Panagiotis Selviaridis

Volumetric and MGMT parameters in glioblastoma patients: Survival analysis

BackgroundIn this study several tumor-related volumes were assessed by means of a computer-based application and a survival analysis was conducted to evaluate the prognostic significance of pre- and postoperative volumetric data in patients harboring glioblastomas. In addition, MGMT (O6-methylguanine methyltransferase) related parameters were compared with those of volumetry in order to observe possible relevance of this molecule in tumor development.MethodsWe prospectively analyzed 65 patients suffering from glioblastoma (GBM) who underwent radiotherapy with concomitant adjuvant temozolomide. For the purpose of volumetry T1 and T2-weighted magnetic resonance (MR) sequences were used, acquired both pre- and postoperatively (pre-radiochemotherapy). The volumes measured on preoperative MR images were necrosis, enhancing tumor and edema (including the tumor) and on postoperative ones, net-enhancing tumor. Age, sex, performance status (PS) and type of operation were also included in the multivariate analysis. MGMT was assessed for promoter methylation with Multiplex Ligation-dependent Probe Amplification (MLPA), for RNA expression with real time PCR, and for protein expression with immunohistochemistry in a total of 44 cases with available histologic material.ResultsIn the multivariate analysis a negative impact was shown for pre-radiochemotherapy net-enhancing tumor on the overall survival (OS) (p = 0.023) and for preoperative necrosis on progression-free survival (PFS) (p = 0.030). Furthermore, the multivariate analysis confirmed the importance of PS in PFS and OS of patients. MGMT promoter methylation was observed in 13/23 (43.5%) evaluable tumors; complete methylation was observed in 3/13 methylated tumors only. High rate of MGMT protein positivity (> 20% positive neoplastic nuclei) was inversely associated with pre-operative tumor necrosis (p = 0.021).ConclusionsOur findings implicate that volumetric parameters may have a significant role in the prognosis of GBM patients. Furthermore, volumetry could help not only to improve the prediction of outcome but also the outcome itself by identifying patients at high risk of treatment failure and, thus, seek alternative treatment for these patients. In this small series, MGMT protein was associated with less aggressive tumor characteristics.

Intraventricular administration of morphine for control of intractable cancer pain in 90 patients.

OBJECTIVE To quantitate the relief of intractable cancer pain by the use of intraventricular morphine administration. METHODS Intraventricular morphine administration was performed through an Ommaya reservoir. An initial dose of 0.25 mg of morphine sulfate per 24 hours was administered to all of the patients. This dose was progressively increased in 0.25-mg increments until optimal analgesia was attained. RESULTS Sixty men and 30 women with a median age of 58 years (range, 23-80 yr) entered the study. The median duration of pain was 6 months (range, 0.5-120 mo). A daily morphine dose of up to 1 mg was adequate to achieve an analgesic effect in 77% of the patients. Only nine patients (10%) achieved < 50% pain relief. Using a multiple regression analysis, only the morphine dosage was found to be an independent prognostic factor. The most frequent side effect (22%) was nausea/vomiting. Also, there were two patients with opioid intolerance and two with intracerebral hematomas. Three reservoirs failed. CONCLUSION Intraventricular morphine administration is a useful method for palliation of intractable cancer pain.

The Importance of Tumor Volume in the Prognosis of Patients with Glioblastoma

Background and Purpose:The importance of tumor volume as a prognostic factor in high-grade gliomas is highly controversial and there are numerous methods estimating this parameter. In this study, a computer-based application was used in order to assess tumor volume from hard copies and a survival analysis was conducted in order to evaluate the prognostic significance of preoperative volumetric data in patients harboring glioblastomas.Patients and Methods:50 patients suffering from glioblastoma were analyzed retrospectively. Tumor volume was determined by the various geometric models as well as by an own specialized software (Volumio). Age, performance status, type of excision, and tumor location were also included in the multivariate analysis.Results:The spheroid and rectangular models overestimated tumor volume, while the ellipsoid model offered the best approximation. Volume failed to attain any statistical significance in prognosis, while age and performance status confirmed their importance in progression-free and overall survival of patients.Conclusion:Geometric models provide a rough approximation of tumor volume and should not be used, as accurate determination of size is of paramount importance in order to draw safe conclusions in oncology. Although the significance of volumetry was not disclosed, further studies are definitely required.Hintergrund und Ziel:Die Bedeutung des Tumorvolumens als prognostischer Faktor fur maligne Gliome ist nach wie vor umstritten. In dieser Studie wurden eine computerbasierte Methode zur Beurteilung des Tumorvolumens anhand von magnetresonanztomographischen Bildern bei Patienten mit Glioblastoma multiforme (GBM) durchgefuhrt und mittels einer Uberlebensanalyse die prognostische Bedeutung praoperativer volumetrischer Daten untersucht.Patienten und Methodik:50 Patienten mit GBM, welche zwei unterschiedliche Chemotherapieregime erhalten hatten, wurden retrospektiv analysiert und die Tumorvolumina durch verschiedene geometrische Modelle sowie eine spezielle Software (Volumio) gemessen. Alter, Performance-Status, Tumorlokalisation sowie Art der Exzision wurden in der multivariaten Uberlebensanalyse berucksichtigt.Ergebnisse:Die angewandten spharoiden und rektangularen geometrischen Modelle uberschatzten das Tumorvolumen, wohingegen die ellipsoiden Modelle die beste Annaherung im Vergleich zu Volumio ermoglichten. Das Tumorvolumen erwies sich nicht als statistisch signifikanter Prognosefaktor. In der multivariaten Analyse bestatigte sich die Bedeutung des Alters und des Performance-Status fur das progressionsfreie Uberleben und das Gesamtuberleben der Patienten.Schlussfolgerung:Geometrische Modelle bieten eine ungenaue Messung des Tumorvolumens und sollten in der klinischen Praxis nicht zur Anwendung kommen, zumal die prazise Erfassung der Tumorgrose von entscheidender onkologischer Bedeutung ist. Obwohl die vorgelegten Daten den Einfluss des Tumorvolumens als statistisch nicht signifikant zeigten, sind weitere Studien bezuglich der Bedeutung dieses Parameters notwendig.

The importance of tumor volume in the prognosis of patients with glioblastoma: comparison of computerized volumetry and geometric models.

Background and Purpose:The importance of tumor volume as a prognostic factor in high-grade gliomas is highly controversial and there are numerous methods estimating this parameter. In this study, a computer-based application was used in order to assess tumor volume from hard copies and a survival analysis was conducted in order to evaluate the prognostic significance of preoperative volumetric data in patients harboring glioblastomas.Patients and Methods:50 patients suffering from glioblastoma were analyzed retrospectively. Tumor volume was determined by the various geometric models as well as by an own specialized software (Volumio). Age, performance status, type of excision, and tumor location were also included in the multivariate analysis.Results:The spheroid and rectangular models overestimated tumor volume, while the ellipsoid model offered the best approximation. Volume failed to attain any statistical significance in prognosis, while age and performance status confirmed their importance in progression-free and overall survival of patients.Conclusion:Geometric models provide a rough approximation of tumor volume and should not be used, as accurate determination of size is of paramount importance in order to draw safe conclusions in oncology. Although the significance of volumetry was not disclosed, further studies are definitely required.Hintergrund und Ziel:Die Bedeutung des Tumorvolumens als prognostischer Faktor fur maligne Gliome ist nach wie vor umstritten. In dieser Studie wurden eine computerbasierte Methode zur Beurteilung des Tumorvolumens anhand von magnetresonanztomographischen Bildern bei Patienten mit Glioblastoma multiforme (GBM) durchgefuhrt und mittels einer Uberlebensanalyse die prognostische Bedeutung praoperativer volumetrischer Daten untersucht.Patienten und Methodik:50 Patienten mit GBM, welche zwei unterschiedliche Chemotherapieregime erhalten hatten, wurden retrospektiv analysiert und die Tumorvolumina durch verschiedene geometrische Modelle sowie eine spezielle Software (Volumio) gemessen. Alter, Performance-Status, Tumorlokalisation sowie Art der Exzision wurden in der multivariaten Uberlebensanalyse berucksichtigt.Ergebnisse:Die angewandten spharoiden und rektangularen geometrischen Modelle uberschatzten das Tumorvolumen, wohingegen die ellipsoiden Modelle die beste Annaherung im Vergleich zu Volumio ermoglichten. Das Tumorvolumen erwies sich nicht als statistisch signifikanter Prognosefaktor. In der multivariaten Analyse bestatigte sich die Bedeutung des Alters und des Performance-Status fur das progressionsfreie Uberleben und das Gesamtuberleben der Patienten.Schlussfolgerung:Geometrische Modelle bieten eine ungenaue Messung des Tumorvolumens und sollten in der klinischen Praxis nicht zur Anwendung kommen, zumal die prazise Erfassung der Tumorgrose von entscheidender onkologischer Bedeutung ist. Obwohl die vorgelegten Daten den Einfluss des Tumorvolumens als statistisch nicht signifikant zeigten, sind weitere Studien bezuglich der Bedeutung dieses Parameters notwendig.

Biopsy versus resection in the management of malignant gliomas: a systematic review and meta-analysis

OBJECT The aim of this study was to answer the question whether quality of life and progression-free and overall survival are increased in adults with supratentorial malignant glioma who are treated with cytoreductive resection as compared with those who only undergo biopsy. METHODS A literature search of the electronic databases MEDLINE, EMBASE, and CENTRAL was performed to identify relevant studies published before May 2008. Hand-searching of reference lists of the identified studies and relevant review articles was also performed. A study was considered eligible, regardless of study design (prospective or retrospective), if: 1) quality of life and/or progression-free and/or overall survival was compared among adult patients undergoing biopsy or resection, and 2) patient age and Karnofsky Performance Scale scores were not significantly different among the 2 groups compared. RESULTS One randomized controlled trial and 4 retrospective studies (involving a total of 1111 patients) were found eligible for this systematic review. A meta-analysis of the eligible studies demonstrated a significant increase in overall survival in the patients treated with resection instead of biopsy (hazard ratio 0.61, 95% CI 0.52-0.71, p < 0.0001, fixed-effect model). Although statistical pooling was not feasible, the available data suggest that quality of life was increased in patients treated with resection rather than biopsy, while there did not seem to be any significant difference in progression-free survival between the 2 groups. CONCLUSIONS Based on the best available evidence, it appears that cytoreductive resection in adults with supratentorial malignant glioma is associated with improved overall survival as compared with biopsy. However, well-designed prospective studies are needed for more solid conclusions to be drawn.

Primary angiosarcoma of the brain: case report.

A 41-year-old patient with a primary angiosarcoma of the brain is reported. The tumor was located in the left parietal lobe and was radically removed. The diagnosis of angiosarcoma was established by immunohistochemistry. The patient was postoperatively treated with adjuvant chemotherapy and then radiation therapy. After 41 months, she was in excellent clinical and neurological condition without any sign of recurrence.

Spontaneous spinal cord herniation: recurrence after 10 years

BACKGROUND CONTEXT Transdural spontaneous spinal cord herniation is a very rare nosological entity, which despite recent reports in the medical literature remains often misdiagnosed preoperatively. Usually it affects the thoracic segment, protrudes ventrally, presents clinically as a progressive Brown-Séquard syndrome and carries a favorable surgical outcome. PURPOSE To describe a rare case of delayed recurrence of spontaneous spinal cord herniation despite excellent outcome for 10 years, and discussion of management and observation issues. STUDY DESIGN/SETTING Case report/University Hospital. METHODS We describe the management of a patient with spontaneous spinal cord herniation that presented initially with a Brown-Séquard syndrome and has been treated successfully with surgery. After 10 years free of symptoms, the patient developed progressive paraparesis and urinary incontinence because of recurrence of the herniation at the same level. RESULTS Despite technical challenges, during the second operation the enlarged ventral dural defect was meticulously closed and the patients neurological condition presents 9-month postsurgery considerable improvement. To our best knowledge, recurrences of spontaneous spinal cord herniation are extremely rare. CONCLUSIONS The reported case underlines the necessity to be aware of this rare but treatable spinal disease, notify the possibility of late recurrences and the need of long-term follow-up even if initial outcome is favorable.

Linezolid Penetration Into Cerebrospinal Fluid and Brain Tissue

Abstract The aim of the study was to evaluate the penetration of linezolid into cerebrospinal fluid (CSF) and brain tissue after a single i.v. dose of 600 mg. The penetration of linezolid into cerebrospinal fluid and brain tissue was studied in 18 patients undergoing a neurosurgical procedure. Linezolid 600 mg i.v. was given with the induction of anesthesia. Mean concentrations of linezolid 2h after the final dose, in serum, cerbrospinal fluid and brain tissue were assayed by HPLC. CSF/serum and brain/serum ratios were 69.57% and 44.66% respectively. Concentrations of linezolid were above the MIC90s for staphylococci and streptococci. The concentrations obtained indicate good penetration of linezolid into CSF and brain tissue and support its use in the management of multidrug-resistant Gram-positive CNS infections.

Subependymal giant cell astrocytoma with intratumoral hemorrhage in the absence of tuberous sclerosis

Subependymal giant cell astrocytoma (SEGA) is an uncommon tumor that usually occurs in the setting of tuberous sclerosis (TS) syndrome. We report a rare case of an intratumoral and a small intraventricular hemorrhage complicating a SEGA in an adult patient without any signs of TS. Although pre-operative CT and MRI findings for the tumor were typical of SEGA, SEGA was not considered in the differential diagnosis because the patient was lacking any symptoms of TS. This is the second report of intraventricular and intratumoral hemorrhage complicating a SEGA and the first case in which these complications occurred in an adult patient in whom there was no previous suspicion of systemic disease.

Management of spontaneous cerebrospinal fluid leaks of the sphenoid sinus: our experience.

BACKGROUND Closure of spontaneous sphenoid sinus cerebrospinal fluid leaks can be challenging because of the relative inaccessibility of the lateral recess and the presence of intracranial hypertension. We present our experience of such cases and highlight factors associated with a successful outcome. METHODS Eleven patients with spontaneous, laboratory confirmed, sphenoid sinus cerebrospinal fluid leaks were included. All patients underwent endoscopic closure by either a three-layer technique or fat obliteration. RESULTS In all but one patient, the leak was successfully sealed (success rate, 90.9 per cent; mean follow up, 37.1 months). Elevated intracranial pressure was measured in eight patients, two of whom did not exhibit relevant clinical or radiological characteristics. Five patients received diuretics and dietary advice for weight reduction. In one patient with recurrence two weeks after repair, successful revision was performed by additional placement of a ventriculoperitoneal shunt (follow up, 67 months). CONCLUSION Long-lasting cerebrospinal fluid fistula sealing in the sphenoid sinus requires stable reconstruction of the defect in three layers or fat obliteration if the anatomy is unfavourable. All patients should be intra- and post-operatively screened for elevated intracranial pressure to identify those who need additional intracranial pressure reduction measures.