Development of innovative pediocin PA-1 by DNA shuffling among class IIa bacteriocins

Pediocin PA-1 is a member of the class IIa bacteriocins, which show antimicrobial effects against lactic acid bacteria. To develop an improved version of pediocin PA-1, reciprocal chimeras between pediocin PA-1 and enterocin A, another class IIa bacteriocin, were constructed. Chimera EP, which consisted of the C-terminal half of pediocin PA-1 fused to the N-terminal half of enterocin A, showed increased activity against a strain of Leuconostoc lactis isolated from a sour-spoiled dairy product. To develop an even more effective version of this chimera, a DNA-shuffling library was constructed, wherein four specific regions within the N-terminal half of pediocin PA-1 were shuffled with the corresponding sequences from 10 other class IIa bacteriocins. Activity screening indicated that 63 out of 280 shuffled mutants had antimicrobial activity. A colony overlay activity assay showed that one of the mutants (designated B1) produced a >7.8-mm growth inhibition circle on L. lactis, whereas the parent pediocin PA-1 did not produce any circle. Furthermore, the active shuffled mutants showed increased activity against various species of Lactobacillus, Pediococcus, and Carnobacterium. Sequence analysis revealed that the active mutants had novel N-terminal sequences; in active mutant B1, for example, the parental pediocin PA-1 sequence (KYYGNGVTCGKHSC) was changed to TKYYGNGVSCTKSGC. These new and improved DNA-shuffled bacteriocins could prove useful as food additives for inhibiting sour spoilage of dairy products.

Expression of matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinase (TIMP) in cerebral cavernous malformations: immunohistochemical analysis of MMP-2, -9 and TIMP-2

OBJECT

Hemorrhage from cerebral vascular malformations such as cerebral cavernous malformation (CCM) can result in significant mortality and morbidity, but its underlying mechanism is undetermined. Excessive degradation of the vascular matrix by matrix metalloproteinases (MMPs), proteolytic enzymes that degrade all the components of extracellular matrix, can lead to instability of the vascular structure and can thereby cause bleeding. Thus we examined the expression of MMPs and tissue inhibitors of metalloproteinase (TIMP) in CCM.

PATIENTS AND METHODS

We performed immunohistochemistry for MMP-2, -9, and TIMP-2 using Paraffin-embedded sections of the surgical specimens obtained from seven patients with CCM. All patients had a history of hemorrhage from CCM.

FINDINGS

In all patients (7/7, 100%), MMP-2 and -9 were strongly expressed in endothelial cells of CCMs. Endothelial expression of TIMP-2 was also evident in all seven patients. In contrast, MMP-2, -9 and TIMP-2 were not identified in adjacent normal brain tissue.

CONCLUSION

We found that CCM showed the increased endothelial expression of MMP-2, -9, and TIMP-2. Endothelial expression of MMPs and/or TIMP may affect the vascular matrix stability, and thus can contribute to hemorrhage from CCM.

Cytological affinities and interfertilities between Lolium temulentum and L. persicum (Poaceae) accessions

Interspecific crossing between L. temulentum L. and L. persicum Boiss. & Hohen. ex Boiss. was performed to clarify their interfertility based on the results of chromosome pairing, pollen fertility and seed set. Both parents were normal with a high percentage of chromosome association of ring bivalents in contrast to rod bivalents at metaphase I, pollen fertility and seed set, but F1 hybrids showed different proportions of them for each crossing combination. Chromosome affinity expressed by pairing was certainly a factor affecting the pollen fertility or seed set in F1 hybrids, but it was not the most important. The positive correlation was generally found between pollen fertility and seed set of F1 hybrids. The L. persicum accession with relatively high interfertility with L. temulentum was supposed to be derived from natural hybridization between L. temulentum and L. persicum. The degree of cytogenetic differentiation between L. temulentum and L. persicum existed because of lower chromosomal pairing, pollen fertility and seed set, but their F1 hybrids were partially fertile.

Rapid discrimination of Listeria monocytogenes strains by microtemperature gradient gel electrophoresis

Microtemperature gradient gel electrophoresis (mu-TGGE) was examined for use for the rapid subtyping of Listeria monocytogenes strains. Comparison of genomes between L. monocytogenes strains F2365 and H7858 identified a sequence encoding a portion of the PRT/PTS system IIA 2 protein domain as appropriate for mu-TGGE analysis. Thirty-one strains belonging to 10 different serovar types were tested by PCR, and sequence analysis of the amplified products revealed that the strains comprise 11 groups. All 55 possible pairs within the 11 groups were examined by mu-TGGE analysis. Of these, 47 pairs could be successfully discriminated, with a total electrophoresis time of only 7 min. Moreover, Cy3/Cy5 labeling allowed rapid identification of the sequence type in unknown strains of L. monocytogenes isolated from meat. These findings collectively indicate that mu-TGGE can be used for the rapid analysis of L. monocytogenes strains, facilitating determination of routes of contamination when these bacteria are found in food products.

Modified surgical technique for the treatment of idiopathic spinal cord herniation

OBJECTIVE AND IMPORTANCE

Spinal cord herniation is not a common disease and only 80 cases have been reported to the best of our knowledge. The treatment of this lesion is thought to be difficult and a better surgical technique has not been established.

CLINICAL PRESENTATION

A 57-year-old man presented with gradually worsening spastic gait and hypoesthesia in the bilateral lower extremities suspected to be due to Brown-Séquard syndrome. Magnetic resonance imaging showed a thoracic spinal cord herniation into the anterior hiatus at T2 - 3.

INTERVENTION

A modified technique of closure of the hiatus in front of the herniation was performed. A surgical artificial dural membrane was introduced between the herniated portion of the thoracic cord and the dural hiatus and was placed to cover the whole dural defect in order to minimize the operative procedure at the ventral side of the spinal cord. On subsequent magnetic resonance imaging, the herniation was remarkably improved and patient's symptoms were abolished.

CONCLUSION

The direct widening of the dural defect has been reported to be the only treatment providing a good outcome. We suggest that our modified technique for its closure can be as safe and effective as the direct widening method.

Listeriolysin O derived from Listeria monocytogenes inhibits the effector phase of an experimental allergic rhinitis induced by ovalbumin in mice

Listeriolysin O (LLO) derived from Listeria monocytogenes is highly capable of inducing interleukin (IL)-12, IL-18 and interferon (IFN)-gamma, and facilitates the generation of Th1 cells. We have recently shown that recombinant LLO (rLLO) inhibits generation of ovalbumin (OVA)-specific Th2 immune response by skewing maturation of antigen-specific T cells into Th1 cells. In the present study, we investigated the effect of rLLO on the effector phase of Th2-dependent allergic rhinitis in BALB/c mice sensitized with OVA. In mice sensitized intraperitoneally and challenged intranasally with OVA, nasal allergic symptoms such as sneezing and nose-scratching were observed at a high frequency. A high titre of anti-OVA IgE antibody was detected in sera and a large number of eosinophils migrated into the nasal tissue. However, rLLO treatment during the intranasal challenge inhibited the allergic symptoms, production of anti-OVA IgE antibody and eosinophil infiltration. Though rLLO did not affect antigen-specific cytokine production from splenic CD4(+) T cells, rLLO significantly suppressed OVA-specific IL-4 and IL-5 production from nasal mononuclear cells. We further found that rLLO inhibited the recruitment of CD4(+) T cells in nasal mucosa, and diminished the transcription and cell surface expression of CCR4 on splenic CD4(+) T cells. Moreover, rLLO was able to inhibit the passive cutaneous anaphylaxis reaction mediated by anaphylactic antibodies (IgE and IgG(1)) and mast cells. Taken together, these data showed that rLLO suppresses the effector phase of allergic rhinitis by inhibition of Th2 cell recruitment to nasal mucosa and type I allergic reaction.

Age frequency distribution of joint ER/PR phenotypes in primary breast cancer patients: An analysis of 3,620 cases at a single Japanese institute

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Background: Hormone receptor (HR) expression may reflect the different subtypes of breast cancer. Recent clinical trials have reported that joint Estrogen receptor (ER)/Progesterone receptor (PR) phenotypes in breast cancer have specific spectrum for treatment response. To analyze the epidemiologic character of ER/PR subtypes in Japanese patients, a retrospective data survey was conducted for 3,620 breast cancer patients treated at a single institute during 1975–2005. Methods: Patients records were obtained from cancer registration of the Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital and analyzed with SAS software. Among 3,620 operated patients, data of ER/PR subtypes were available in 2,707 cases. HRs were evaluated by ligand binding assay (LBA) or enzyme immuno assay (EIA) from 1975 to 2000 (n=1721), and by immunohistochemistry (IHC) after that (n=986). Results: Both mean and median of patient’s age increased through the operated year (p<0.0001). Therefore, all analysis related to distribution of age were adjusted by the operated year. As reported before, ER+ population showed liner trend with age by LBA/EIA (p<0.0001), while this was not observed by IHC. ER-/PR+ population was 10.6% by LBA/EIA, whereas it decreased to 2.1% by IHC. These are due to the increase of ER+ population with IHC analysis, since marginal distribution between two methods in the patients tested by both assays was significantly different for ER, but not for PR (n=181, p=0.0038 and n=175, p=0.1944). Irrespective of assay methods, peak age frequency of ER+/PR+ was between 46 and 50 years of age, whereas that of ER+/PR- was 56–60. For ER/PR phenotypes there was a significant difference of odds ratio across the age (<55 vs. ≥55, p=0.04 for IHC, p=0.0002 for LBA/EIA). Conclusion: Changes of standard assay from LBA/EIA to IHC affected the population of ER+ and lead the decrease of ER-/PR+ subtype. Japanese women’s peak age frequency of ER+/PR+ was in the premenopausal period compared to that of non-Hispanic white women in the postmenopausal age (Anderson WF, JCO 2001). Difference of most frequent age of each subtype among the races may be taken into account for the development of chemoprevention strategy with anti-estrogens.

No significant financial relationships to disclose.

Determination of essential and variable residues in pediocin PA-1 by NNK scanning

Pediocin PA-1 is an antimicrobial peptide (called bacteriocin) that shows inhibitory activity against the food-borne pathogen Listeria monocytogenes. To elucidate which residue(s) is responsible for this function, the antimicrobial activities of pediocin PA-1 mutants were evaluated and compared. Each of the 44 native codons was replaced with the NNK triplet oligonucleotide in a technique termed NNK scanning, and 35 mutations at each position were examined for antimicrobial activities using a modified colony overlay screening method. As a consequence, the functional responsibility of each residue was estimated by counting the number of active mutants, allowing us to identify candidate essential/variable residues. Activity was abrogated by many of the mutations at residues Y2, G6, C9, C14, C24, W33, G37, and C44, indicating that these residues may be essential. In contrast, activity was retained by almost all versions harboring mutations at K1, T8, G10, S13, G19, N28, and N41, indicating that these are functionally redundant residues. Sequence analysis revealed that only the wild type was active and 14 and 11 substitutions were inactive at G6 and C14, respectively, while 12 and 11 substitutions were active and 2 and 0 substitutions were inactive at T8 and K1, respectively. These findings suggest that NNK scanning is effective for determining essential and variable residues in pediocin PA-1, leading to an elucidation of structure-function relationships and to improvements in the antimicrobial function efficiently by peptide engineering.

Malignant transformation of pleomorphic xanthoastrocytoma

A 31-year-old woman presented with a pleomorphic xantho-astrocytoma (PXA) manifesting as epilepsy. The tumour was partially resected. Histological examination revealed cellular pleomorphism and cytoplasmic vacuolation consistent with PXA, but no mitoses, necrosis, or endothelial proliferation. Follow-up neuro-imaging showed the residual tumour had grown rapidly with dissemination in the spinal cord. The recurrent lesion was totally resected and was shown to be glioblastoma. The patient has survived without signs of recurrence for 36 months after adjuvant radiochemotherapy. The biological behaviour of PXA cannot be predicted based on the histological features and careful follow up is essential.

Listeriolysin O, a cytolysin derived from Listeria monocytogenes, inhibits generation of ovalbumin-specific Th2 immune response by skewing maturation of antigen-specific T cells into Th1 cells

Listeriolysin O (LLO), a cholesterol-dependent cytolysin derived from Listeria monocytogenes, is a potent inducer of interleukin (IL)-12, IL-18 and interferon (IFN)-gamma. We have shown that LLO facilitates development of T cells mediating protective immunity against L. monocytogenes through the induction of IFN-gamma production at an early stage. Based on this finding, it is postulated that LLO inhibits differentiation of Th2 cells and the Th2 immune response. By using a murine model of ovalbumin (OVA)-induced allergic rhinitis, we investigated whether LLO has an ability to modulate the Th2-type immune disorder. In mice sensitized intraperitoneally with ovalbumin (OVA)/alum and challenged intranasally with OVA, a large number of eosinophils migrated into the nasal tissue, and high titres of anti-OVA IgE and IgG(1) antibodies were detected in sera. However, LLO treatment during sensitization markedly inhibited the eosinophil infiltration and production of these anti-OVA antibodies. A large number of T cells from mice sensitized and challenged with OVA produced high level of IL-4 and IL-5 but not IFN-gamma after stimulation with OVA. In contrast, OVA-specific IFN-gamma-producing T cells were preferentially induced in mice treated with LLO at the time of sensitization. In the absence of LLO administration, the expression level of GATA-3 and SOCS-3 in CD4(+) T cells was enhanced after sensitization with OVA. LLO treatment resulted in a reduction of GATA-3 and SOCS-3 expressions but induced the transcription of T-bet instead. Taken together, these data show clearly that LLO is capable of inhibiting Th2 immune response by skewing differentiation of antigen-specific T cells into Th1 cells.

Stereotactic Radiosurgery Followed by Whole Ventricular Irradiation for Primary Intracranial Germinoma of the Pineal Region

Intracranial germinomas can be cured by radiotherapy and/or chemotherapy. Three patients with pineal germinoma were treated with stereotactic radiosurgery using the gamma knife (10 - 12 Gy) to the tumors followed by whole ventricular irradiation (24 Gy). All patients had solitary pineal tumor measuring less than 3 cm, clinically compatible with germinoma, normal cerebrospinal fluid (CSF) and serum levels of alpha-fetoprotein and beta-human chorionic gonadotropin, no disseminated disease on spinal magnetic resonance (MR) imaging, and no abnormal CSF cytology. All patients showed complete response to the combined radiotherapy, and MR imaging has shown no recurrence of the tumor. Combined radiotherapy using gamma knife radiosurgery is effective for pineal germinoma, and reduced the cost of treatment with less need for hospitalization.

Rapid identification of pickle yeasts by fluorescent PCR and microtemperature-gradient gel electrophoresis

Monitoring the yeast populations within pickle soaking fluid is imperative for ensuring optimum taste, but these analyses have proven time-consuming and expensive, limiting their industrial application. Here, yeasts were identified in the soaking fluid from Japanese radish pickles using fluorescent PCR amplification of the variable D1/D2 region of the 26S rDNA, followed by analysis with microtemperature-gradient gel electrophoresis (micro-TGGE). This smaller version of the normal TGGE apparatus is capable of analyzing samples 10- to 20-fold faster without sacrificing data quality. Each primer set was labeled with a different fluorescent dye, allowing easy isolation of the various PCR products and identification of the bands corresponding to the various yeasts. The results indicate that fluorescent PCR and micro-TGGE may be a useful new method for rapid, easy monitoring of yeast flora in various food industries. This new method can be used on a daily basis to provide overviews of yeast flora during pickle production, allowing producers to quickly grasp pickle readiness at a single glance.

Intraoperative localisation of the lip sensory area by somatosensory evoked potentials

Accurate localisation of the central sulcus enables maximum tumour resection with minimum morbidity in peri-Rolandic surgery. We investigated intraoperative somatosensory evoked potentials (SSEPs) with combined recording of lower lip and median nerve stimuli during craniotomy in nine patients with peri-Rolandic glioma. Using a custom clip electrode, the lip mucous membrane was stimulated with biphasic pulses with 0.2 ms duration, 10-14 mA intensity and a frequency of 0.7 Hz. Polarity inversion of the SSEP was detected across the central sulcus using median nerve and/or lower lip stimulation in eight of the nine patients in whom the tumour did not infiltrate the lip or hand sensory area. Recording of SSEPs with lower lip stimulation is useful if the resection margin is planned lateral to the hand representation area, if the hand representation area is not exposed by the craniotomy, or if the SSEPs for median nerve stimulation are not clear due to tumour infiltration.

Usefulness of Constructive Interference in Steady State (CISS) Imaging for the Diagnosis and Treatment of a Large Extradural Spinal Arachnoid Cyst

We present a rare case of a symptomatic large extradural arachnoid cyst extending from the lower thoracic to sacral region in a 12-year-old boy, who presented with the signs and symptoms of spinal cord compression over 4 years. Since the pedicle of the cyst could not be delineated using conventional magnetic resonance imaging (MRI), cine-mode MRI, and computed tomography scan, partial resection of the cyst was initially performed, which significantly improved motor function. After the first operation, a single pedicle was clearly demonstrated by 3D constructive interference in steady state (CISS) MRI. Thus, additional surgery aimed at closing the dural defect was performed to prevent future enlargement of the cyst. The operative findings were consistent with those of 3D CISS imaging. Clinical and radiological features of this lesion are discussed, focusing on the usefulness of 3D CISS MRI for preoperative evaluation, and especially for delineating the pedicle in cases of large extradural spinal arachnoid cysts.

Familial leptomeningeal amyloidosis with a transthyretin variant Asp18Gly representing repeated subarachnoid haemorrhages with superficial siderosis

OBJECTIVES

To report the clinical features of two Japanese brothers with familial leptomeningeal amyloidosis, showing a causative gene abnormality of a transthyretin (TTR) variant Asp18Gly, previously reported only in a Hungarian family.

METHODS

The authors reported on a 42 year old man (patient 1) and his 45 year old brother (patient 2), both suffering from subarachnoid haemorrhage (SAH) without and with hydrocephalus, respectively. DNA sequences of the TTR gene were determined in both patients and the patients' clinical features described. A surgical biopsy of the leptomeninges was performed on patient 1.

RESULTS

DNA sequence analyses demonstrated the glycine-for-aspartate substitution at position 18 of the TTR variant. Both patients revealed pyramidal tract signs and cerebellar ataxia. Audiometric studies showed bilateral, mild sensorineural hearing loss in the patients whose cerebrospinal fluid (CSF) protein levels increased. T1 weighted MRI after contrast administration showed diffuse leptomeningeal enhancement along the Sylvian fissures and over the surface of the brainstem, cerebellum, and spinal cord. Gradient echo T2* weighted MRI showed superficial siderosis mainly in the cerebellum. A biopsy of the leptomeninges was obtained from the spinal cord of patient 1. While performing the biopsy, the authors observed the varicose, elongating, and fragile veins on the dorsal surface of the spinal cord. Immunohistochemical study revealed marked deposits of TTR derived amyloid on his leptomeninges.

CONCLUSIONS

This is the second report of familial leptomeningeal amyloidosis with an Asp18Gly TTR gene mutation, clinically causing only CNS symptoms. Repeated SAH from fragile veins on the dorsal surface of the spinal cord seemed to induce superficial siderosis of the CNS. So far, there have been two reliable hallmarks leading to the diagnosis of leptomeningeal amyloidosis: diffuse leptomeningeal enhancement on contrast MRI and greatly increased CSF protein content. This study has contributed a third hallmark: the presence of superficial siderosis is useful in diagnosing leptomeningeal amyloidosis.

Atypical teratoid/rhabdoid tumour with leptomeningeal dissemination in an adult

A 22-year-old man presented with a rare case of atypical teratoid/rhabdoid tumour (AT/RT). Magnetic resonance imaging showed a left cerebellar mass with leptomeningeal dissemination. Partial resection was performed. Histological examination revealed AT/RT. Postoperatively, whole neuraxis and local irradiation were performed. Three-drug chemotherapy with ifosfamide, cisplatin, and etoposide, and adjuvant intrathecal administration of methotrexate were repeated. Near complete response was achieved, and no tumour recurrence/progression has been noticed during the follow up of 24 months. Intensive radiochemotherapy can successfully control AT/RT, even with leptomeningeal dissemination.

Combined Three-Dimensional Anisotropy Contrast Imaging and Magnetoencephalography Guidance to Preserve Visual Function in a Patient with an Occipital Lobe Tumor

OBJECTIVE

Three-dimensional anisotropy contrast (3-DAC) magnetic resonance imaging and magnetoencephalography (MEG) of visually evoked magnetic fields (VEFs) were used to accurately localize the optic radiation and primary visual cortex before surgery for an occipital tumor.

PATIENT AND METHODS

A 26-year-old male presented with an occipital lobe tumor located intrinsically underneath the right calcarine fissure. 3-DAC imaging showed that the right optic radiation was located along the superior and lateral surfaces of the lesion. Mapping of the VEFs demonstrated that the primary visual cortex was located superior and lateral to the lesion. The lesion was totally resected via an infero-medial cortical incision using a frameless stereotactic system. Histopathology indicated a pilocytic astrocytoma. No visual deficit was found before or after surgery.

CONCLUSION

Combined 3-DAC imaging and MEG can provide essential information about the optic radiation and primary visual cortex for planning the surgical treatment of occipital lobe tumors.

Chondrocyte transplantation for osteochondral defects with the use of suspension culture

Cartilage graft is considered to be useful in repairing chondral or osteochondral defects. One method of the cartilage graft is achieved by autologous chondrocyte transplantation following cell culture. However, chondrocytes change their phenotype during culture. We used costal chondrocytes cultured over agarose (suspension culture) as a source of graft materials. The suspension-cultured chondrocytes formed aggregate in culture. We first examined the expressions of cartilage-specific matrices of cultured chondrocytes after two weeks in culture. The chondrocytes cultured over agarose expressed more type II collagen mRNA than those cultured on plastic dishes did after two weeks in culture. Safranin O staining showed the presence of glycosaminoglycans in the chondrocyte culture over agarose, while glycosaminoglycans were not observed in the culture on plastic dishes. We then examined the changes of rat articular osteochondral defects after transplantation of suspension-cultured chondrocytes. The aggregate of suspension-cultured chondrocytes was easily picked up with forceps and transplanted in the osteochondral defects. The defects were filled with safranin O-stained hyaline cartilage tissue two weeks after chondrocyte transplantation. On the contrary, the fibrous materials, which were not stained with safranin O, were observed in the control defects. These results suggest that the suspension-cultured chondrocytes are useful for autologous cartilage grafts by preserving chondrocyte phenotype.

Use of Intraoperative Dynamic Infrared Imaging with Detection Wavelength of 7 - 14 µm in the Surgical Obliteration of Spinal Arteriovenous Fistula: Case Report and Technical Considerations

BACKGROUND AND OBJECTIVE

Although improvements of spatial and temporal resolution in infrared (IR) imaging have enabled intraoperative real-time acquisition of physiological and pathological information on living organs, the imaging qualities of anatomical delineation of blood vessels and functional delineation of blood flow were insufficient to serve as visual monitoring. The main reason was partly due to the lack of an appropriate IR detection IR band (formerly 3 - 5 micro m), and the broad dynamic range in previous modalities.

METHODS

To make a good contrast between blood vessels and surrounding tissues, the detection wavelength was shifted to the long-wave (7 - 14 micro m) part of IR spectrum, which includes the peak IR wave from living tissue (9 - 10 micro m), and the dynamic range was confined to +/- 10 degrees C around 35 degrees C. The novel camera system (IRIS IV infrared imaging system) was used for the visual monitoring of blood flow during the obliteration of a spinal perimedullary arteriovenous fistula at Th 7 in 71-year-old male patient. The temperature resolution of camera was 0.15 degrees C, with its intensity resolution of 16 bit (320 x 240 pixels), and data were stored at a rate of 30 frames/second. High-quality delineation of blood vessels and blood flow was obtained all through the procedure without use of cold saline, which was an inevitable procedure to make contrast in the previously used thermography. However, the occasional use of an air blower was helpful to achieve adequate images in the deep and narrow area of the surgical field. The amount of shunt flow reduction was visualized by the intensity in the acquired imaging, which was also confirmed later by digital subtraction angiography.

CONCLUSION

From the present experience, it is considered that this type of imaging may be able to substitute intraoperative blood vessel and blood flow monitoring in spinal and other neurosurgical disorders.

GAFChromic film dosimetry with a flatbed color scanner for Leksell Gamma Knife therapy

GAFChromic films MD-55-2 have recently been established widely in industrial, scientific, and medical applications as radiation dosimeters. We applied these films to the dosimetry for Leksell Gamma Knife therapy. We used a flatbed image scanner to take digital images of irradiated MD-55-2, and the data were converted to Red, Green and Blue pixel values. The absorbed dose, as derived from the response curve of the Red pixel value, was consistent with the Leksell Gamma Plan dose planning system, for exposures using collimator sizes, 4 mm, 8 mm, and 14 mm. However, the maximum dose in the exposure of the 18 mm collimator was measured to be about 5% smaller than Gamma Plan due to the density effect of the compound material in the head phantom.

Routine clinical adoption of magnetic resonance imaging was associated with better outcome after surgery in elderly patients with a malignant astrocytic tumour: a retrospective review

BACKGROUND

There is controversy about extensive surgical treatment for a malignant astrocytic tumour in more elderly patients who may have poorer outcomes and higher complication rates. This retrospective study investigated outcome in elderly patients with malignant astrocytic tumour before and after the adoption of routine clinical use of magnetic resonance (MR) imaging.

METHODS

During 1982 through 1999, 88 patients with malignant astrocytic tumour aged 60 years or over were treated in our institute. Thirty-seven patients had an anaplastic astrocytoma and 51 had a glioblastoma. Thirty-seven patients treated from 1982 to 1988 did not have pre-operative evaluation by MR imaging (Group A), 26 patients treated from 1989 to 1995 had preoperative MR imaging evaluation (Group B), and 25 patients treated after 1996 underwent preoperative MR imaging with functional brain mapping and intra-operative navigation system monitoring (Group C).

FINDINGS

The median survival time was 8.8 months in Group A, 12.7 months in Group B, and 17.6 months in Group C. Patients with glioblastoma in Group B (11.7 months, n = 15) and Group C (16.0 months, n = 19) had significantly longer median survival time than in Group A (6 months, n = 17) (P = 0.0054 between Groups A and B, P = 0.0024 between Groups A and C). Better preoperative performance status, more thorough surgical resection, and better performance status after the initial treatment was obtained after the introduction of MR imaging, and patients with the optimal indicators showed significantly longer survival time compared with the patients without these factors.

INTERPRETATION

Pre-operative MR imaging may contribute to longer survival time by providing an earlier diagnosis in patients with better performance status, by allowing more thorough surgical resection, and resulting in better performance status after the treatment.

Stereotactic radiosurgery for nodular dissemination of anaplastic ependymoma

Dissemination of primary intracranial ependymoma occurs in 10% of all cases and is difficult to treat, so this may be one of the major reasons for the poor prognosis. Two patients with nodular dissemination of anaplastic ependymoma were treated with repeated stereotactic radiosurgery using the gamma knife (GK), resulting in tumour control over 21 months. GK radiosurgery is a safe and effective treatment option for providing good local control in patients with nodular dissemination of ependymoma.