Riccardo Vannozzi

Perioperative High-Dose-Rate Brachytherapy in the Treatment of Recurrent Malignant Gliomas

Purpose:To assess the feasibility and effectiveness of perioperative high-dose-rate brachytherapy for recurrent malignant gliomas.Patients and Methods:Between 2005 and 2008, 21 patients (14 males and seven females) with relapsed malignant glioma underwent a second surgery followed by a brachytherapy implant in the surgical cavity. Median age was 60 years, and median Karnofsky performance status 80. A single fraction of 18 Gy specified at 5 mm depth was administered perioperatively. Then, the applicator was removed nonsurgically. Mean postoperative hospitalization time was 3 days.Results:At the time of analysis, 15 patients (71%) had died and six (29%) were alive. Median follow-up was 32.3 months. Median overall survival from diagnosis amounted to 21.7 months. Median survival after recurrence was 8.0 months, and 6-month progression-free survival 42%. Patients were stratified into classes according to the prognostic recursive partitioning analysis.Conclusion:Perioperative brachytherapy has proven to be safe and well tolerated in patients with recurrent malignant glioma. No severe toxicity was reported, and the treatment has proven to be effective in symptomatic recurrences of malignant gliomas.Hintergrund und Ziel:Beurteilung der Durchführbarkeit und Wirksamkeit einer perioperativen High-Dose-Rate-(HDR-)Brachytherapie bei rezidivierenden malignen Gliomen.Patienten und Methodik:Zwischen 2005 und 2008 wurden 21 Patienten (14 Männer und sieben Frauen) mit rezidivierenden malignen Gliomen einer zweiten Operation zugeführt, gefolgt von einer HDR-Brachytherapie des Rezidivtumorbetts. Das durchschnittliche Alter der Patienten betrug 60 Jahre, der durchschnittliche Karnofsky-Performance-Status 80. Perioperativ wurde eine Einzeldosis von 18 Gy appliziert, dosiert auf 5 mm Gewebetiefe. Anschließend wurde der Applikator entfernt. Die mittlere Dauer des postoperativen Krankenhausaufenthalts lag bei 3 Tagen.Ergebnisse:Zum Zeitpunkt der Analyse waren 15 Patienten (71%) gestorben. Die mediane Nachbeobachtungszeit betrug 32,3 Monate. Die mediane Gesamtüberlebenszeit lag bei 21,7 Monaten. Das mediane Überleben nach Rezidivdiagnose betrug 8,0 Monate, das progressionsfreie 6-Monats-Überleben 42%. Die Patienten wurden gemäß der prognostischen RPA („recursive partitioning analysis“) in Klassen eingeteilt.Schlussfolgerung:Diese Untersuchung hat gezeigt, dass die perioperative HDR-Brachytherapie bei Patienten mit rezidivierten malignen Gliomen sicher und gut verträglich ist. Es wurde keine schwere Toxizität beobachtet. Die Ergebnisse bestätigen die Gültigkeit und Wirksamkeit einer solchen Behandlung bei symptomatischem Auftreten eines malignen Glioms.

Three-dimensional microsurgical anatomy of cerebellar peduncles

The microsurgical anatomy of cerebellar peduncles and their relationships with neighbouring fasciculi were investigated by using a fibre dissection technique. As the dissection progressed, photographs of each progressive layer were obtained and stereoscopic images were created using the 3D anaglyphic method. These findings provided the anatomical basis for a conceptual division of cerebellar peduncles into segments. The middle cerebellar peduncle (MCP) was divided into two segments: cisternal and intracerebellar segments. The inferior cerebellar peduncle (ICP) was divided into three segments: cisternal, ventricular and intracerebellar segments. The superior cerebellar peduncle (SCP) was divided into three segments: intracerebellar, intermediate and intrategmental segments. The fibre dissection technique disclosed a constant course of peduncular fibres inside the white core of the cerebellum. The pontocerebellar fibres of the MCP pass over and laterally to the bundles of the ICP and SCP. The centripetal fibres of the ICP wrap around the radiation of the SCP and the dentate nucleus, directed towards the cortex of the vermis. The centrifugal bundle of the SCP ascends towards the mesencephalon where it sinks passing below the fibres the lateral lemniscus. The knowledge gained by studying the intrinsic anatomy of the cerebellum is useful to accomplish appropriate surgical planning and, ultimately, to understand the repercussions of surgical procedures on the white matter tracts in this region.

Second surgery for recurrent glioblastoma: A concise overview of the current literature

Optimal treatment for recurrent glioblastoma continues to evolve. Currently, however, there is no consensus in the literature on the role of reoperation in the management of these patients, as several studies provide evidence for a longer overall survival in selected patients with recurrent glioblastoma who underwent second surgery and other studies report a limited impact of second surgery in the clinical course. In this paper, a review of the current literature was performed to analyze the role of reoperation in patients with recurrent glioblastoma and to report the overall survival from diagnosis, progression-free survival and quality of life. Using PubMed and Ovid Medline databases, we performed a review of the literature of the last seven years, finding a total of 28 studies and 2279 patients who underwent second surgery, that were included in the final analysis. The median overall survival from diagnosis and the median survival from second surgery were 18.5 months and 9.7 months, respectively. Extent of resection at reoperation improves overall survival, even in patients with subtotal resection at initial operation. Preoperative performance status and age are important predictors of a longer survival, reason why younger patients with a good preoperative performance status could benefit from reoperation.

Use of near-infrared indocyanine videoangiography and Flow 800 in the resectioning of a spinal cord haemangioblastoma

Abstract Haemangioblastomas are hypervascularized tumours. Their surgical management requires a complete resectioning and a prompt handling of the vascular inlets and outlets. The use of intraoperative indocyanine green video angiography (ICG-VAG) depicts the precise vascular pattern for the surgeon. Its use is safe and easy, and the procedure can be repeated during the operation. Here we present a case of spinal haemangioblastoma treated with the aid of intraoperative ICG-VAG and the Flow 800 software. The use of the Flow 800 allowed the surgeon to detect, at a glance, minimal changes in the vascular supply during the dissection. The colour-coded images generated by the Flow 800 increase the ICG-CAG sensitivity, improving the capability to detect changes in vascular patterns.

Survival outcomes following repeat surgery for recurrent glioblastoma: a single-center retrospective analysis.

The aim of the present study is to evaluate the impact of extent of resection at initial and repeat craniotomy on overall survival of patients with recurrent glioblastoma. The authors retrospectively reviewed the records of all adults patients who underwent repeat resection of recurrent glioblastoma following radiation and chemotherapy at an academic tertiary-care institution between 2011 and 2015. We evaluated the survival outcomes with regard to extent of resection considering both the initial and repeat resections. The role of possible prognostic factors that may affect survival after repeat resection, including age, preoperative performance status, tumor location and adjuvant treatment, was evaluated using Cox regression analyses. Forty-eight patients were included in this study. The overall median survival of 14 patients who had subtotal resection at recurrence after initial subtotal resection did not statistically differ from seven patients who had gross-total resection at recurrence after initial subtotal resection (18 months vs. 22 months, p = 0.583). The overall median survival of 13 patients who had gross-total resection at recurrence after initial gross-total resection was significantly increased compared with survival of 13 patients who had subtotal resection at recurrence after initial gross-total resection (47 months vs. 14 months, p = 0.009). A Cox proportional hazards model was created demonstrating that preoperative performance status at recurrence (HR 0.418, p = 0.035) and the extent of repeat resection (HR 0.513, p = 0.043) were independent predictors of survival. Gross-total resection at repeat craniotomy is associated with longer overall survival and should be performed whenever possible in patients with recurrent glioblastoma and in good performance status.

Hydrocephalus following bilateral dumbbell-shaped c2 spinal neurofibromas resection and postoperative cervical pseudomeningocele in a patient with neurofibromatosis type 1: a case report.

Study Design Case report. Objective To present a rare case of hydrocephalus following bilateral dumbbell-shaped C2 spinal neurofibromas resection and postoperative cervical pseudomeningocele in a patient with neurofibromatosis type 1 (NF1). Methods The patients clinical course is retrospectively reviewed. A 37-year-old man affected by NF1 referred to our department for progressive weakness of both lower extremities and gait disturbance. Radiological imaging showed bilateral dumbbell-shaped C2 spinal neurofibromas. After its resection, at the 1-month follow-up evaluation, the patient reported headache and nausea. A CT brain scan showed a postoperative cervical pseudomeningocele and an increase in the ventricular sizes, resulting in hydrocephalus. Results A ventriculoperitoneal shunting was performed using a programmable valve opening pressure set to 120 mmH20. After surgery, the patients neurological status markedly improved. Conclusion Hydrocephalus must be considered a possible complication of cervical spine tumor resection.

Cancer astrocytes have a more conserved molecular status in long recurrence free survival (RFS) IDH1 wild-type glioblastoma patients: new emerging cancer players

Glioblastoma is a devastating disease that despite all the information gathered so far, its optimal management remains elusive due to the absence of validated targets from clinical studies. A better clarification of the molecular mechanisms is needed. In this study, having access to IDH1 wild-type glioblastoma of patients with exceptionally long recurrence free survival (RFS), we decided to compare their mutational and gene expression profile to groups of IDH1 wild-type glioblastoma of patients with shorter RFS, by using NGS technology. The exome analysis revealed that Long-RFS tumors have a lower mutational rate compared to the other groups. A total of 158 genes were found differentially expressed among the groups, 112 of which distinguished the two RFS extreme groups. Overall, the exome data suggests that shorter RFS tumors could be, chronologically, in a more advanced state in the muli-step tumor process of sequential accumulation of mutations. New players in this kind of cancer emerge from the analysis, confirmed at the RNA/DNA level, identifying, therefore, possible oncodrivers or tumor suppressor genes.

Arterial aneurysms associated with intracranial dural arteriovenous fistulas: epidemiology, natural history, and management. A systematic review

Arterial aneurysms are uncommon among patients with dural arteriovenous fistulae (DAVFs), and there is limited information available to guide treatment decisions in such cases. We performed a systematic review of the literature, including a case of a DAVF associated with a flow-related intraorbital ophthalmic artery (OA) aneurysm that we have recently managed. The purpose of our study was to clarify epidemiology, natural history, and management of these lesions. A total of 43 published cases of DAVF associated aneurysms were found in 26 studies on the topic. Anterior cranial fossa was the most common location (40%), and ethmoidal branches were the most common arterial feeders (55%). In about 63% of cases, the aneurysm was located on artery unrelated to DAVF supply. Approximately 10% of intracranial DAVFs were associated with aneurysms located in the intraorbital OA. Overall, 70% of lesions were Borden type III, and 50% of patients presented with hemorrhage. In approximately 17% of cases, the source of bleeding was a feeding artery aneurysm. All of the reported intraorbital OA aneurysms associated with DAVFs remained stable during follow-up. DAVF associated aneurysms are fairly rare. Anterior cranial fossa location and direct cortical venous drainage are common among these lesions. The aneurysms are less likely to be located on feeding arteries, and hemorrhagic presentation related to flow-related aneurysm rupture is uncommon.

Disseminated bone metastases from occult thyroid cancer effectively treated with debulking surgery and a single dosimetry-guided administration of radioiodine

In this paper we report on a successful management of multiple bone metastases from differentiated thyroid cancer. In 2007, a 75-year-old female patient, previously referred for thyroidectomy for multinodular goiter, underwent surgical removal of a lumbar mass with histological findings of metastasis from well differentiated thyroid cancer. After surgery, serum thyroglobulin (sTg) was 204.4 ng/mL. A diagnostic/dosimetric (123)I WBS was performed, following stimulation by rTSH. Serial WBSs were acquired, along with SPECT/CT and bone scan for localization of lesions. sTg raised to 3.810 ng/mL, and (123)I WBS showed thyroid remnants and numerous areas with high iodine-uptake corresponding to skeletal sites, the two largest loading on the skull, with osteolytic pattern. Calculated radiation absorbed dose for skull lesions, determined by mean of MIRD methodology, was 63.5 mGy/MBq. The patient underwent surgical removal of the two major skull lesions. Successively, 100 mCi (131)I was administered after stimulation by rTSH, with stimulated sTg 297 ng/mL. After 8 months, diagnostic WBS was negative both for remnants and metastases and rTSH-stimulated Tg was 0.6 ng/mL. To date, the patient has maintained sTg values <1 ng/mL during L-T4 suppressive therapy and after rTSH stimulations. In this unusual case of extensive bone cancerous involvement with high iodine avidity, a multidisciplinary approach based on surgery and dosimetry-guided radiometabolic therapy allowed to accurately assess the patient, execute a small number of treatments and achieve a complete remission of the disease in a very short time, with no additive morbidity.

Epidural spinal cord compression in Langerhans cell histiocytosis: A case report

Abstract Langerhans cell histiocytosis, also known as histiocytosis X, is a rare proliferative disorder of histiocytes. Spinal involvement in the course of Langerhans cell histiocytosis in adult is rare, and epidural location is exceptional. We present a rare case of epidural involvement by Langerhans cell histiocytosis in a 71-year-old man to highlight the importance of considering Langerhans cell histiocytosis in the differential diagnosis of epidural spinal cord compression.