Photodynamic therapy with verteporfin to induce regression of aggressive retinal astrocytomas

PURPOSE

To evaluate the effect of photodynamic therapy (PDT) with verteporfin on symptomatic, aggressive retinal astrocytomas.

METHODS

A prospective, interventional study in a tertiary referral centre. Two patients were treated with a single session of PDT using the standard parameters of the Verteporfin in Photodynamic Therapy (VIP) study: a 34-year-old man whose previously stationary juxtapapillary retinal astrocytoma, secondary to tuberous sclerosis, progressed within 7 months to involve the foveola; and a 68-year-old man whose acquired retinal astrocytoma progressed over 18 months in spite of standard photocoagulation. Both tumours were vascularized and had caused secondary lipid exudation and an exudative retinal detachment. Outcome measures were visual acuity, resorption of subretinal fluid, tumour height and fluorescein angiography.

RESULTS

The progressing, vascularized part of both retinal astrocytomas regressed, with little change in the poorly vascularized, stationary part of the congenital hamartoma. Visual acuity improved in the first patient and was unchanged in the second by 3 months, with stable vision in both and no sign of recurrence at 2 years. The exudative retinal detachments resolved completely. Tumour height reduced a median of 30%. Regression was associated with obliteration of tumour vessels within the progressing part of the lesion, with closure of some of the dilated retinal capillaries over the tumour. Intraretinal microvascular abnormalities and scattered haemorrhages appeared outside the treated area in the first patient.

CONCLUSION

PDT with verteporfin can induce regression of progressive, vascularized, aggressive retinal astrocytomas and may prevent typical progression to total retinal detachment and enucleation, whether the astrocytoma is associated with tuberous sclerosis or not. PDT may be considered a first-line treatment for aggressive retinal astrocytomas.

Calcified pilocytic astrocytoma of the medulla mimicking a brainstem "stone"

Brainstem gliomas are a heterogeneous group of tumours commonly found in children, comprising about 10% of central nervous system tumours in paediatric patients, but less than 2% in adults. Pilocytic astrocytomas usually involve the midbrain and the medulla, and their surgical resection, when feasible, is generally curative. Thin calcifications can be normally found within low grade gliomas, but densely calcified pilocytic astrocytomas of the brainstem have been only rarely reported. We present the case of a young man presenting with a large brainstem calcification involving the medulla, which was subtotally resected using a posterior suboccipital approach. The definitive pathological diagnosis was calcified pilocytic astrocytoma.

Low-grade astrocytoma associated with abscess formation: case report and literature review

A rare case of low-grade astrocytoma associated with abscess formation occurred in a 52-year-old man presenting with Broca's aphasia. He underwent craniotomy and tumor removal under the impression of brain tumor with necrotic cystic change. Abscess accumulation within the intra-axial tumor was found intraoperatively. Literature related to brain abscess with brain tumor is reviewed, with an emphasis on abscesses with astrocytoma. We discuss the common brain tumors that are associated with abscess, pathogens that coexist with brain tumor, and the pathogeneses of coexisting brain abscess and tumor. It is very important to know how to differentiate between and diagnose a brain abscess and tumor, or brain abscess with tumor, preoperatively from clinical presentation and through the use of computed tomography, conventional magnetic resonance imaging, diffusion-weighted imaging or magnetic resonance spectroscopy.

Adverse medical events associated with childhood cerebellar astrocytomas and medulloblastomas: natural history and relation to very long-term neurobehavioral outcome

OBJECTIVES

The objectives of the study are to document the incidence of medical events in survivors of childhood posterior fossa astrocytoma or medulloblastoma in four time periods (diagnosis, perioperative, short-term survival, long-term survival), and to study whether medical events predict neurobehavioral outcome.

MATERIALS AND METHODS

Twenty-nine astrocytoma and 29 medulloblastoma survivors were studied at least 5 years post-diagnosis. The incidence of medical events in each time period was compared in each group in relation to long-term intelligence, memory, functional independence, and health-related quality of life. As expected, medical and neurobehavioral outcome were poorer in the medulloblastoma group. In the astrocytoma group, poorer long-term neurobehavioral outcome was associated with more adverse medical events in the perioperative and short-term survival periods.

CONCLUSIONS

Long-term neurobehavioral outcome is related to time-dependent medical events in astrocytoma survivors. The data confirm earlier reports of poorer outcome after medulloblastoma and add new information about clinical markers of poor neurobehavioral outcome in survivors of childhood astrocytoma.

[Ophthalmological findings in pediatric brain neoplasms: 58 cases]

PURPOSES

To describe the visual manifestations of brain neoplasms, and to analyze the effect of tumor control on these.

METHODS

This is a descriptive retrospective study, which includes patients under 14 years of age, suffering from different brain neoplasms in our hospital between 1996 and 2005 inclusive.

RESULTS

In the group of patients with low visual acuity, 44% had organic amblyopias. In 28% of cases, the amblyopia was secondary to the strabismus/nystagmus produced by the developing tumor. Corrective treatment was successful in some cases of partial or total organic amblyopia. Ophthalmologic evaluation (including perimetry and fundoscopy) enabled detection of 3 tumor relapses.

CONCLUSIONS

Visual analysis (visual acuity, perimetry, fundoscopy) should be an essential component of assessment during brain neoplasm treatment and follow-up. Corrective treatment is sometimes successful in organic amblyopias

Pilomyxoid astrocytoma of the spinal cord in an adult

We report a 45-year old woman with a pilomyxoid astrocytoma (PMA) of the cervical spinal cord with a rapid clinical course and fatal outcome. Moreover, two family members of the patient were reported to have brainstem tumours with similar histopathological features. This may be the first report of familial PMAs.

[Clinical study on temporal lobe epilepsy in childhood caused by temporal lobe space-occupying lesions]

We studied the clinicoelectrical and neuroimaging features of 11 patients with symptomatic temporal lobe epilepsy (TLE) caused by temporal lobe space occupying lesions (SOLs), and compared its characteristics with those of 19 mesial TLE (MTLE) patients. Brain MRI demonstrated SOLs in the mesiotemporal lobe in 9, and laterotemporal lobe in the remaining 2 patients. Ten of the 11 patients successfully underwent surgery, which revealed tumors in 7 and focal cortical dysplasia in 3 patients. Comparisons of the clinical features between those with SOTLE and MTLE showed that both conditions shared the same clinical seizure manifestations such as gastric uprising sensation or ictal fear and a favorable response to surgery. However, the patients with SOTLE had fewer febrile convulsion, and more frequent seizure recurrences as well as TLE EEG discharges and associations of the monophasic clinical course than those with MTLE. In addition, the MRI findings were characterized by unilateral hippocampal atrophy in MTLE and expanding or SOLs in the SOTLE group. Children with complex partial seizures of suspected temporal lobe origin should undergo extensive neuroimaging evaluation.

Intravascular thrombosis in central nervous system malignancies: a potential role in astrocytoma progression to glioblastoma

The presence of necrosis within a diffuse glioma is a powerful predictor of poor prognosis, yet little is known of its origins. Intravascular thrombosis is a frequent finding in glioblastoma [GBM; World Health Organization (WHO) grade IV] specimens and could potentially be involved in astrocytoma progression to GBM or represent a surrogate marker of GBM histology. We investigated whether intravascular thrombosis was more frequent or prominent in GBM than other central nervous system (CNS) malignancies and considered its prognostic significance in anaplastic astrocytoma (AA; WHO grade III), which lacks necrosis. Histologic sections were examined for thrombosis, necrosis and microvascular hyperplasia from each of 297 CNS tumors, including 103 GBMs, 46 AAs, 20 diffuse astrocytoma (DAs; WHO grade II), eight anaplastic oligodendrogliomas (AOs; WHO grade III), 20 oligodendrogliomas (ODs; WHO grade II), 49 metastatic carcinomas (METs), 31 primary central nervous system lymphomas (PCNSLs) and 20 medulloblastomas (MBs). Among newly diagnosed tumors, thrombosis was present in 92% of GBM resections, significantly greater than other types of CNS malignancies. Of tumors with thrombosis, GBMs had a higher frequency of affected vessels than AAs, DAs, AOs, ODs and MBs, but had a frequency similar to METs and PCNSLs. The sensitivity of thrombosis for the diagnosis of GBM in this set of tumors was 92% and the specificity was 91%. Intravascular thrombosis was uncommon in AAs and was only noted in stereotactic biopsies. This subset of patients had shorter survivals than those AAs without thrombosis. Thus, intravascular thrombosis is more frequent in GBM than other CNS malignancies. When present in AAs, it appears to indicate aggressive clinical behavior.

Vascular endothelial growth factor and basic fibroblast growth factor expression positively correlates with angiogenesis and peritumoural brain oedema in astrocytoma

BACKGROUND

Astrocytoma is the most malignant intracranial neoplasm and is characterized by high neovascularization and peritumoural brain oedema. Angiogenesis is a complicated process in oncogenesis regulated by the balance between angiogenic and antiangiogenic factors.

METHODS

The expression of two angiogenic growth factors, vascular endothelial growth factor and basic fibroblast growth factor were investigated using immunohistochemistry for astrocytoma from 82 patients and 11 normal human tissues.

RESULTS

The expression of vascular endothelial growth factor and basic fibroblast growth factor positively correlate with the pathological grade of astrocytoma, microvessel density numbers and brain oedema, which may be responsible for the increased tumour neovascularization and peritumoural brain oedema.

CONCLUSION

The results support the idea that inhibiting vascular endothelial growth factor and basic fibroblast growth factor are useful for the treatment of human astrocytoma and to improve patient's clinical outcomes and prognosis.

Speech-language and hearing complaints of children and adolescents with brain tumors

Central nervous system (CNS) tumors generally leave sequelae that may compromise speech, language, swallowing, hearing, and voice functions. This report describes the incidence of speech-language and hearing complaints and disorders in children and adolescents with CNS tumor under treatment at one of the most important Brazilian reference center for pediatric cancer. One-hundred ninety patients were examined for speech-pathology screening and analysis: forty-two percent presented with complaints and symptoms. From the remaining patients, 68% presented clinical symptoms and 32% were actually free from any speech-language and hearing-related symptoms. The high incidence of complaints and symptoms indicate that these patients might benefit from specific rehabilitation interventions.

Neurological outcome after resection of intramedullary spinal cord tumors in children

OBJECTIVE

With modern surgical advances, radical resection of pediatric intramedullary spinal cord tumors (IMSCT) can be achieved with preservation of long-term neurological function. Clinical and radiographic risk factors predictive of postoperative neurological outcome may serve as a guide for surgical risk stratification.

MATERIALS AND METHODS

We prospectively reviewed the outcomes of 16 consecutive cases of pediatric IMSCT resection at a single institution. Clinical, radiographic, and operative variables were analyzed as predictors of postoperative neurological function defined by the modified McCormick score (MMS).

RESULTS

Sixteen children 10 +/- 5 years old presented with median (interquartile range) MMS score of 2 (1-2) with IMSCTs (eight cervical, eight thoracic) involving 4 +/- 2 levels. Pathology revealed astrocytoma in 12 cases (three pilocytic, four grade II, three grade III, two GBM), gangliogliomas in two, ependymoma in one, and gliosis in one case. At median follow-up of 7 months, six (38%) patients experienced improved neurological function, eight (50%) remained stable, one (6%) experienced a delayed decrease in neurological function (GBM progression), and one (6%) died (GBM progression). Five (31%) patients developed persistent dysesthetic symptoms. Four (80%) patients with cystic tumors experienced neurological improvement compared to only two (18%) patients with noncystic tumors, p < 0.05. Preoperative steroid use (odds ratio, OR [95% confidence interval, CI] = 18.0 [1.24-260.1], p = 0.03) and cystic tumor (OR [95%CI] = 18.0 [1.24-260.1], p = 0.03) predicted neurological improvement after surgery.

CONCLUSION

Radical resection of pediatric IMSCTs can be achieved with low incidence of neurological injury. Sensory syndromes frequently occur after pediatric IMSCT resection and frequently affect patient's quality of life. Tumors with compressive cysts may identify patients more likely to experience improved neurological function after surgical resection.

Acromegaly and anaplastic astrocytoma: coincidence or pathophysiological relation?

Insulin-like growth factor type I (IGF-I) is an important promoter in the tumorigenesis of several extracranial and intracranial neoplasms. In astrocytic-cell tumors, the role of autocrine and paracrine IGF-I expression in enhancing tumoral progression is well established. However, the influence of systemic IGF-I levels on the clinical behavior of astrocytic neoplasms remains an open subject of research. We report the case of a 28-year-old man who presented simultaneously with acromegaly and an anaplastic astrocytoma, which had rapidly progressed from a low-grade astrocytoma. The coexistence of systemic IGF-I hypersecretion with a quick progression in the histopathological grade of the astrocytoma raises the compelling question of whether the clinical behavior of the astrocytic tumor was influenced by the acromegalic status. The role of IGF-I signaling in the pathogenesis of astrocytic-cell tumors and the experience with therapeutic strategies addressing this pathway in astrocytomas are also discussed.

An upper thoracic spinal cord tumor presenting as hemifacial hyperhidrosis

BACKGROUND

Hyperhidrosis as the sole presenting symptom of an upper thoracic intramedullary tumor has never been reported in the English literature.

CASE DESCRIPTION

A 17-year-old boy presented with a long history of hemifacial flushing and hyperhidrosis on the left side of his face and neck. The MRI revealed a large spinal cord tumor at the T1-T2 levels. The patient underwent total excision of the intramedullary tumor via a posterior myelotomy. The histopathological diagnosis was low-grade astrocytoma. The symptoms resolved immediately after the surgery and did not return during the follow-up period of 9 months.

CONCLUSIONS

We suggest that sympathetic irritation on the left side is the mechanism behind this clinical presentation. Its unusual presentation and lack of motor and sensory deficits resulted in delayed diagnosis of this potentially disabling lesion. When autonomic dysfunction of the face and neck is encountered, in addition to the cranial and cervical regions, the upper thoracic levels should be investigated using MRI.

HSV encephalitis in a child with brain stem glioma: a rare complication of therapy. Case report and review of the neurosurgical literature

BACKGROUND

Herpes simplex virus (HSV) encephalitis is a rare association with pediatric neurosurgical pathologies.

CASE REPORT

A 13-year-old boy was diagnosed with an inoperable, biopsy-proven pontine grade II astrocytoma. During radiotherapy, he developed status epilepticus controlled by thiopentone with intubation and ventilation. Empiric cefotaxime and aciclovir were given. Lumbar cerebrospinal fluid (CSF) showed a normal white cell count, normal glucose, and a slightly elevated protein level. However, the CSF showed a positive polymerase chain reaction (PCR) for HSV type 1 DNA. Intravenous aciclovir was given for 21 days and foscarnet for 7 days. He was extubated after 4 weeks at which time he was aphasic with spastic diplegia. After 8 weeks, MRI brain scan showed the typical bitemporal pattern of HSV encephalitis. He made slow improvement but died 8 months after diagnosis from tumor progression.

CONCLUSION

HSV encephalitis is a rare but life threatening complication in neurosurgical patients. A low threshold for both investigation with CSF PCR and empirical treatment with intravenous aciclovir is warranted. As in this case, initial microscopic examination of the CSF may be normal. The literature on HSV encephalitis in neurosurgical patients is discussed.

Oligoastrocytoma presenting with intractable epilepsy

OBJECTIVE

Oligoastrocytomas (OA) are mixed gliomas with distinct oligodendroglial and astrocytic neoplastic components. Very little about OA has been reported in the intractable epilepsy population.

METHODS

We undertook a retrospective review of 923 patients who underwent resective surgery for intractable epilepsy between 1996 and 2004.

RESULTS

6/923 (0.7%) patients were diagnosed with OA. Five patients were female, one was male. Median age at diagnosis was 25 years (range 19-44 years). Tumors arose from the left side in all patients and from the temporal lobe in five patients. Three patients had complex partial seizures. Median length of refractory epilepsy prior to surgery was 10.5 years (range 1-28 years), and the median number of antiepileptic drugs used was 2 (range 1-10). Preoperative WADA testing for language and memory localization was done for three patients; preoperative stereotactical localization was done for three patients. Surgical pathology revealed low-grade OA (WHO II) in five patients, and anaplastic OA in one. There were no surgical complications, clinical or radiographic tumor recurrence at a mean follow up period of 3.2 years (range 2-8). Excellent seizure freedom was achieved in 5/6 patients.

CONCLUSION

As a result of our small sample size, general conclusions may be imprecise, but this review suggests that OA behave similar to other tumors related to intractable epilepsy: they usually have a preoperative seizure course of many years, an excellent rate of seizure-freedom following surgery, and are in general, low-grade tumors with an indolent course for which serial imaging is sufficient follow-up.

Apnea caused by mesial temporal lobe mass lesions in infants: report of 3 cases

Apnea as an isolated manifestation of seizures is well described in neonates but is only occasionally observed in infants. This article reports 3 infants presenting with apneic events as the main manifestation of seizure, documented by video electroencephalogram, all with mesial temporal lobe lesions. The 3 infants, after normal pregnancy and delivery at term, showed the first apnea at the age of 4 to 10 months. Although the interictal electroencephalogram result was often normal, ictal video electroencephalogram in all infants showed focal rhythmic discharges with or without generalization. Magnetic resonance imaging showed an inferior mesial temporal lobe mass lesion in all infants. All patients underwent lesion removal, and they are seizure free with normal psychomotor development.

Gaze-evoked nystagmus: A case report and literature review

BACKGROUND

A sustained gaze-evoked nystagmus (GEN) is an important ocular finding that may indicate serious neurologic pathology. It is also a finding that can be missed easily during routine extraocular muscle (EOM) testing. This report presents a case that should familiarize the reader with GEN and presents a novel approach to testing EOM function.

CASE REPORT

The mother of an otherwise healthy 4-year-old girl noted that her daughter's eyes crossed occasionally, the right lid drooped on one occasion, and she had been having strange headaches. An asymmetric, sustained, gaze-evoked nystagmus was detected using a different approach to EOM testing. Magnetic resonance imaging found a large, brainstem astrocytoma in the cerebellar-pontine angle.

CONCLUSION

EOM function often is overlooked or underperformed but is an important part of the battery of clinical tests to rule out neurologic problems. Most forms of EOM testing will check for muscle palsies but little else. If the time is taken to extend the patient's gaze to the extreme ends, to attempt to hold the gaze in all 9 positions, and to maintain an accurate speed, the clinician can stand to gain much more information regarding the neurologic system.

Atypical cervical astrocytoma manifesting as occipitalgia

A 23-year-old female presented with chronic occipitalgia without signs of increased intracranial pressure followed by worsening headache and slight gait unsteadiness. Cerebral magnetic resonance (MR) imaging showed no corresponding lesions. Cervical MR imaging revealed a cervical intramedullary tumor. Intraoperatively the subpial tumor was found to stretch the 3rd-5th dorsal nerve roots posteriorly, which was thought to cause the intolerable headache. Total tumor resection was achieved without requiring myelotomy using electrophysiological monitoring with somatosensory and motor evoked potentials. Histological examination identified diffuse astrocytoma. Postoperatively the headache had completely resolved. Cervical astrocytoma of subpial location is a very rare cause of headache in adults. The subpial location enables surgical extirpation because minimal or no myelotomy is needed.

Cerebellar astrocytoma presenting with precocious puberty in a girl. Case report

Central precocious puberty in girls is uncommon and tends to be idiopathic in most cases. In about 20 to 30% of cases there is an intracranial mass lesion. The common lesions are hypothalamic hamartomas, optic nerve gliomas, suprasellar arachnoid cysts, hydrocephalus, germinomas, and other sellar/suprasellar lesions. Central precocious puberty secondary to a cerebellar astrocytoma is extremely rare. The authors report the first case in a girl who presented with several episodes of bleeding per vaginum. There was no clinical or radiological evidence of raised intracranial pressure.