated in good condition tended to remain neurologically stable or improve in the long term, while those operated on while in poor condition did not show any improvement at all. No definitive conclusions were possible regarding the value of radiotherapy, because it was only performed in 6 of the 45 cases. The authors limited its use to highly malignant lesions in view of the well-known sensitivity of the spinal cord to radiation, especially in children.

Intramedullary cavernous angiomas of the spinal cord: report of six cases.

The authors report six cases of intramedullary cavernoma. Symptoms evolved by episodes of stepwise neurologic deterioration or slow progression. All patients had preoperative and postoperative magnetic resonance imaging (MRI). Removal of the cavernoma was total in all cases and in one a transthoracic approach was performed because of the ventral and superficial position of the lesion. At follow-up, ranging from 6 to 18 months, two patients improved, two were unchanged, and one had deteriorated. Prognosis was influenced by the length of clinical history and the severity of preoperative symptoms. The principal clinical and therapeutic aspects of cavernoma are discussed in light of the published data.

Intramedullary spinal cord cavernous malformations: report of ten new cases.

Spinal cord cavernous malformations (SCCM), once thought to be extremely rare, have been diagnosed more frequently since the advent of MRI. In addition to the six personal cases surgically treated between 1992 and 1993 and already described in the literature, the authors report here a further ten cases operated on between April 1993 and January 2001. These involved five males and five females whose ages at operation ranged from 12 to 69xa0years. The SCCM were thoracic in five patients and cervical in five. In seven cases, the malformations bulged on the surface of the pia mater, while in the other three there was subpial discoloration due to the presence of hemosiderin. Removal was total in all cases. After surgery, two patients presented transient worsening of preoperative paraparesis. At follow-up ranging from 2.2 to 9.2xa0years (mean 5.7), nine patients had made complete motor recovery while one, in whom preoperative paraparesis had been severe, remained stationary. At least one follow-up MRI investigation was performed in each patient 6 to 12xa0months after operation. As previously reported, the authors confirm that the treatment of choice for symptomatic SCCM is total surgical excision in order to avoid recurrences and the possibility of further hemorrhage. Surgical outcome combines low mortality with a high probability of functional recovery, especially when paraparesis is not severe and of relatively recent onset.

Spontaneous drainage of syringomyelia. Report of two cases

Two cases are reported of Arnold-Chiari type I malformation associated with syringomyelia, in which magnetic resonance (MR) imaging revealed spontaneous decompression of the syrinx. In one case axial MR imaging sections showed a communication between the syrinx and the spinal subarachnoid space, which supports the hypothesis that fissuring of the cord parenchyma is instrumental in the spontaneous resolution of syringomyelia. The MR imaging changes were not accompanied by variations in the patients clinical course.

Transsphenoidal adenomectomy for GH-, PRL- and ACTH-secreting pituitary tumours: outcome analysis in a series of 125 patients

Transsphenoidal surgery (TSS) is a well recognised treatment for secreting pituitary adenomas, however a very wide variation of clinical outcomes and recurrence rates has been reported, depending on the different criteria used to define the cure. We reported the clinical outcome of a large series of patients operated on for a secreting pituitary adenoma according to the most recent stringent criteria of biochemical remission nowadays accepted. One hundred and twenty-five consecutive patients with a secreting pituitary adenoma (42 PRL-, 67 GH- and 16 ACTH-secreting adenomas) who were operated on by the two same neurosurgeons were considered for the study. Biochemical remission of disease was achieved in 56% of patients; 78% for patients with microadenoma and 47% for patients with macroadenomas, respectively. No cases of mortality or major immediate postoperative complications were observed. Tumour size, high hormone levels and dural invasion were significantly correlated to a poor surgical outcome. The recurrence rates ranged between 0 and 24%, being higher for PRL-secreting tumours. In conclusion, TSS is safe and effective in secreting pituitary tumours. It is still the first treatment for GH- and ACTH-secreting adenomas, whereas in patients with prolactinomas, surgery should be reserved for cases of resistance or intolerance to dopamine agonists.

Prolonged stabilization of multiple and single brain metastases from breast cancer with tamoxifen. Report of three cases.

Cancer frequently metastasizes to the brain, and such lesions, whether multiple or solitary, have a poor prognosis, despite all efforts to treat them. There have been recent sporadic reports of brain metastases from breast cancer responding for some years to antiestrogens (particularly tamoxifen) or bromocryptine. We report three cases of brain metastasis from cancer – two multiple and one a solitary lesion. The long survival of the patients – two for 5 years and one for 6 years, with more than an acceptable quality of life – should prompt therapeutic trials to test tamoxifen and designed to assess its effects on a sizable number of patients.

Meningiomas of Meckel's cave

A series of 16 patients with meningiomas of Meckels cave is reported. Trigeminal neuralgia, typical or atypical, was the initial symptom in 10 patients (62.5%). At admission, trigeminal signs and symptoms were present in 15 patients (93.7%); in 7 patients (43.7%), trigeminal dysfunction was combined with the impairment of other cranial nerves. On retrospective analysis, these patients fall into two clinical groups that differ also in prognosis. Group 1 comprises eight patients with trigeminal signs and symptoms only. These patients had small meningiomas strictly affecting Meckels cave. Total removal of the tumor was achieved in seven of eight patients, without adjunctive postoperative neurological deficits. In this group, there were no tumor recurrences. Group 2 comprises the other eight patients in whom trigeminal dysfunction was combined with impairment of other cranial nerves. These patients had large tumors arising from Meckels cave and secondarily invading the cavernous sinus (five patients) or extending into the posterior fossa (two patients) or largely growing into the middle fossa (one patient). Total removal was achieved in only one patient, and a worsening of the preoperative neurological status was observed in four patients; there were three cases of tumor progression. A subtemporal intradural approach (used in the past in every case) is still used for the small tumors of Group 1 with good results. Since 1985, for tumors involving the cavernous sinus, we have employed a frontotemporal craniotomy with extradural clinoidectomy and superior and lateral approach to the cavernous sinus. When the tumor extends toward the posterior fossa, we use a combined temporosuboccipital-transpetrosal approach.(ABSTRACT TRUNCATED AT 250 WORDS)

Osteoblastoma of the calvaria: report of two cases diagnosed with MRI and clinical review.

The authors describe 2 cases of osteoblastoma of the calvaria and review the clinical features of the 28 cases reported in the world literature. Benign osteoblastoma is a rare tumor that effects young patients, most frequently at temporal level. On the basis of its neuroradiological appearance, it is difficult to formulate a differential diagnosis against other osteoblastic tumors or against osteoid osteoma. In only a few cases MRI findings are reported. In our cases, MRI was more effective than CT scans and radiographs for evaluating the intracranial and intraosseous extension of the tumor. The definitive diagnosis was obtained by combining the histopathological features of the tumor with the clinical and radiological data. The prognosis of this tumor is very good regardless of the type of treatment performed, although both relapse and, more rarely, malignant tumor evolution are possible.