Lucio Palma

Histologic prognostic factors in ependymoma

The prognostic value of a series of histologic signs and clinical features was studied in a series of 298 ependymomas, collected from different institutions. The distribution of tumor sites varied in relation to patient age, with infratentorial cases prevailing under 4 years. Life table univariate analysis demonstrated as highly significant prognostic factors: (1) the number of mitoses; (2) endothelial hyperplasia; (3) necrosis; (4) intracranial site; (5) age <4 years. Multivariate analysis by tumor site revealed mitoses cell density, age >16 years in supratentorial cases, and subependymoma in infratentorial cases to be prognostically important. Comparison of the anaplastic variant with the other tumor types in intracranial cases did not show a significant difference in survival even though the median survival time of anaplastic cases was shorter. The main conclusion is that the histological criteria employed to diagnose anaplasia in gliomas are not useful for recognizing anaplasia in ependymomas. The number of mitoses is a very important prognostic factor in supratentorial cases, whereas endothelial proliferations and necroses are much less important as prognostic factors than in gliomas.

Intraneural synovial cyst of the peroneal nerve: Report of two cases and review of the literature

We report two cases of peroneal nerve compression caused by an intraneural synovial cyst and discuss the pathogenesis, clinical and electrophysiological diagnosis, and treatment of these uncommon lesions in the light of the salient published work on the subject.

The importance of surgery in supratentorial ependymomas : Long-term survival in a series of 23 cases

Abstract In view of the widely recognized correlation between extent of surgical resection and length of survival of children with intracranial ependymoma and the statement that total resection is more likely to be achieved in supratentorial than infratentorial primaries, we decided to review our experience with supratentorial ependymomas and the pertinent literature to verify the importance of surgery in treating this subgroup of pediatric ependymal neoplasms. Of 23 patients operated on, 12 are still alive without evidence of disease 72–357 months after surgery (mean 227, median 237 months). One girl treated by surgery alone was lost to follow-up after 234 months when she, and 7 other patients in the series, had already passed the end of the period of risk for recurrence according to Collins’ law. Six surviving patients (2 with subependymoma and 4 with ependymoma) were treated by surgery alone and only 1, the oldest in the series, had to undergo a second operation for recurrence after 10 years. The idea of treating intracranial ependymoma by surgery alone was favored by eminent neurosurgeons in the past and has recently received renewed attention. This was in part the consequence of recognizing that unlike diffuse astrocytoma, in which neoplastic cells can be found up to several centimeters away from the apparent tumor borders, ependymoma has more or less well-defined margins and grows mainly by expansion. Early experience with the policy of electively deferring adjuvant therapy after radiologically controlled total resection of ependymoma seems encouraging, although postoperative MRI does not yet indicate absolute certainty. Close surveillance is recommended. The majority of ependymomas so far treated by surgery alone, with relatively good success, have been supratentorial. In conclusion, on the basis of our experience and a review of the literature we favor a change in attitude to the management of intracranial ependymomas, especially of the cerebrum, with radiologically controlled radical surgery alone followed by close surveillance with periodic MR imaging until the child passes the period of risk for recurrence according to Collins’ law as the initial option. In children less than 3 years old the period of surveillance should be doubled. In case of recurrence, reoperation should be considered first, particularly for supratentorial primaries. Radiotherapy continues to be a major option in malignant ependymoma and unresectable primary or recurrent benign ependymoma.

Preliminary results of a soft novel lumbar intervertebral prothesis (DIAM) in the degenerative spinal pathology.

The authors report a series of 43 patients suffering from lower limb pain, almost constantly associated with chronic or acute backpain, treated by microsurgical nerve root decompression and by implantation of a soft intervertebral prothesis (DIAM). Satisfying results were obtained in 97% of cases, inducing the authors to consider the device a reliable tool for curing low-back pain and sciatica. Selection criteria are exposed and discussed.

Vagus nerve stimulation for drug-resistant epilepsy in children and young adults

We present our experience with the use of intermittent vagal nerve stimulation in 13 patients with medically intractable epilepsy. A surgical approach, with the exception of callosotomy, was impossible. The age range was 6-28 years (median 17 years). In all patients the epilepsy was severe and in six of them was symptomatic. Seven patients had Lennox-Gastaut syndrome, one epilepsy with myoclonic-astatic seizures, four localization-related and one symptomatic generalized epilepsy. The length of the follow-up averaged 22 months (range 8 months-3 years). Of the 13 patients, five (38.4%) had a 50% or more reduction in the number of seizures compared with preimplantation. Of these patients, one with a localization-related epilepsy had a 90% reduction as well as a significant improvement in alertness. Three patients showed no improvement with regard to the number of seizures but there was an improvement in alertness and, in one case in hyperactivity. Some seizure types responded better than others did: complex partial seizures with secondary generalization and atonic seizures. All our responsive patients improved in the first 2 months of VNS activation and only one case with further improvement was observed after this period. Considering the severity of the epilepsy the results can be considered satisfactory. We think that this treatment appears to be a safe adjunctive therapy for children and adults with medically and surgically intractable epilepsy.

Oligodendrogliomas of the spinal cord

SummaryThe clinical, surgical, and pathological data from 35 published cases of oligodendroglioma and of one personal case are analysed and compared with those from other tumours of the cord and from cerebral oligodendrogliomas. Oligodendroglioma of the cord has a slightly lower average age than other gliomas and is closer to that of glioblastoma. In oligodendroglioma of the cord, as of the brain, acute onset or aggravation of the symptoms and an oscillating course are frequent. Two correlated data are particularly worth noting: a) the mean CSF protein content in oligodendroglioma of the cord is higher than in any other glioma; b) intracranial hypertension, in the form of papilloedema or hydrocephalus, or both, was present in 31% of cases. This signifies cerebral oligodendrogliomatosis, which was found in 6 out of 10 necropsied cases. At operation most oligodendrogliomas of the cord appear as infiltrating “gelatinous” tumours, though a minority have a firm consistency and apparently clearcut contours, which seem to be associated with a better prognosis. Postoperative radiotherapy seems to be useful.

Long-term follow-up of childhood cerebellar astrocytomas after incomplete resection with particular reference to arrested growth or spontaneous tumour regression.

SummaryBackground. The long-term prognosis for incompletely excised benign cerebellar astrocytomas in children remains largely unpredictable as the incidence of symptomatic recurrence ranges from 18 to 100%. Arrested growth and spontaneous tumour regression are a recognized but neglected phenomenon, the incidence and objective demonstration of which have received relatively little attention in the literature. With the aim of providing more information on this question, we reviewed our experience with incompletely resected benign cerebellar astrocytomas in children. Clinical material and methods. Our series consisted of 31 children with long-term follow-up. None had signs of type 1 neurofibromatosis (NF1). Histology included 22 classic pilocytic and nine diffuse astrocytomas. Seventeen children had symptomatic recurrence after 25 to 450 months and fourteen children remained in good health for 84 to 516 months.In looking for evident clinical differences that could help elucidate the different courses, we also examined recent radiographic images to assess tumour status. The literature was reviewed to obtain further information on nonrecurring and on regressing cerebellar astrocytomas after partial resection in the setting of modern surveillance imaging resources. Findings. No differences in factors that could elucidate the different clinical courses were found between the two groups of children. Recent negative CT scans or NMR images were reported in seven cases. In two cases arrested growth or regression of a previously visible neoplastic remnant was noted. Review of the literature showed that radiographic follow-up has revealed arrested growth or spontaneous regression of benign cerebellar astrocytoma remnants in 32.5% and 14% of cases, respectively. Conclusions. As hypothesized by Cushing, our study shows that a large proportion of cerebellar astrocytomas do not progress or even regress after partial excision. This phenomen is not understood and unfortunately cannot be anticipated. However, it suggests that a policy of “wait and see” with serial MR imaging can reasonably be recommended in children with cerebellar astrocytoma after partial resection, if the remnant is too risky to be removed by second-look surgery.

Supratentorial glioblastoma in children: a series of 27 surgically treated cases

Reporting a series of 27 supratentorial glioblastomas in pediatric patients treated surgically in the Department of Neurosurgical Sciences-Neurosurgery Section—of “La Sapienza” University of Rome, we discuss the principal clinical features, treatment and prognosis of the tumour with reference to the salient published series.

Growing skull fractures: progressive evolution of brain damage and effectiveness of surgical treatment

The growing skull fracture of childhood is a well-known but variously interpreted syndrome. Attempts have been made to find different pathogeneses for clinical and pathological patterns that are really successive phases of a single process, arising from the interaction of three basic conditions: (1) head injury with a large gaping fracture; (2) corresponding dural tear; (3) occurrence nearly always in infancy (the first year of life or period of maximum brain growth). This combination of factors alters the normal distribution of the intracranial pressure vectors and the fracture behaves like a “neosuture” with abnormal growth of the skull on the injured side. Simultaneously, the ventricular system tends to deform, dilating and shifting towards the side of the fracture. Three cases, successfully treated at a very late stage, are described. The good surgical results confirm the validity of the surgical method and its underlying theoretical basis.

Histologically benign recurrent meningioma metastasizing to the parotid gland: case report and review of the literature.

This report presents a very rare case of metastatic meningioma of the parotid gland from a recurring intracranial lesion. The primary tumor, intracranial residues, and parotid metastasis were histologically benign. Meningiomas rarely metastasize; even rarer are cases in which both the primary and the secondary tumors have benign histological characteristics. The 11 cases reported in the literature have been critically reviewed. The case we present is noteworthy also for the exceptional localization of the metastasis in the parotid gland.