Long-term follow-up of vanishing tumors in the brain: How should a lesion mimicking primary CNS lymphoma be managed?

Objectives

The spontaneous disappearance of a tumor is referred to as a vanishing tumor. Most vanishing tumors in the brain are eventually diagnosed as malignant tumors or multiple sclerosis. However, their long-term clinical course remains unclear. This study aims to elucidate the management of vanishing tumors in the brain.

Patients and methods

We defined a vanishing tumor as a case in which the tumor spontaneously disappeared or decreased to less than 70% of the initial tumor volume before definitive diagnosis and treatment (other than steroid treatment). Ten cases of vanishing tumors are reviewed.

Results

Nine patients underwent biopsy at least once. Five patients, all of whom had malignant tumors (primary central nervous system lymphoma: 4, germinoma: 1) that recurred in 4–45 months (median: 7 months), underwent a second biopsy after the reappearance of the tumors. Five patients (tumefactive demyelinating lesion: 1, undiagnosed: 4) who had no relapse are alive, and their median follow-up time is 44 months. No cases have yet been reported of malignant brain tumors that recurred more than 5 years after spontaneous regression.

Conclusions

Patients with vanishing tumors should be followed up carefully by magnetic resonance imaging for at least 5 years, even after the disappearance of an enhancing lesion.     

Cordectomy as final treatment option for diffuse intramedullary malignant glioma using 5-ALA fluorescence-guided resection

Background

We present a case of an anaplastic astrocytoma (WHO-grade III, AA III) in a 27-year-old woman treated by spinal cordectomy. The patient was pretreated by surgery, radiation therapy and temozolomide chemotherapy and repeat surgery at recurrence. Later on, she developed paraplegia and a diffuse severe pain syndrome. MRI demonstrated intramedullar invasion from T12 to T9. To assess tumor invasion intraoperatively, we used tumor fluorescence derived from 5-aminolevulinic acid (5-ALA).

Patients course

The spinal cord was amputated caudally to the root entry zones of the T10 sensory roots. Additional cordectomy was performed because of tumor infiltration at the cut end to T9 as identified by intraoperative tumor fluorescence, and as verified histologically. The final transected level was between T8 and T9, and the cut end did not reveal any tumor invasion intraoperatively by tumor fluorescence and postoperatively by MRI and with regard to the pathological result. After surgery, the patient was unchanged concerning spasticity, motor and sensory function, and showed complete relief of pain. She refused additional adjuvant therapy. The patient is free of recurrence 15 months after surgery.

Conclusion

Our observation suggests 5-ALA fluorescence-guided resections to be useful in the context of malignant spinal cord gliomas. Furthermore, our particular case indicates that palliative spinal cordectomy with a wide margin and intraoperative resection using fluorescence guidance may be a final option for patients with recurrent spinal malignant glioma presenting with complete deficit below the lesion.     

The impact of repeated surgery and adjuvant therapy on survival for patients with recurrent glioblastoma

Objective

Treatment of glioblastoma recurrence can have a palliative aim, after considering risks and potential benefits. The aim of this study is to verify the impact of surgery and of palliative adjuvant treatments on survival after recurrence.

Methods

From January 2002 to June 2008, we treated 76 consecutive patients with recurrent glioblastoma. Treatment was: 1-surgery alone – 17 patients; 2-adjuvant-therapy alone – 24 patients; 3-surgery and adjuvant therapy – 16 patients; no treatment – 19 patients. The impact on median overall-survival (OS-time between recurrence and death/last follow-up) of age, Karnofsky performance scale (KPS), resection extent and adjuvant treatment scheme (Temozolomide alone vs low-dose fractionated radiotherapy vs others) was determined. Survival curves were obtained through the Kaplan–Meier method. Cox proportional-hazards was used for multivariate analyses. Significance was set at p < 0.05.

Results

Median OS was 7 months. At univariate analysis, patients with a KPS ≥ 70 had a longer OS (9 months vs 5 months – p < 0.0001). OS was 6 months for patients treated with surgery alone, 5 months for patients that received no treatment, 8 months for patients treated with chemotherapy alone, 14 months for patients treated with surgery and adjuvant therapy-p = 0.01. Patients with a KPS < 70 were significantly at risk for death – HR 2.8 – p = 0.001.Subgroup analysis showed no significant differences between patients receiving gross total or partial tumor resection and among patients receiving different adjuvant therapy schemes. Major surgical morbidity at tumor recurrence occurred in 16 out of 33 patients (48%).

Conclusion

It is fundamental, before deciding to operate patients for recurrence, to carefully consider the impact of surgical morbidity on outcome.     

Clinical Analysis of Intracranial Hemangiopericytoma

Objective

Intracranial hemangiopericytomas (HPCs) are rare tumors with aggressive behavior, including local recurrence and distant metastasis. We conducted this retrospective study to evaluate the efficacy of grossly total resection and adjuvant radiotherapy (RT) for these tumors.

Methods

A total of 13 patients treated for intracranial HPC from January 1995 through May 2013 were included in this retrospective study. We analyzed the clinical presentations, radiologic appearances, treatment results, and follow-up outcomes, as well as reviewed other studies.

Results

The ages of the patients at the time of diagnosis ranged from 26 to 73 years (mean : 48 years). The majority of the patients were male (92.3%), and the majority of the tumors were located in the parasagittal and falx. The ratio of intracranial HPCs to meningiomas was 13 : 598 in same period, or 2.2%. Seven patients (53.8%) had anaplastic HPCs. Nine patients (69.2%) underwent gross total tumor resection in the first operation without mortality. Eleven patients (84.6%) underwent postoperative adjuvant RT. Follow-up period ranged from 13 to 185 months (mean : 54.3 months). The local recurrence rate was 46.2% (6/13), and there were no distant metastases. The 10-year survival rate after initial surgery was 83.9%. The initial mean Karnofsky performance scale (KPS) was 70.8 and the final mean KPS was 64.6.

Conclusion

Gross total tumor resection upon initial surgery is very important. We believe that adjuvant RT is helpful even with maximal tumor resection. Molecular biologic analyses and chemotherapy studies are required to achieve better outcomes in recurrent intracranial HPCs.     

Efficacy of temozolomide as adjuvant chemotherapy after postsurgical radiotherapy alone for glioblastomas

Objectives

The aim of this study was to assess the efficacy of adjuvant TMZ chemotherapy for newly diagnosed GBM patients who were treated with surgery followed by radiotherapy alone.

Material and methods

Between January 2003 and April 2005, 59 consecutive GBM patients underwent radiation therapy after surgical resection and subsequently received TMZ chemotherapy. For the comparative analysis, we selected 60 clinically matched GBM patients who underwent radiotherapy followed by nitrosourea-based chemotherapy (NUBC), at the same institution between June 1995 and April 2005. The study cohort was divided into two groups, those with adjuvant TMZ treatment and with NUBC.

Results

59 patients with adjuvant TMZ treatment were assigned to the treatment group and 60 patients with NUBC to the control group. The median overall survival for the treatment group was 18.2 months (95% CI, 11.7–24.7 months), compared with the survival of 14.5 months (95% CI, 11.2–17.7 months) for the control group (p = 0.019). The progression-free survival for the treatment group was 5.6 months (95% CI, 4.4–6.7 months), while the control group showed progression-free survival of 3.3 months (95% CT, 3.2–6.0 months) (p = 0.030). Uni- and multivariate analysis revealed that extent of surgical resection, age ≥55 years and postoperative KPS were significantly associated with survival.

Conclusion

Adjuvant TMZ chemotherapy provided a clinically relevant benefit of survival, as compared with NUBC. Thus, we suggest that adjuvant TMZ chemotherapy may be effective even for patients who did not receive concomitant chemoradiotherapy for GBM.     

Growing teratoma syndrome in intracranial non-germinomatous germ cell tumors (iNGGCTs): a risk for secondary malignant transformation—a report of two cases

Purpose

About 5 % of pediatric intracranial germ cell tumors and 20 % of non-germinomatous germ cell tumors (NGGCT) progress to growing teratoma syndrome (GTS) following chemoradiotherapy. The growing teratoma is thought to arise from the chemotherapy-resistant, teratomatous portion of a germ cell tumor and is commonly benign but may undergo malignant transformation.

Methods

Two pediatric patients whose intracranial NGGCTs progressed to growing teratomas during chemotherapy and later transformed to secondary malignant tumors after partial resection and radiation therapy (RT).

Results

Both tumors were diagnosed by MRI scans and elevated serum and CSF markers. Following normalization of tumor markers with chemotherapy and initial decrease in tumor volume, subsequent imaging showed regrowth during chemotherapy with pathology revealing benign teratoma. RT was administered. Several years following this treatment, further growth was seen with pathology indicating malignant carcinoma in one patient and malignant rhabdomyosarcoma in the other. The patient with carcinoma received palliative care while the patient with the sarcoma received further resection, intensive chemotherapy, and an autologous stem cell transplant and is currently in remission, 36 months since malignant transformation.

Conclusion

Malignant transformation of presumed residual teratoma has been seldom reported. Treatment of NGGCT involves platinum-based chemotherapy with craniospinal RT and boost to the primary site, with cure rates of around 80 %. Teratomas are characteristically chemotherapy and RT resistant and are treated surgically. In the event that residual or growing teratoma is suspected, a complete resection should be considered early in the management as there is a risk of malignant transformation of residual teratoma.     

Glioblastoma: clinical characteristics, prognostic factors and survival in 492 patients

Objective

Glioblastoma is the most common and most malignant primary brain tumor in adults. The only overall accepted independent prognostic factors are patient age and performance. We present a large single institution patient series examined for prognostic factors using uni- and multivariate survival analysis.

Methods

492 patients were included who underwent craniotomy for newly diagnosed glioblastoma WHO grade IV between 1990 and 2007 at our department. The association to patient survival was estimated using log-rank test for univariate analysis and cox regression method for multivariate analysis.

Results

Median patient age was 62 years (mean: 60.4 years, range: 22–93 years), the male: female ratio was 1.26:1. Primary genesis was found in 91.0% of cases. A multifocal tumor was present in 110 cases (22.4%). The median pre- and post-operative Karnofsky Performance Score was 70. Total tumor resection was performed in 288 cases (58.5%), subtotal removal in 134 cases (27.2%). The following parameters were significantly associated with survival in univariate analysis: age, performance, primary genesis, multifocal tumor, neurological deficit, neuropsychological findings, seizures, incidental finding, total or subtotal resection, radiotherapy, chemotherapy, combined radio-/chemotherapy with temozolomide, re-craniotomy, second tumor in patient history. The following parameters were significantly associated with survival in multivariate analysis: age, performance, multifocal tumor, total or subtotal resection, radiotherapy, chemotherapy, combined radio-/chemotherapy with temozolomide.

Conclusion

In addition to patient age and performance, we identified multiple lesions and resection status as independent prognostic factors. Radiotherapy, chemotherapy and combined radio-/chemotherapy with temozolomide were significantly associated with prolonged survival.     

Gamma knife radiosurgery for orbital tumors

Objective

This study was performed to investigate the radiological and functional outcomes of patients with orbital tumors treated by gamma knife radiosurgery (GKS).

Patients and methods

Fifteen patients with orbital tumors (7 meningiomas, 3 cavernous hemangiomas, 2 schwannomas, 2 metastatic tumors and 1 adenoid cystic carcinoma of the lacrimal gland) were treated. Seven patients with preserved vision and tumors located near the optic nerve were treated with multisession (3 or 4 fractions) radiosurgery. The mean tumor volume was 3695 mm³ (737–13,300). The median marginal dose was 14 Gy (13–20) in single-session radiosurgery, and the median cumulative marginal dose was 20 Gy (15–20) in multisession radiosurgery.

Results

After a mean follow-up of 20.9 months (6–50), tumor control was confirmed in 12 of 15 patients. Three patients with malignant lesions had to undergo another operation due to tumor progression. Of the 13 patients whose preoperative vision was preserved, 6 patients showed improvement in visual acuity and/or visual field, 4 patients showed no change in vision, and 3 patients showed deterioration (2 related to tumor progression).

Conclusions

As with intracranial tumors with similar pathologies, GKS may be an effective treatment option for orbital tumors. Multisession radiosurgery may be a good strategy for increasing the possibility of visual function preservation in selected cases in which the lesion is adjacent to the optic apparatus.     

Treatment and outcomes of primary intracranial teratoma

Purpose

Until recently, postoperative adjuvant treatment for intracranial teratomas has remained controversial because of the rarity of the tumors and the heterogeneity of histologic types. To define optimal therapy modalities, we retrospectively analyzed the treatment of patients with intracranial teratomas.

Methods

Between 1979 and 2007, 31 patients with intracranial teratomas were treated at our institution. The median age of the 31 patients was 14.8 years. The median follow-up time was 72.7 months (range 11～291 months). Perioperative radiochemotherapy was done in 19 patients. Proper chemotherapy regimens were followed, such as PE (cisplatin and VP-16), PVB (cisplatin, VP-16, and bleomycin), ICE (carboplatin, VP-16, and ifosfamide), and NGGCT (etoposide, carboplatin, bleomycin, and cyclophosphamide with mesna).

Results

Eight patients experienced recurrence, and a second operation was carried out in six patients. Fifteen patients survived for more than 5 years without recurrence, irrespective of having received adjuvant therapies. The 5-year survival rate of the 31 patients was 74%.

Conclusion

Treatment of intracranial teratomas is very difficult because of the heterogeneity of the tumor cells from totipotent origins. Accurate histological diagnosis of teratoma subtypes is the most important factor for adequate treatment, and proper therapeutic protocols are needed to cure teratomas.

     

Vascular complications of stereotactic radiosurgery for arteriovenous malformations

Objective

Although vasculopathy and de novo aneurysm formation are known complications of traditional radiation therapy, their occurrence following AVM SRS is rare and thus infrequently addressed in the literature. We sought to evaluate these phenomena through a review of our institutional experience.

Methods

Our review afforded 32 patients treated with LINAC-based SRS over an eight year period. We noted obliteration rates, complication rates and long-term outcomes, with particular attention paid to follow-up angiographic studies.

Results

After a mean follow-up of 4.3 years, the overall obliteration rate was 50%, increasing to 87% for AVMs less than 3 cm. Eight patients had nine hemorrhages following SRS (25%). One occurred in the context of a de novo arterial pseudoaneurysm and another in the context of a new venous varix. Two patients with post-SRS hemorrhage had intranidal aneurysms that were not as apparent on initial angiography. Two patients that did not suffer from latency period hemorrhage developed dysplastic changes of feeding arteries, and one patient suffered from early venous thrombosis with resultant permanent hemiparesis from infarction. After a mean follow-up of 4.3 years, 8 patients were clinically improved (25%), 19 were the same (59%), and 5 were worse (16%), including 2 that died as a result of latency period hemorrhage.

Conclusion

While radiosurgery of AVMs is safe and successful in the vast majority of cases, vasculopathic complications including de novo aneurysm and varix development, early venous occlusion and stenotic vasculopathy, while infrequent, can occur. Closer long-term angiographic surveillance of these patients may thus be warranted.     

Systemic illness moderates the impact of N-acetyl cysteine in bipolar disorder

Objectives

Bipolar disorder (BD) is intricately associated with chronic clinical conditions. Medical comorbidity is not only more prevalent in mood disorders, but is associated with increased costs, cognitive impairment and, ultimately, premature mortality. Oxidative stress and inflammation may mediate part of this association. To further investigate the association between medical comorbidity status and clinical improvement with adjuvant N acetyl cysteine (NAC) in the context of a placebo-controlled trial.

Methods

Placebo-controlled randomized clinical trial assessing the effect of NAC over 24 weeks. Symptomatic and functional outcomes were collected over the study period. Medical comorbidities were self-reported, and we took special interest in cardiovascular and endocrine conditions. We evaluated change from baseline to endpoint and the interaction between change and reported medical comorbidities.

Results

Fifty-one percent of patients reported have a cardiovascular or endocrine comorbidity. Although not found for depressive symptoms or quality of life, a significant interaction between medical comorbidity and change scores was consistently found for all functional outcomes. This indicated an advantage of NAC over placebo in those with a clinical comorbidity.

Conclusion

Systemic illness moderated only the effect of NAC on functioning, not on depression. Demonstrating an improvement in functional outcomes with an agent that modulates redox and inflammatory pathways, this study lends empirical support to the idea that medical and psychiatric comorbidity are additive in contributing to allostatic states. One intriguing possibility is that comorbid clinical illness could be a marker for more severe oxidative stress states – and thus guide antioxidant use – in BD.     

Microsurgical management of cerebral parenchymal cysticercosis

Objective

Microsurgery is an optional way to treat parenchymal neurocysticercosis. The aim of this study is to evaluate the therapeutic efficacy of microsurgery in cerebral parenchymal cysticercosis.

Materials and methods

A retrospective analysis was performed of the clinical data and outcomes of microsurgery in 20 cases of cerebral parenchymal cysticercosis.

Results

All head segments found in cysticercus cysts were removed completely. Total resection of the cystic wall was achieved in 16 cases and subtotal resection in 4 cases. Twelve patients recovered from intracranial hypertension soon after the operation. No novel complications or deaths occurred postoperatively. The patients were followed up for 3 months to 10 years; among them, 14 patients who had epilepsy before surgery were markedly improved and controlled, 4 of 5 patients recovered from hemiparesis within 6 months after surgery, and 2 patients with cerebellar ataxia showed improvement. Two patients were lost to follow-up.

Conclusions

Despite a high rate of misdiagnosis of cerebral parenchymal cysticercosis, microsurgery is associated with satisfactory clinical outcomes in appropriately selected patients.     

Risk factors for multiple intracranial aneurysms rupture: A retrospective study

Background and purpose

The presence of predicting the rupture risk of intracranial aneurysms has recently generated considerable controversy. We retrospectively investigated the risk factors for multiple intracranial aneurysms related to rupture.

Methods

Between July 2007 and July 2011, 134 patients with 294 aneurysms were identified after review. Every patient had two or more aneurysms. Univariate and multivariate logistic regression models were used to analyze the risk factors for multiple intracranial aneurysms with age, gender, site and size.

Results

134 patients were divided into three groups according to patient age category (<45, 45–65, >65 years of age). The incidence of aneurysms ruptured in the second group was significantly higher. Three groups showed significant difference (P = 0.001 versus >65 years of age). Thirteen of 35 AComA aneurysms were ruptured, accounting for 26% of all ruptured aneurysms, and the rate of rupture at AComA aneurysms in patients was 37.1%. The rate of aneurysm rupture in the AComA was significantly higher than that in other sites (P = 0.001). In all 294 aneurysms, 88.1% of the aneurysms were 5 mm or less, of which 58.2% were less than 3 mm. In the ruptured aneurysms, 68% were 5 mm or less.

Conclusions

Our study reveals the pattern of ruptured multiple intracranial aneurysms, in terms of age, size and location of aneurysms. Age, size, and site of aneurysm should be considered in the decision whether to treat an unruptured aneurysm or not. Especially, in cases of multiple aneurysm, the AComA aneurysm is most prone to hemorrhage.     

Comparing the cost-effectiveness of two brain metastasis treatment modalities from a payer's perspective: Stereotactic radiosurgery versus surgical resection

Objectives

This study aims to identify the cost-effectiveness of two brain metastatic treatment modalities, stereotactic radiosurgery (SRS) versus surgical resection (SR), from the perspective of Germany's Statutory Health Insurance (SHI) System.

Methods

Retrospectively reviewing 373 patients with brain metastases (BMs) who underwent SR (n = 113) and SRS (n = 260). Propensity score matching was used to adjust for selection bias (n = 98 each); means of survival time and survival curves were defined by the Kaplan–Meier estimator; and medical costs of follow-up treatment were calculated by the Direct (Lin) method. The bootstrap resampling technique was used to assess the impact of uncertainty.

Results

Survival time means of SR and SRS were 13.0, 18.4 months, respectively (P = 0.000). Medians of free brain tumor time were 10.4 months for SR and 13.8 months for SRS (P = 0.003). Number of repeated SRS treatments significantly influenced the survival time of SRS (R² = 0.249; P = 0.006). SRS had a lower average cost per patient (€9964 – SD: 1047; Skewness: 7273) than SR (€11647 – SD: 1594; Skewness: 0.465), leading to an incremental cost effectiveness ratio of €−3740 per life year saved (LYS), meaning that using SRS costs €1683 less than SR per targeted patient, but increases LYS by 0.45 years.

Conclusion

SRS is more cost-effective than SR in the treatment of brain metastasis (BM) from the SHI perspective. When the clinical conditions allow it, early intervention with SRS in new BM cases and frequent SRS repetition in new BM recurrent cases should be advised.     

The importance of microsurgery in childhood meningioma: a case report

Introduction

Although meningiomas are frequently diagnosed in adults, it is a rare (intracranial) tumor in the pediatric population, with an incidence of 0.06/100,000. The pathology and treatment of meningiomas in adulthood has been a topic of increasing investigation. So far, the treatment of pediatric meningiomas has been extrapolated from these results. The question remains, however, whether translation of adult meningioma data into the childhood population is legitimate.

Methods

We present the case of a 3-year-old girl diagnosed with an intraventricular malignant meningioma and type 2 neurofibromatosis. She was operated on multiple times to achieve complete resection and received adjuvant chemotherapy. Since, she has been stable with no neurological sequelae and/or recurrence of the meningioma.

Conclusion

Pediatric meningiomas are rare tumors and differ from their adult counterparts in various aspects. We believe that gross total resection of meningioma in the pediatric population, when possible, is the treatment of choice. In the event of a subtotal resection, repeat resection is recommended. Any adjuvant treatment with chemotherapy or radiation therapy should be carefully considered during multidisciplinary meetings.

     

Intracranial dissection: Incidence and long term endovascular treatment results of a not so rare disease

Objective

The objective of this communication was to study the incidence and course of ICD and the long term outcome of this severe disease. The second goal was to analyze the different endovascular treatment modalities according to their long term results.

Methods

It is a retrospective analysis of 14 patients with ICD admitted in a single center in two consecutive years, treated with endovascular procedures. Patients harbouring blister-like ruptured intracranial aneurysms were excluded from this study.

Results

In this case series, 12 patients presented with subarachnoid hemorrhage (SAH) and 2 with brain stem symptoms. Mean age was 51 years and 13 patients were female. Six patients (43%) died and 8 (57%) survived with a mRS at 0–1. Mean follow up was 21 months.

Conclusions

ICD as a cause of SAH seems to be more frequent than previously thought and usually has a severe course. It requires a high level of suspicion to diagnosis and specific endovascular treatment modalities are required for each location to ensure long term stability and change the poor prognosis.     

Radiation induced early necrosis in patients with malignant gliomas receiving temozolomide

Background

Temozolomide is the major drug in the treatment of malignant gliomas. Radiation induced necrosis can behave radiologically and clinically like a recurrent tumor. The major problem is the differentiation between recurrence and radiation injury especially in early phases of treatment. The aim of this study was to evaluate the patients receiving temozolomide showing early clinical or radiological progression and impact of early necrosis on follow-up.

Patients and methods

We retrospectively evaluated medical records of 67 patients with malignant glioma receiving temozolomide. All patients received concomitant radiotherapy and temozolomide followed by adjuvant temozolomide. In case of any radiological or clinical progression, MRI spectroscopy evaluation was used to confirm tumoral progression.

Results

Radiological or clinical progression was observed in 17 (25.4%) patients. Early radiation induced necrosis was diagnosed in 4 of 17 patients (23.5%) by surgery (n = 3) and MRI spectroscopy (n = 1). The observed incidence of pseudoprogression was 4 in 67 (6%) patients. Patients with diagnosis of early radiation injury had median progression-free survival of 7 months compared to 5 months in patients without radiation damage (p = 0.004). However, there was no statistically significant difference in terms of overall survival between groups.

Conclusion

Temozolomide can cause early radiation induced injury which can mimic progressive tumor. Although the discrimination between two entities results in the accurate evaluation of response to therapy and benefits those patients, it did not affect overall survival. MRI spectroscopy is a valuable tool to define early radiation necrosis and should be further evaluated in larger prospective studies.     

Primary hydatidosis of the central nervous system: A retrospective study of 39 Tunisian cases

Objective

To analyze epidemiological characteristics, clinical symptoms, radiological aspects, treatment and outcome of central nervous system hydatidosis and compare our results with those reported in literature.

Patients and methods

In our retrospective study, we reviewed 39 cases of primary central nervous system hydatid cysts operated on in our hospital between 1998 and 2007.

Results

There were 20 male and 19 female patients (sex-ratio M/F = 1.05) between 2 and 68 years of age (mean = 26.5 years). Thirteen of the patients were children (33.3%) with a mean age of 6.8 years and 26 were adults (66.7%) with a mean age of 36.3 years. The location of hydatid cysts was intracranial in 27 cases (69.2%) and spinal in 12 cases (30.8%). Headache and motor deficits were the predominant symptoms in patients with intracranial hydatidosis whereas back pain and spinal cord compression syndrome were the most frequent clinical presentations in patients with spinal hydatidosis. All patients underwent surgical resection of the cyst. Pathologic findings were consistent with hydatid cyst in all cases. During the follow-up period which ranged between 12 months and 5 years, 12 patients had recurrence (30.7%). Only one patient with intracranial hydatid cyst died postoperatively due to anaphylactic shock.

Conclusion

Despite all the advances in imaging techniques and therapeutic methods, central nervous system hydatidosis remains difficult to cure and patient outcomes are not satisfactory especially in case of spinal involvement due to the high incidence of recurrence.     

No effect of obstetric complications on basal ganglia volumes in schizophrenia

Background

Heterogeneous findings have been reported in studies of basal ganglia volumes in schizophrenia patients as compared to healthy controls. The basal ganglia contain dopamine receptors that are known to be involved in schizophrenia pathology and to be vulnerable to pre- and perinatal hypoxic insults. Altered volumes of other brain structures (e.g. hippocampus and lateral ventricles) have been reported in schizophrenia patients with a history of obstetric complications (OCs). This is the first study to explore if there is a relationship between OCs and basal ganglia volume in schizophrenia.

Methods

Thorough clinical investigation (including information on medication) of 54 schizophrenia patients and 54 healthy control subjects was undertaken. MR images were obtained on a 1.5 T scanner, and volumes of nucleus caudatus, globus pallidum, putamen, and nucleus accumbens were quantified automatically. Information on OCs was blindly collected from original birth records.

Results

Unadjusted estimates demonstrated a relationship between increasing number of OCs and larger volume of nucleus accumbens in schizophrenia patients and healthy controls. No statistically significant relationships were found between OCs and the basal ganglia volumes when controlled for intracranial volume, age, and multiple comparisons. There were no effects of typical versus atypical medication on the basal ganglia volumes. The patients with schizophrenia had larger globus pallidum volumes as compared to healthy controls, but there were no case–control differences for accumbens, putamen, or caudate volumes.

Conclusion

The present results do not support the hypothesis that OCs are related to alterations in basal ganglia volume in chronic schizophrenia.     

Impact of the per-operatory application of GLIADEL wafers (BCNU, carmustine) in combination with temozolomide and radiotherapy in patients with glioblastoma multiforme: Efficacy and toxicity

Purpose

For the last few years wafers of Gliadel have been inserted into the operation cavity in patients with glioblastoma multiforme. This is followed by concurrent radio-chemotherapy with temozolomide (TMZ) according to the Stupp protocol. Only a few studies have investigated this kind of treatment regimen and the impact in terms of survival and toxicity of the combination of Gliadel with TMZ and radiotherapy.

Methods and materials

From November 2006 to January 2010, 24 patients with a newly diagnosed glioblastoma have undergone a tumour resection which was considered to be macroscopically complete in 12 cases and with tumour residue in another 12 cases. The mean age at the moment of diagnosis was 60.25 years and the median age 63.Twenty-three patients underwent subsequently concurrent radio-chemotherapy with TMZ followed by cycles of elevated doses of TMZ as an adjuvant treatment. One patient had adjuvant radiotherapy alone followed by adjuvant chemotherapy. Thirteen were able to receive 6 or more cycles of adjuvant TMZ. Seven patients had received less than 6 cycles of TMZ as an adjuvant therapy. Two patients did not receive adjuvant TMZ at all.

Results

The median overall survival of our group was 19.2 months and the median progression free survival was 12.3 months. Overall survival for the macroscopically complete-resection patients was 14 months, and 12.85 months in subtotal-resection patients. The median OS was 14.25 months for patients PS 0 – 1 at the moment of diagnosis and 12.65 for PS 2 patients. Chemotherapy with TMZ had to be stopped prematurely in 10 cases due to haematotoxicity, digestive toxicity or early relapse.

Conclusions

The concomitant use of surgery with implantation of BCNU wafers and radio-chemotherapy seems to be well tolerated. Despite the small number of patients treated in our group, particular attention should be paid to the potential haematological consequences of this multimodal treatment regimen.