Revisiting the Relationship Between Ethnicity and Outcome in Glioblastoma Patients

Background: Relationships between various ethnicities and glioma subtype have recently been established. As a tertiary referral center for Latin America and the Caribbean, our institution treats a diverse glioblastoma (GBM) population. We sought to clarify the role of ethnicity on patient prognosis in GBM and also compared these findings to a group consisting of elderly patients. We included ‘elderly’ as a group because the subgroups for ethnicities within them were too small. It allowed us to put in scope the effects of ethnicities on the overall survival. 

Material and Methods: After Institutional Review Board approval, 235 patients with GBM were retrospectively identified. A total of 140 patients were separated into four groups: White adults (n = 47), Hispanic adults (n = 27), elderly (n = 58), and Black adults (n = 6). Overall survival (OS) was our primary endpoint.

Results: Overall survival in the White adult group was 24.3 months, compared to 13.0 months in the Hispanic adult group, 20.2 months in the Black group, and 13.8 months in the elderly group (p = 0.01). In the Hispanic group, hypertension (37.9%, p = 0.01) and diabetes (24.1%, p = 0.009) were significantly more prevalent compared to the White adult cohort. No difference in insurance status or postoperative complications was found between subgroups.

Conclusion: Based on our analysis, Hispanic adults may have a decreased survival compared to White adults. However, the incidence of hypertension and diabetes was markedly higher in our Hispanic adult cohort; thus, estimating the risk of ethnicity and comorbidities on patient prognosis may be difficult. A prospective study correlating the genome and subgroup prognosis may help elucidate the role of ethnicity in GBM patients.

Heterotopic Intracranial Skin Presenting as Chronic Draining Sinus After Remote Craniotomy

BACKGROUND

Craniotomies for trauma are associated with a significant risk of wound complications. We report a case in which a chronic nonhealing draining sinus was caused by an ectopic epidermal lining deep to the craniotomy bone flap, adherent to the underlying dura.

CASE DESCRIPTION

A 61-year-old man was examined for a 3-year-old, nonhealing scalp wound resulting after a traumatic brain injury. His initial surgery consisted of an intracranial hematoma evacuation through a temporoparietal craniotomy; this was complicated by wound dehiscence and a chronic sinus draining clear fluid that did not resolve with antimicrobial therapy. Intraoperatively, a layer of hair-bearing skin adherent to the dura was found deep to the entirety of the previous bone flap. There was no dura tear or overt cerebrospinal fluid leak. This necessitated removal of the skin over the dura as well as the overlying bone flap. The resultant defect was reconstructed with a titanium mesh and hydroxyapatite cranioplasty, with a scalp rotation flap for coverage of the cutaneous defect. Pathology confirmed skin with intact adnexal structures.

CONCLUSION

This case demonstrates that it is possible for hair-bearing skin to grow directly on dura, deep to an intact craniotomy bone flap. With a chronic draining sinus in the absence of computed tomography and magnetic resonance imaging findings, this should be part of the differential diagnosis.

Introduction for Laser Interstitial Thermal Therapy (LITT) in Neurosurgery Supplement

ABBREVIATION

LITT, laser interstitial thermal therapy.

Use of a Mobile Intraoperative Computed Tomography Scanner for Navigation Registration During Laser Interstitial Thermal Therapy of Brain Tumors

OBJECTIVE

In recent years laser interstitial thermal therapy (LITT) has become the ablative neurosurgical procedure of choice. Multiple methods for registration and laser fiber verification have been described, with each method requiring multiple steps and significant time expenditure. We evaluated the use of a commercially available mobile computed tomography (CT) scanner for stereotactic registration during LITT for brain tumors in an attempt to simplify the procedure and improve intraoperative awareness of laser position.

METHODS

This is a retrospective chart review comparing LITT of brain tumors in 23 patients undergoing a standard protocol requiring skull pins and transport of the patient to a CT suite to obtain a reference scan compared with 14 patients in whom the Medtronic O-arm was used intraoperatively for navigation registration and confirmation of laser position.

RESULTS

Total ablation of the target was achieved in all patients with no surgical complications. Total surgery time was shorter for the O-arm group than for the standard protocol group, once experience was gained with bringing the O-arm in and out of the surgical field. Return from the magnetic resonance imaging suite to the operating room for repositioning of the laser was required for 1 patient in the standard protocol group, but for no patients in the O-arm group. Once experience was gained with using the O-arm, estimated surgical costs were lower for this group.

CONCLUSIONS

Use of a mobile intraoperative CT scanner for navigation registration and confirmation of laser position during LITT may play a role in streamlining the procedure and improving patient safety and comfort.

Glioblastoma multiforme of the optic chiasm: A rare case of common pathology

BACKGROUND

Malignant optic and chiasmatic gliomas are extremely rare, and are classified pathologically as anaplastic astrocytoma or glioblastoma multiforme (GBM). Approximately 40 cases of optic GBM in adults have been reported in the literature, and only five of them were described to originate from the optic chiasm.

CASE DESCRIPTION

An 82-year-old male patient with a past medical history of diabetes mellitus type 2, melanoma, and bladder cancer presented with gradual vision loss of the left eye in a period of 1 month. After neuro-ophthalmological examination, the decision of thither magnetic resonance imaging (MRI) studies was made. It showed a contrast enhancing mass in the region of the optic chiasm. In this case, imaging study was not enough to establish an accurate diagnosis and a left pterional craniotomy for biopsy and resection of the optic chiasmal mass was performed. After histological evaluation of the mass tissue, the diagnosis of GBM was made. Taking into account the patient's poor condition and unfavorable prognosis he was moved to inpatient hospice. The patient deceased within 2 months after surgery.

CONCLUSION

Chiasmal GBM is an extremely rare condition where a biopsy is necessary for accurate diagnosis and optimal treatment. Differential diagnosis for such lesions can be very difficult and include demyelinating optic neuritis and non-demyelinating inflammatory optic neuropathy (e.g., sarcoid), vascular lesions (e.g., cavernoma), compressive lesions of the optic apparatus, metastatic malignancy, and primary tumors of the anterior optic pathway. The role of chemotherapy and radiotherapy including novel stereotaxic radiosurgery methods is still unclear and will need to be evaluated.

Investigating the therapeutic role and molecular biology of curcumin as a treatment for glioblastoma

OBJECTIVES

Despite the aggressive standard of care for patients with glioblastoma multiforme, survival rates typically do not exceed 2 years. Therefore, current research is focusing on discovering new therapeutics or rediscovering older medications that may increase the overall survival of patients with glioblastoma. Curcumin, a component of the Indian natural spice, turmeric, also known for its antioxidant and anti-inflammatory properties, has been found to be an effective inhibitor of proliferation and inducer of apoptosis in many cancers. The goal of this study was to investigate the expanded utility of curcumin as an antiglioma agent.

METHODS

Using the PubMed MeSH database, we conducted a systematic review of the literature to include pertinent studies on the growth inhibitory effects of curcumin on glioblastoma cell lines based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 19 in vitro and five in vivo studies were analyzed. All of the studies indicated that curcumin decreased glioblastoma cell viability through various pathways (i.e. decrease in prosurvival proteins such as nuclear factor κB, activator protein 1, and phosphoinositide 3 kinase, and upregulation of apoptotic pathways like p21, p53, and executor caspase 3). Curcumin treatment also increased animal survival compared with control groups.

CONCLUSIONS

Curcumin inhibits proliferation and induces apoptosis in certain subpopulations of glioblastoma tumors, and its ability to target multiple signaling pathways involved in cell death makes it an attractive therapeutic agent. As such, it should be considered as a potent anticancer treatment. Further experiments are warranted to elucidate the use of a bioavailable form of curcumin in clinical trials.

Management of Atypical and Anaplastic Meningiomas

Meningiomas are the most prevalent primary tumor of central nervous system origin and, although most neoplasms are benign, a small proportion exemplifies an aggressive profile characterized by high recurrence rates, pleomorphic histology, and overall resistance to standard treatment. Standard initial therapy for malignant meningiomas includes maximal safe surgical resection followed by focal radiation in certain cases. The role for chemotherapy during recurrence of these aggressive meningiomas is less clear. Prognosis is poor and recurrence of malignant meningiomas is high. This article provides an overview of atypical and anaplastic malignant meningiomas, their treatment, and ongoing research for more effective treatments.

Frameless Stereotactic Ommaya Reservoir Placement: Efficacy and Complication Comparison with Frame-Based Technique

BACKGROUND

Ommaya reservoirs are ventricular access devices used primarily for the administration of intrathecal antineoplastic chemotherapy. In patients with low or normal ventricular volume, stereotaxy can improve accuracy of catheter placement with minimal morbidity. Frameless stereotaxy has become an increasingly popular alternative to frame-based stereotaxy. Relative rates of successful catheter placement between these two techniques are not described in the literature.

OBJECTIVES

To compare a large series of frameless to frame-based stereotactic catheter placements for Ommaya reservoirs, with an aim to compare accuracy and complication rate between the two procedures.

METHODS

A consecutive series of 41 frame-based and 68 frameless Ommaya reservoir placement procedures performed at our institution from 1998 to 2013 was reviewed. Patient demographics, operative accuracy and complication rates for the two techniques were compared.

RESULTS

Characteristics of the two groups were similar in diagnoses, age and other related factors. Comparison of frameless to frame-based stereotactic Ommaya catheter placement did not show significant differences in accuracy of placement, overall morbidity or mortality, or in any subcategory of complications.

CONCLUSIONS

These findings suggest that frameless stereotactic Ommaya reservoir placement is as safe and accurate as the frame-based technique.

Pseudotumor-like syndrome and cerebrospinal fluid leak in meningiomas involving the posterior third of the superior sagittal sinus: report of 4 cases

Meningiomas that partially or completely occlude the superior sagittal sinus may create a pseudotumor-like syndrome in certain patients. These patients may have impaired CSF absorption as a result of higher proximal venous pressure. Higher pressures after resection may encumber adequate wound healing and worsen symptoms. Here, the authors present a small series of patients with meningiomas involving the posterior third of the superior sagittal sinus, with documented high intracranial pressure prior to surgery. This paper aims to address the proposed etiology of high intracranial pressure in these patients and its associated complications, including CSF leak, wound dehiscence, pressure-related headaches, and visual complaints. In this paper, the authors propose a management plan to avoid wound complications and pseudotumor-related complications. When considering surgical intervention for patients with compromise of the posterior third of the superior sagittal sinus, careful attention must be paid to addressing potentially elevated intracranial pressure perioperatively.

The role of awake craniotomy in reducing intraoperative visual field deficits during tumor surgery

Objective:

Homonymous hemianopia due to damage to the optic radiations or visual cortex is a possible consequence of tumor resection involving the temporal or occipital lobes. The purpose of this review is to present and analyze a series of studies regarding the use of awake craniotomy (AC) to decrease visual field deficits following neurosurgery.

Materials and Methods:

A literature search was performed using the Medline and PubMed databases from 1970 and 2014 that compared various uses of AC other than intraoperative motor/somatosensory/language mapping with a focus on visual field mapping.

Results:

For the 17 patients analyzed in this study, 14 surgeries resulted in quadrantanopia, 1 in hemianopia, and 2 without visual deficits. Overall, patient satisfaction with AC was high, and AC was a means to reduce surgery-related complications and cost related with the procedure.

Conclusion

AC is a safe and tolerable procedure that can be used effectively to map optic radiations and the visual cortices in order to preserve visual function during resection of tumors infiltrating the temporal and occipital lobes. In the majority of cases, a homonymous hemianopia was prevented and patients were left with a quadrantanopia that did not interfere with daily function.

Banking Brain Tumor Specimens Using a University Core Facility

Within the past three decades, the significance of banking human cancer tissue for the advancement of cancer research has grown exponentially. The purpose of this article is to detail our experience in collecting brain tumor specimens in collaboration with the University of Miami/Sylvester Tissue Bank Core Facility (UM-TBCF), to ensure the availability of high-quality samples of central nervous system tumor tissue for research. Successful tissue collection begins with obtaining informed consent from patients following institutional IRB and federal HIPAA guidelines, and it needs a well-trained professional staff and continued maintenance of high ethical standards and record keeping. Since starting in 2011, we have successfully banked 225 brain tumor specimens for research. Thus far, the most common tumor histology identified among those specimens has been glioblastoma (22.1%), followed by meningioma (18.1%). The majority of patients were White, non-Hispanics accounting for 45.1% of the patient population; Hispanic/Latinos accounted for 23%, and Black/African Americans accounted for 14%, which represent the particular population of the State of Florida according to the 2010 census data. The most common tumors found in each subgroup were as follows: Black/African American, glioblastoma and meningioma; Hispanic, metastasis and glioblastoma; White, glioblastoma and meningioma. The UM-TBCF is a valuable repository, offering high-quality tumor samples from a unique patient population.

The role of stereotactic radiosurgery in the treatment of intramedullary spinal cord neoplasms: a systematic literature review

Advances in imaging technology and microsurgical techniques have made microsurgical resection the treatment of choice in cases of symptomatic intramedullary tumors. The use of stereotactic radiosurgery (SRS) for spinal tumors is a recent development, and its application to intramedullary lesions is debated. We conducted a literature search through PubMed's MeSH system, compiling information regarding intramedullary neoplasms treated by SRS. We compiled histology, tumor location and size, treatment modality, radiation dose, fractionation, radiation-induced complications, follow-up, and survival. Ten papers reporting on 52 patients with 70 tumors were identified. Metastatic lesions accounted for 33%, while 67% were primary ones. Tumor location was predominantly cervical (53%), followed by thoracic (33%). Mean volume was 0.55 cm(3) (95% confidence interval (CI), 0.26-0.83). Preferred treatment modality was CyberKnife® (87%), followed by Novalis® (7%) and linear particle accelerator (LINAC) (6%). Mean radiation dose was 22.14 Gy (95% CI, 20.75-23.53), with mean fractionation of 4 (95% CI, 3-5). Three hemangioblastomas showed cyst enlargement. Symptom improvement or stabilization was seen in all but two cases. Radionecrotic spots adjacent to treated areas were seen at autopsy in four lesions, without clinical manifestations. Overall, clinical and radiological outcomes were favorable. Although surgery remains the treatment of choice for symptomatic intramedullary lesions, SRS can be a safe and effective option in selected cases. While this review suggests the overall safety and efficacy of SRS in the management of intramedullary tumors, future studies need randomized, homogeneous patient populations followed over a longer period to provide more robust evidence in its favor.