Preoperative 3D volume reconstruction of the posterior wall of the sphenoid sinus with Horos: A free, simple and reliable tool in endoscopic endonasal trans-sphenoidal surgery

Brain metastases: Comparing clinical radiological differences in patients with lung and breast cancers treated with surgery

Purpose

Brain metastases (BMs) most frequently originate from the primary tumors of the lung and breast. Survival in patients with BM can improve if they are detected early. No studies attempt to consider all potential surgical predictive factors together by including clinical, radiological variables for their recognition.

Methods

The study aims to simultaneously analyze all clinical, radiologic, and surgical variables on a cohort of 314 patients with surgically-treated BMs to recognize the main features and differences between the two histotypes.

Results

The two groups consisted of 179 BM patients from lung cancer (Group A) and 135 patients from breast cancer (Group B). Analysis showed that BMs from breast carcinoma are more likely to appear in younger patients, tend to occur in the infratentorial site and are frequently found in patients who have other metastases outside of the brain (46 %, p = 0.05), particularly in bones. On the other hand, BMs from lung cancer often occur simultaneously with primitive diagnosis, are more commonly cystic, and have a larger edema volume. However, no differences were found in the extent of resection, postoperative complications or the presence of decreased postoperative performance status.

Conclusion

The data presented in this study reveal that while the two most prevalent forms of BM exhibit distinctions with respect to clinical onset, age, tumor location, presence of extra-cranial metastases, and lesion morphology from a strictly surgical standpoint, they are indistinguishable with regard to outcome, demonstrating comparable resection rates and a low risk of complications.

Clinical Efficacy of Adjuvant Radiotherapy for World Health Organization Grade II Intracranial Meningioma

BACKGROUND

Maximal surgical resection remains the treatment of choice for grade II meningiomas, and for some authors it is sufficient to guarantee a long indolent course even without postsurgical radiotherapy (RT), but there is no consensus on the use of RT in this patient population.

METHODS

We retrospectively compared clinical and radiologic outcomes between World Health Organization grade I (group A) and grade II (group B) surgically treated meningiomas, focusing on the role of adjuvant RT. We registered clinical, surgical, and radiologic data to detect differences in survival and functional outcome between the 2 groups.

RESULTS

The final cohort consisted of 284 patients for group A and 94 patients for group B. Group B showed a higher risk of developing recurrence independently of the extent of resection (7.75% for Group A vs. 27.7% for Group B, P = 0.01). Patients who did not undergo adjuvant RT documented recurrence in 50% of cases, compared with 19% of patients who underwent RT (P = 0.024). There is a weak difference in the risk of developing postoperative seizures in the group submitted to radiotherapy (P = 0.08). Performance status remained stable for both groups, but for Group B it tended to decrease significantly after 1 year with regard to extent of resection and RT.

CONCLUSIONS

Recurrence is more frequent for grade II meningiomas, even though there are no significant differences in terms of complications and functional outcome. Radiotherapy in grade II meningiomas does indeed lead to better control of recurrence but leads to an increased risk of seizures and reduced performance status.

EGFR-Driven Mutation in Non-Small-Cell Lung Cancer (NSCLC) Influences the Features and Outcome of Brain Metastases

Background: Brain metastases (BMs) is one of the most frequent metastatic sites for non-small-cell lung cancer (NSCLC). It is a matter of debate whether EGFR mutation in the primary tumor may be a marker for the disease course, prognosis, and diagnostic imaging of BMs, comparable to that described for primary brain tumors, such as glioblastoma (GB). This issue was investigated in the present research manuscript. Methods: We performed a retrospective study to identify the relevance of EGFR mutations and prognostic factors for diagnostic imaging, survival, and disease course within a cohort of patients affected by NSCLC-BMs. Imaging was carried out using MRI at various time intervals. The disease course was assessed using a neurological exam carried out at three-month intervals. The survival was expressed from surgical intervention. Results: The patient cohort consisted of 81 patients. The overall survival of the cohort was 15 ± 1.7 months. EGFR mutation and ALK expression did not differ significantly for age, gender, and gross morphology of the BM. Contrariwise, the EGFR mutation was significantly associated with MRI concerning the occurrence of greater tumor (22.38 ± 21.35 cm³ versus 7.68 ± 6.44 cm³, p = 0.046) and edema volume (72.44 ± 60.71 cm³ versus 31.92 cm³, p = 0.028). In turn, the occurrence of MRI abnormalities was related to neurological symptoms assessed using the Karnofsky performance status and mostly depended on tumor-related edema (p = 0.048). However, the highest significant correlation was observed between EGFR mutation and the occurrence of seizures as the clinical onset of the neoplasm (p = 0.004). Conclusions: The presence of EGFR mutations significantly correlates with greater edema and mostly a higher seizure incidence of BMs from NSCLC. In contrast, EGFR mutations do not affect the patient's survival, the disease course, and focal neurological symptoms but seizures. This contrasts with the significance of EGFR in the course and prognosis of the primary tumor (NSCLC).

Peritumoral Brain Edema in Relation to Tumor Size Is a Variable That Influences the Risk of Recurrence in Intracranial Meningiomas

Peritumoral brain edema (PBE) is common in intracranial meningiomas (IM) and can increase their morbidity. It is not uncommon for a neurosurgeon to confront meningiomas with a large proportion of PBE independently from the site and size of the contrast-enhancing lesion with increased surgical risks. We performed a retrospective review of 216 surgically-treated patients suffering from IM. We recorded clinical, biological, and radiological data based on the rate of tumor and edema volume and divided the patients into a group with high Edema/Tumor ratio and a group with a low ratio. We investigated how the ratio of edema/lesion may affect the outcome. Multivariate analysis was performed for the two groups. Smokers were found to be more likely to belong to the high-rate group. The edema/tumor ratio did not affect the surgical radicality; however, independently of the biological sub-type, WHO grading, and EOR, a higher frequency of recurrence is shown in patients with a high edema/tumor ratio (70.5% vs. 8.4%. p < 0.01). There is evidence to suggest that the blood-brain barrier (BBB) damage from smoke could play a role in an increased volume of PBE. The present study demonstrates that IMs showing a high PBE ratio to tumor volume at diagnosis are associated with a smoking habit and a higher incidence of recurrence independently of their biological type and grading.

Giant Prolactinoma Embedded by Pseudoaneurysm of the Cavernous Carotid Artery Treated with a Tailored Therapeutic Scheme

The coexistence of intracranial aneurysm (IA) is generally thought to be highest in patients with pituitary adenomas (PAs). Different mechanisms may play a role in aneurysm formation, but whether the PA contributes to aneurysm formation is still unclear. In the literature, there are numerous reported cases of this association; however, the analyses of the characteristics of PAs, aneurysms, and treatment management are rare and limited to a restricted number of case reports. We report a rare case of an embedded aneurysm in a macroprolactinoma treated with therapeutic management tailored to the clinical, neurological, and radiological characteristics of the patient. To select the best treatment, we reviewed the literature and reported the only cases in which the radiological characteristics of aneurysms, PAs, therapeutic management, and patient outcome are described. We aimed to understand what are the variables that determine the best therapeutic management with the best possible outcome. The presence of a large pseudoaneurysm of the internal carotid artery completely embedded in a giant macroprolactinoma is rare and needs a tailored treatment strategy. The importance of the preoperative knowledge of asymptomatic IA coexisting with PA can avoid accidental rupture of the aneurysm during surgical resection and may lead to planning the best treatment. A high degree of suspicion for an associated aneurysm is needed, and if magnetic resonance imaging shows some atypical features, digital subtraction angiography must be performed prior to contemplating any intervention to avoid iatrogenic aneurysmal rupture. Our multimodal approach with the first-line therapy of low-dose cabergoline to obtain prolactin normalization with minimum risks of aneurysms rupture and subsequent endovascular treatment with flow diverter has not been described elsewhere to our knowledge. In the cases, we suggest adopting a tailored low-dose cabergoline therapy scheme to avoid rupture during cytoreduction and initiate a close neuroradiological follow-up program.