Mechanisms of tumor-related brain edema

Role of Advanced Magnetic Resonance Imaging in Differentiating among Glioma Subtypes and Predicting Tumor-Proliferative Behavior

Objective  Gliomas are a devastating and heterogeneous group of primary brain tumors. Previously, the source of glioma was undetermined. Recent literature indicates that neural stem cells, or progenitors, are proposed to be the source of glioma. The prognosis of different types of gliomas differs due to their various biological tissue types. Besides the histological grade, the two useful immunohistochemistry markers that show the tumor's biological behavior are isocitrate dehydrogenase (IDH) labeling and the K i -67 labeling index. We sought to determine the magnetic resonance imaging (MRI) characteristics associated with IDH mutational status and ascertain whether MRI combined with IDH mutational status, can better predict the clinical outcomes of gliomas. Materials and Methods  This period study was conducted in the Department of Radiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India for 5 years (May 2016-May 2021). The study cohort included 30 patients diagnosed with gliomas who underwent preoperative MRI followed by surgical resection and histopathological examination. Preoperative MRI images were done to assess qualitative tumor characteristics such as location, margin of tumor, extent, cortical involvement, cystic component, mineralization or hemorrhage, and contrast enhancement. Discussion  Differences in MRI features between IDH-mutant (MT) and IDH-wild-type (WT) groups were analyzed using the chi-square test for categorical variables and the Mann-Whitney U test for continuous variables. Statistical analysis was conducted using SPSS software. Results  Among the 30 patients evaluated, 18 had IDH-WT and 12 had IDH-MT type gliomas. Male predominance (73.33%) was noted in our study. Brainstem location, indistinct borders (83.33%), less cortical involvement (72.22%), less cystic changes (88.89%), more area of necrotic component (44.44%), significantly increased choline/creatine (Cho/Cr) ratio, and choline/N-acetyl aspartate (Cho/NAA) ratio favors IDH-WT tumors. Positive T2-fluid-attenuated inversion recovery mismatch sign is more frequently seen in IDH-MT (7/12; 58.33%) tumors than in IDH-WT (4/18; 22.22%) tumors. Whereas well-defined contours (66.67%), more cortical involvement (83.33%), more cystic changes (58.33%), and less area of necrotic component favor IDH-MT type tumors. Conclusion  MRI is a very promising and valuable tool for differentiating among glioma subtypes and predicting tumor-proliferative behavior in glioma cases. The combination of MRI characteristics with IDH mutation status enhances the predictive accuracy for clinical outcomes in glioma patients. This approach could potentially guide treatment planning and improve prognostic assessments.

Quantitative Physiologic MRI Combined with Feature Engineering for Developing Machine Learning-Based Prediction Models to Distinguish Glioblastomas from Single Brain Metastases

Background: The accurate and early distinction of glioblastomas (GBMs) from single brain metastases (BMs) provides a window of opportunity for reframing treatment strategies enabling optimal and timely therapeutic interventions. We sought to leverage physiologically sensitive parameters derived from diffusion tensor imaging (DTI) and dynamic susceptibility contrast (DSC)-perfusion-weighted imaging (PWI) along with machine learning-based methods to distinguish GBMs from single BMs. Methods: Patients with histopathology-confirmed GBMs (n = 62) and BMs (n = 26) and exhibiting contrast-enhancing regions (CERs) underwent 3T anatomical imaging, DTI and DSC-PWI prior to treatment. Median values of mean diffusivity (MD), fractional anisotropy, linear, planar and spheric anisotropic coefficients, and relative cerebral blood volume (rCBV) and maximum rCBV values were measured from CERs and immediate peritumor regions. Data normalization and scaling were performed. In the next step, most relevant features were extracted (non-interacting features), which were subsequently used to generate a set of new, innovative, high-order features (interacting features) using a feature engineering method. Finally, 10 machine learning classifiers were employed in distinguishing GBMs and BMs. Cross-validation and receiver operating characteristic (ROC) curve analyses were performed to determine the diagnostic performance. Results: A random forest classifier with ANOVA F-value feature selection algorithm using both interacting and non-interacting features provided the best diagnostic performance in distinguishing GBMs from BMs with an area under the ROC curve of 92.67%, a classification accuracy of 87.8%, a sensitivity of 73.64% and a specificity of 97.5%. Conclusions: A machine learning based approach involving the combined use of interacting and non-interacting physiological MRI parameters shows promise to differentiate between GBMs and BMs with high accuracy.

Magnetic resonance imaging (MRI)-based intratumoral and peritumoral radiomics for prognosis prediction in glioma patients

AIM

The purpose of this study was to identify robust radiological features from intratumoral and peritumoral regions, evaluate MRI protocols, and machine learning methods for overall survival stratification of glioma patients, and explore the relationship between radiological features and the tumour microenvironment.

MATERIAL AND METHODS

A retrospective analysis was conducted on 163 glioma patients, divided into a training set (n=113) and a testing set (n=50). For each patient, 2135 features were extracted from clinical MRI. Feature selection was performed using the Minimum Redundancy Maximum Relevance method and the Random Forest (RF) algorithm. Prognostic factors were assessed using the Cox proportional hazards model. Four machine learning models (RF, Logistic Regression, Support Vector Machine, and XGBoost) were trained on clinical and radiological features from tumour and peritumoral regions. Model evaluations on the testing set used receiver operating characteristic curves.

RESULTS

Among the 163 patients, 96 had an overall survival (OS) of less than three years postsurgery, while 67 had an OS of more than three years. Univariate Cox regression in the validation set indicated that age (p=0.003) and tumour grade (p<0.001) were positively associated with the risk of death within three years postsurgery. The final predictive model incorporated 13 radiological and 7 clinical features. The RF model, combining intratumor and peritumor radiomics, achieved the best predictive performance (AUC = 0.91; ACC = 0.86), outperforming single-region models.

CONCLUSION

Combined intratumoral and peritumoral radiomics can improve survival prediction and have potential as a practical imaging biomarker to guide clinical decision-making.

Amide proton transfer-weighted CEST MRI for radiotherapy target delineation of glioblastoma: a prospective pilot study

BACKGROUND

Extensive glioblastoma infiltration justifies a 15-mm margin around the gross tumor volume (GTV) to define the radiotherapy clinical target volume (CTV). Amide proton transfer (APT)-weighted imaging could enable visualization of tumor infiltration, allowing more accurate GTV delineation. We quantified the impact of integrating APT-weighted imaging into GTV delineation of glioblastoma and compared two APT-weighted quantification methods-magnetization transfer ratio asymmetry (MTRasym) and Lorentzian difference (LD) analysis-for target delineation.

METHODS

Nine glioblastoma patients underwent an extended imaging protocol prior to radiotherapy, yielding APT-weighted MTRasym and LD maps. From both maps, biological tumor volumes were generated (BTVMTRasym and BTVLD) and added to the conventional GTV to generate biological GTVs (GTVbio,MTRasym and GTVbio,LD). Wilcoxon signed-rank tests were performed for comparisons.

RESULTS

The GTVbio,MTRasym and GTVbio,LD were significantly larger than the conventional GTV (p ≤ 0.022), with a median volume increase of 9.3% and 2.1%, respectively. The GTVbio,MTRasym and GTVbio,LD were significantly smaller than the CTV (p = 0.004), with a median volume reduction of 72.1% and 70.9%, respectively. There was no significant volume difference between the BTVMTRasym and BTVLD (p = 0.074). In three patients, BTVMTRasym delineation was affected by elevated signals at the brain periphery due to residual motion artifacts; this elevation was absent on the APT-weighted LD maps.

CONCLUSION

Larger biological GTVs compared to the conventional GTV highlight the potential of APT-weighted imaging for radiotherapy target delineation of glioblastoma. APT-weighted LD mapping may be advantageous for target delineation as it may be more robust against motion artifacts.

RELEVANCE STATEMENT

The introduction of APT-weighted imaging may, ultimately, enhance visualization of tumor infiltration and eliminate the need for the substantial 15-mm safety margin for target delineation of glioblastoma. This could reduce the risk of radiation toxicity while still effectively irradiating the tumor.

TRIAL REGISTRATION

NCT05970757 (ClinicalTrials.gov).

KEY POINTS

Integration of APT-weighted imaging into target delineation for radiotherapy is feasible. The integration of APT-weighted imaging yields larger GTVs in glioblastoma. APT-weighted LD mapping may be more robust against motion artifacts than APT-weighted MTRasym.

Advances in Anti-Cancer Drug Development: Metformin as Anti-Angiogenic Supplemental Treatment for Glioblastoma

According to the WHO 2016 classification, glioblastoma is the most prevalent primary tumor in the adult central nervous system (CNS) and is categorized as grade IV. With an average lifespan of about 15 months from diagnosis, glioblastoma has a poor prognosis and presents a significant treatment challenge. Aberrant angiogenesis, which promotes tumor neovascularization and is a prospective target for molecular target treatment, is one of its unique and aggressive characteristics. Recently, the existence of glioma stem cells (GSCs) within the tumor, which are tolerant to chemotherapy and radiation, has been linked to the highly aggressive form of glioblastoma. Anti-angiogenic medications have not significantly improved overall survival (OS), despite various preclinical investigations and clinical trials demonstrating encouraging results. This suggests the need to discover new treatment options. Glioblastoma is one of the numerous cancers for which metformin, an anti-hyperglycemic medication belonging to the Biguanides family, is used as first-line therapy for type 2 diabetes mellitus (T2DM), and it has shown both in vitro and in vivo anti-tumoral activity. Based on these findings, the medication has been repurposed, which has shown the inhibition of many oncopromoter mechanisms and, as a result, identified the molecular pathways involved. Metformin inhibits cancer cell growth by blocking the LKB1/AMPK/mTOR/S6K1 pathway, leading to selective cell death in GSCs and inhibiting the proliferation of CD133+ cells. It has minimal impact on differentiated glioblastoma cells and normal human stem cells. The systematic retrieval of information was performed on PubMed. A total of 106 articles were found in a search on metformin for glioblastoma. Out of these six articles were Meta-analyses, Randomized Controlled Trials, clinical trials, and Systematic Reviews. The rest were Literature review articles. These articles were from the years 2011 to 2024. Appropriate studies were isolated, and important information from each of them was understood and entered into a database from which the information was used in this article. The clinical trials on metformin use in the treatment of glioblastoma were searched on clinicaltrials.gov. In this article, we examine and evaluate metformin's possible anti-tumoral effects on glioblastoma, determining whether or not it may appropriately function as an anti-angiogenic substance and be safely added to the treatment and management of glioblastoma patients.

Peritumoral Edema in Gliomas: A Review of Mechanisms and Management

Treating malignant glioma is challenging owing to its highly invasive potential in healthy brain tissue and the formation of intense surrounding edema. Peritumoral edema in gliomas can lead to severe symptoms including neurological dysfunction and brain herniation. For the past 50 years, the standard treatment for peritumoral edema has been steroid therapy. However, the discovery of cerebral lymphatic vessels a decade ago prompted a re-evaluation of the mechanisms involved in brain fluid regulation and the formation of cerebral edema. This review aimed to describe the clinical features of peritumoral edema in gliomas. The mechanisms currently known to cause glioma-related edema are summarized, the limitations in current cerebral edema therapies are discussed, and the prospects for future cerebral edema therapies are presented. Further research concerning edema surrounding gliomas is needed to enhance patient prognosis and improve treatment efficacy.

PACS-Integrated Tools for Peritumoral Edema Volumetrics Provide Additional Information to RANO-BM-Based Assessment of Lung Cancer Brain Metastases after Stereotactic Radiotherapy: A Pilot Study

Stereotactic radiotherapy (SRT) is the standard of care treatment for brain metastases (METS) today. Nevertheless, there is limited understanding of how posttreatment lesional volumetric changes may assist prediction of lesional outcome. This is partly due to the paucity of volumetric segmentation tools. Edema alone can cause significant clinical symptoms and, therefore, needs independent study along with standard measurements of contrast-enhancing tumors. In this study, we aimed to compare volumetric changes of edema to RANO-BM-based measurements of contrast-enhancing lesion size. Patients with NSCLC METS ≥10 mm on post-contrast T1-weighted image and treated with SRT had measurements for up to seven follow-up scans using a PACS-integrated tool segmenting the peritumoral FLAIR hyperintense volume. Two-dimensional contrast-enhancing and volumetric edema changes were compared by creating treatment response curves. Fifty NSCLC METS were included in the study. The initial median peritumoral edema volume post-SRT relative to pre-SRT baseline was 37% (IQR 8-114%). Most of the lesions with edema volume reduction post-SRT experienced no increase in edema during the study. In over 50% of METS, the pattern of edema volume change was different than the pattern of contrast-enhancing lesion change at different timepoints, which was defined as incongruent. Lesions demonstrating incongruence at the first follow-up were more likely to progress subsequently. Therefore, edema assessment of METS post-SRT provides critical additional information to RANO-BM.

Ferroptosis and PPAR-gamma in the limelight of brain tumors and edema

Human malignant brain tumors such as gliomas are devastating due to the induction of cerebral edema and neurodegeneration. A major contributor to glioma-induced neurodegeneration has been identified as glutamate. Glutamate promotes cell growth and proliferation in variety of tumor types. Intriguently, glutamate is also an excitatory neurotransmitter and evokes neuronal cell death at high concentrations. Even though glutamate signaling at the receptor and its downstream effectors has been extensively investigated at the molecular level, there has been little insight into how glutamate enters the tumor microenvironment and impacts on metabolic equilibration until recently. Surprisingly, the 12 transmembrane spanning tranporter xCT (SLC7A11) appeared to be a major player in this process, mediating glutamate secretion and ferroptosis. Also, PPARγ is associated with ferroptosis in neurodegeneration, thereby destroying neurons and causing brain swelling. Although these data are intriguing, tumor-associated edema has so far been quoted as of vasogenic origin. Hence, glutamate and PPARγ biology in the process of glioma-induced brain swelling is conceptually challenging. By inhibiting xCT transporter or AMPA receptors in vivo, brain swelling and peritumoral alterations can be mitigated. This review sheds light on the role of glutamate in brain tumors presenting the conceptual challenge that xCT disruption causes ferroptosis activation in malignant brain tumors. Thus, interfering with glutamate takes center stage in forming the basis of a metabolic equilibration approach.

Magnetic Resonance Imaging Features of Zinc Finger Translocation Associated-RELA Fusion Ependymoma Compared to Its Wild-Type Counterpart

OBJECTIVE

To explore the predictive value of quantitative features extracted from conventional magnetic resonance imaging (MRI) in distinguishing Zinc Finger Translocation Associated (ZFTA)-RELA fusion-positive and wild-type ependymomas.

METHODS

Twenty-seven patients with pathologically confirmed ependymomas (17 patients with ZFTA-RELA fusions and 10 ZFTA-RELA fusion-negative patients) who underwent conventional MRI were enrolled in this retrospective study. Two experienced neuroradiologists who were blinded to the histopathological subtypes independently extracted imaging features using Visually Accessible Rembrandt Images annotations. The consistency between the readers was evaluated with the Kappa test. The imaging features with significant differences between the 2 groups were obtained using the least absolute shrinkage and selection operator regression model. Logistic regression analysis and receiver operating characteristic analysis were performed to analyze the diagnostic performance of the imaging features in predicting the ZFTA-RELA fusion status in ependymoma.

RESULTS

There was a good interevaluator agreement on the imaging features (kappa value range 0.601-1.000). Enhancement quality, thickness of the enhancing margin, and edema crossing the midline have high predictive performance in identifying ZFTA-RELA fusion-positive and ZFTA-RELA fusion-negative ependymomas (C-index = 0.862 and area under the curve= 0.8618).

CONCLUSIONS

Quantitative features extracted from preoperative conventional MRI by Visually Accessible Rembrandt Images provide high discriminatory accuracy in predicting the ZFTA-RELA fusion status of ependymoma.

The Brain's Glymphatic System: Drawing New Perspectives in Neuroscience

This paper delves into the intricate structure and functionality of the brain's glymphatic system, bringing forth new dimensions in its neuroscientific understanding. This paper commences by exploring the cerebrospinal fluid (CSF)-its localization, production, and pivotal role within the central nervous system, acting as a cushion and vehicle for nutrient distribution and waste elimination. We then transition into an in-depth study of the morphophysiological aspects of the glymphatic system, a recent discovery revolutionizing the perception of waste clearance from the brain, highlighting its lymphatic-like characteristics and remarkable operations. This paper subsequently emphasizes the glymphatic system's potential implications in Alzheimer's disease (AD), discussing the connection between inefficient glymphatic clearance and AD pathogenesis. This review also elucidates the intriguing interplay between the glymphatic system and the circadian rhythm, illustrating the optimal functioning of glymphatic clearance during sleep. Lastly, we underscore the hitherto underappreciated involvement of the glymphatic system in the tumoral microenvironment, potentially impacting tumor growth and progression. This comprehensive paper accentuates the glymphatic system's pivotal role in multiple domains, fostering an understanding of the brain's waste clearance mechanisms and offering avenues for further research into neuropathological conditions.

Do animal models of brain tumors replicate human peritumoral edema? a systematic literature search

INTRODUCTION

Brain tumors cause morbidity and mortality in part through peritumoral brain edema. The current main treatment for peritumoral brain edema are corticosteroids. Due to the increased recognition of their side-effect profile, there is growing interest in finding alternatives to steroids but there is little formal study of animal models of peritumoral brain edema. This study aims to summarize the available literature.

METHODS

A systematic search was undertaken of 5 literature databases (Medline, Embase, CINAHL, PubMed and the Cochrane Library). The generic strategy was to search for various terms associated with "brain tumors", "brain edema" and "animal models".

RESULTS

We identified 603 reports, of which 112 were identified as relevant for full text analysis that studied 114 peritumoral brain edema animal models. We found significant heterogeneity in the species and strain of tumor-bearing animals, tumor implantation method and edema assessment. Most models did not produce appreciable brain edema and did not test for observable manifestations thereof.

CONCLUSION

No animal model currently exists that enable the investigation of novel candidates for the treatment of peritumoral brain edema. With current interest in alternative treatments for peritumoral brain edema, there is an unmet need for clinically relevant animal models.

Biomedical applications of terahertz spectra in clinical and molecular pathology of human glioma

Gliomas are the most common type of primary tumor originating in the central nervous system of adults. Tumor histological type, pathological grade, and molecular pathology are significant prognosis and predictive factors. In this study, we were aiming to predict histological type and molecular pathological features based on terahertz time-domain spectroscopy technology. Nine gliomas with different grades, one meningioma, and one lymphoma were enrolled. There were significant differences in terahertz absorption coefficient between normal brain tissue, tumoral-periphery, and tumoral-center tissue in specific frequency bands (0.2-1.4 THz). Histological type, pathological grade, and glioma-specific biomarkers were closely related to the terahertz absorption coefficient in both tumoral-periphery and tumoral-center tissues. Interestingly, tumoral-periphery showed more obvious differences than tumoral-center tissues in almost all aspects. All the results show that the terahertz technology has potential application value in the intraoperative real-time glioma recognition and diagnosis of glioma histological and molecular pathological features.

[Perifocal edema and glymphatic system dysfunction: quantitative assessment based on diffusion tensor magnetic resonance imaging]

BACKGROUND

Pathogenesis of peritumoral cerebral edema is unclear and potentially associated with glymphatic system dysfunction. Diffusion tensor MRI (DT-MRI) with analysis of ALPS (Analysis along the Perivascular Space) index may be valuable for assessment of edema. This approach visualizes fluid flow along perivascular spaces of deep cerebral veins.

OBJECTIVE

To assess glymphatic system function in supratentorial tumors and healthy volunteers using DT-MRI.

MATERIAL AND METHODS

There were 52 patients (59% men) aged 43 (28-64) years with supratentorial tumors (meningioma - 20, grade 3-4 glioma - 15, metastases - 9, lymphoma - 8). Tumors and perifocal edema did not involve deep cerebral veins. The control group included 6 healthy volunteers aged 34-66 years. MRI protocol (Signa HDxt, 3 T) contained standard T1, T2, T2FLAIR, DWI and post-contrast T1 (3D BRAVO). DT-MRI had the following parameters: TR=10 000 ms, TEmin=102 ms, FOV=240 mm, isotropic voxel size 3×3×3 mm3, 60 directions of diffusion gradients. Measurements were carried out at b-factor 0 and 1000 s/mm2. Analysis was carried out in the ReadyView software.

RESULTS

Right- and left-sided ALPS indices were similar in the control group (p=0.917). Perifocal edema (regardless of histological type of tumor) in the ipsilateral hemisphere was accompanied by significantly lower ALPS index (p<0.005), while these values in contralateral (intact) hemisphere were similar in both groups (p=0.7).

CONCLUSION

We found significantly lower ALPS index in deep parts of the affected hemisphere in patients with perifocal edema. These data can indicate the role of glymphatic system dysfunction in pathogenesis of this pathology.

Posterior Fossa Calcifying Pseudoneoplasm of the Neuraxis (CAPNON): Presentation of Three Surgical Cases

BACKGROUND

Calcifying pseudoneoplasm of the neuraxis (CAPNON) is an extremely rare entity with fewer than 150 cases reported in the literature and mostly with a supratentorial or spinal location. Posterior fossa CAPNON has been reported scarcely, and association with perilesional edema is a topic not yet approached which might play a significant role in treatment decision and clinical progression. Our objective is to report, to our knowledge, the first series of 3 posterior fossa CAPNON surgically treated in a single institution and assess features that help provide a systematic approach to diagnosis and timely treatment.

METHODS

This was a monocentric, retrospective study of surgical patients diagnosed with a posterior fossa CAPNON in the last 5 years. A thorough bibliographic research was conducted.

RESULTS

Three patients were included. Locations involved IV ventricle, right cerebellopontine angle with extension to foramen magnum, and cerebellar vermis. Two of them presented with symptoms linked to acute hydrocephalus, and the other one presented with progressive cranial nerve palsy and brainstem compression signs. The 3 of them showed radiological signs of perilesional edema on their preoperative magnetic resonance imaging. Gross total resection was accomplished in one case, with near and subtotal resections in the others. There were no complications. The outcome was favorable in all cases.

CONCLUSIONS

It is essential to contemplate this infrequent diagnosis in cases of calcified lesions involving the posterior fossa. When symptoms manifest, surgery should be considered. Perilesional edema could be associated with symptomatic progression and hence a sign suggesting the need for surgical treatment.

Reconstruction of ovine axonal cytoarchitecture enables more accurate models of brain biomechanics

There is an increased need and focus to understand how local brain microstructure affects the transport of drug molecules directly administered to the brain tissue, for example in convection-enhanced delivery procedures. This study reports a systematic attempt to characterize the cytoarchitecture of commissural, long association and projection fibres, namely the corpus callosum, the fornix and the corona radiata, with the specific aim to map different regions of the tissue and provide essential information for the development of accurate models of brain biomechanics. Ovine samples are imaged using scanning electron microscopy combined with focused ion beam milling to generate 3D volume reconstructions of the tissue at subcellular spatial resolution. Focus is placed on the characteristic cytological feature of the white matter: the axons and their alignment in the tissue. For each tract, a 3D reconstruction of relatively large volumes, including a significant number of axons, is performed and outer axonal ellipticity, outer axonal cross-sectional area and their relative perimeter are measured. The study of well-resolved microstructural features provides useful insight into the fibrous organization of the tissue, whose micromechanical behaviour is that of a composite material presenting elliptical tortuous tubular axonal structures embedded in the extra-cellular matrix. Drug flow can be captured through microstructurally-based models using 3D volumes, either reconstructed directly from images or generated in silico using parameters extracted from the database of images, leading to a workflow to enable physically-accurate simulations of drug delivery to the targeted tissue.

Imaging and reconstruction of sheep brain axonal cytoarchitecture provides insight for brain biomechanics models that simulate drug delivery and other biological processes governed by interstitial fluid flow and transport.

Anatomical distribution of cancer stem cells between enhancing nodule and FLAIR hyperintensity in supratentorial glioblastoma: time to recalibrate the surgical target?

It is ge nerally accepted that glioblastoma (GBM) arise from cancer stem cells (CSC); however, there is little evidence on their anatomical distribution. We investigated the expression and distribution of SOX-2-positive and CD133-positive CSCs both in the enhancing nodule (EN) of GBM and in the FLAIR hyperintensity zones on a surgical, histopathological series of 33 GBMs. The inclusion criterion was the intraoperative sampling of different tumor regions individualized, thanks to neuronavigation and positivity to intraoperative fluorescence with the use of 5-aminolevulinic acid (5-ALA). Thirty-three patients (20 males and 13 females with a mean age at diagnosis of 56 years) met the inclusion criterion. A total of 109 histological samples were evaluated, 52 for ENs and 57 for FLAIR hyperintensity zone. Considering the quantitative distribution of levels of intensity of staining (IS), ES (extent score), and immunoreactivity score (IRS), no difference was found between ENs and FLAIR regions for both the SOX-2 biomarker (respectively, IS p = 0.851, ES p = 0.561, IRS p = 1.000) and the CD133 biomarker (IS p = 0.653, ES p = 0.409, IRS p = 0.881). This evidence suggests to recalibrate the target of surgery for FLAIRECTOMY and 5-ALA could improve the possibility to achieve this goal.

Prognostic and Predictive Markers of Limited (1-4) Brain Metastases in Patients with Lung Adenocarcinoma After Stereotactic Radiosurgery: A Retrospective Analysis

BACKGROUND

Owing to the complexities of brain metastases (BMs), accurate and reliable prognostic and predictive factors remain critical roadblocks in patients with lung adenocarcinoma (LUAD) BMs who undergo stereotactic radiosurgery (SRS).

METHODS

In total, 132 patients with LUAD BMs who underwent SRS were retrospectively analyzed; Cox proportional hazards analysis of imaging and clinical characteristics was used to identify independent predictors related to overall survival (OS) and progression-free survival (PFS).

RESULTS

Our data indicated that initial brain metastasis velocity (iBMV), Karnofsky performance score (KPS), and Rvol (the sum of peritumoral edema volume/cumulative intracranial tumor volume) could potentially be independent prognostic factors for OS. iBMV ≥2 (P = 0.000), KPS <80 (P = 0.042), and Rvol ≥5.7 (P = 0.017) were strongly associated with unsatisfactory OS. The KPS and BM contrast enhancement were also identified as independent prognostic factors for PFS. A higher KPS (P = 0.004) and homogeneous BM contrast enhancement (P = 0.026) were strongly associated with longer PFS.

CONCLUSIONS

Collectively, iBMV and Rvol are highly related to OS and could be used as potential prognostic indices in patients with LUAD BMs who underwent SRS. Furthermore, we also revealed that the KPS and BM contrast enhancement could be potential indices of PFS in LUAD BMs.

Molecular Mechanisms and Clinical Challenges of Glioma Invasion

Glioma is the most common primary brain tumor, and its prognosis is poor. Glioma cells are highly invasive to the brain parenchyma. It is difficult to achieve complete resection due to the nature of the brain tissue, and tumors that invade the parenchyma often recur. The invasiveness of tumor cells has been studied from various aspects, and the related molecular mechanisms are gradually becoming clear. Cell adhesion factors and extracellular matrix factors have a strong influence on glioma invasion. The molecular mechanisms that enhance the invasiveness of glioma stem cells, which have been investigated in recent years, have also been clarified. In addition, it has been discussed from both basic and clinical perspectives that current therapies can alter the invasiveness of tumors, and there is a need to develop therapeutic approaches to glioma invasion in the future. In this review, we will summarize the factors that influence the invasiveness of glioma based on the environment of tumor cells and tissues, and describe the impact of the treatment of glioma on invasion in terms of molecular biology, and the novel therapies for invasion that are currently being developed.

Peritumoral Brain Edema in Metastases May Be Related to Glymphatic Dysfunction

Objectives

The proliferation of microvessels with increased permeability is thought to be the cause of peritumoral brain edema (PTBE) in metastases. The contribution of the glymphatic system to the formation of PTBE in brain metastases remains unexplored. We aimed to investigate if the PTBE volume of brain metastases is related to glymphatic dysfunction.

Materials and Methods

A total of 56 patients with brain metastases who had preoperative dynamic susceptibility contrast-enhanced perfusion-weighted imaging for calculation of tumor cerebral blood volume (CBV) and diffusion tensor imaging for calculations of tumor apparent diffusion coefficient (ADC), tumor fractional anisotropy (FA), and analysis along perivascular space (ALPS) index were analyzed. The volumes of PTBE, whole tumor, enhancing tumor, and necrotic and hemorrhagic portions were manually measured. Additional information collected for each patient included age, sex, primary cancer, metastasis location and number, and the presence of concurrent infratentorial tumors. Linear regression analyses were performed to identify factors associated with PTBE volume.

Results

Among 56 patients, 45 had solitary metastasis, 24 had right cerebral metastasis, 21 had left cerebral metastasis, 11 had bilateral cerebral metastases, and 11 had concurrent infratentorial metastases. On univariable linear regression analysis, PTBE volume correlated with whole tumor volume (β = -0.348, P = 0.009), hemorrhagic portion volume (β = -0.327, P = 0.014), tumor ADC (β = 0.530, P <.001), and ALPS index (β = -0.750, P <.001). The associations of PTBE volume with age, sex, tumor location, number of tumors, concurrent infratentorial tumor, enhancing tumor volume, necrotic portion volume, tumor FA, and tumor CBV were not significant. On multivariable linear regression analysis, tumor ADC (β = 0.303; P = 0.004) and ALPS index (β = -0.624; P < 0.001) were the two independent factors associated with PTBE volume.

Conclusion

Metastases with higher tumor ADC and lower ALPS index were associated with larger peritumoral brain edema volumes. The higher tumor ADC may be related to increased periarterial water influx into the tumor interstitium, while the lower ALPS index may indicate insufficient fluid clearance. The changes in both tumor ADC and ALPS index may imply glymphatic dysfunction, which is, at least, partially responsible for peritumoral brain edema formation.

Factors Associated With Dysfunction of Glymphatic System in Patients With Glioma

Objectives

Rodent experiments have provided some insights into the changes of glymphatic function associated with glioma growth. The diffusion tensor image analysis along the perivascular space (DTI-ALPS) method offers an opportunity for the noninvasive investigation of the glymphatic system in patients with glioma. We aimed to investigate the factors associated with glymphatic function changes in patients with glioma.

Materials and Methods

A total of 201 glioma patients (mean age = 47.4 years, 116 men; 86 grade II, 52 grade III, and 63 grade IV) who had preoperative diffusion tensor imaging for calculation of the ALPS index were retrospectively included. Information collected from each patient included sex, age, tumor grade, isocitrate dehydrogenase 1 (IDH1) mutation status, peritumoral brain edema volume, tumor volume, and ALPS index. Group differences in the ALPS index according to sex, tumor grade, and IDH1 mutation status were assessed using analysis of covariance with age adjustment. Linear regression analyses were performed to identify the factors associated with the ALPS index.

Results

Group comparisons revealed that the ALPS index of grade II/III gliomas was significantly higher than that of grade IV gliomas (p < 0.001). The ALPS index of IDH1 mutant gliomas was significantly higher than that of IDH1 wild-type gliomas (p < 0.001). On multivariable linear regression analysis, IDH1 mutation (β = 0.308, p < 0.001) and peritumoral brain edema volume (β = −0.353, p < 0.001) were the two independent factors associated with the ALPS index.

Conclusion

IDH1 wild-type gliomas and gliomas with larger peritumoral brain edema volumes were associated with a lower ALPS index, which may reflect impaired glymphatic function.

Expression of Vascular Endothelial Growth Factor A and Its Type 1 Receptor in Supratentorial Neoplasm

BACKGROUND

Vascular endothelial growth factor (VEGF) is one of the primary angiogenesis regulators in solid cancers. Brain solid tumors are life-threatening diseases in which angiogenesis is an important phase of tumor development and progression. In the present study, VEGF-A and VEGF receptor (VEGF-R1) gene expression was evaluated in CNS brain tumors.

METHODS

VEGF-A and VEGF-R1 expression was quantified using real-time PCR on fresh biopsies of 38 supratentorial brain tumors compared to 30 non-tumoral tissues. Then, the correlations were investigated with clinic-pathological and demographic factors of the patients.

RESULTS

PCR product sequencing confirmed the validity of qRT-PCR. Although VEGF-A and VEGF-R1 expression showed increasing trends with the progression of cell proliferation in different stages of astrocytoma, VEGF-R1 did not meet the 95% confidence interval in other brain tumors. An increasing trend in VEGF-A expression and a declining trend in VEGF-R1 expression from Stage I to II were observed in meningioma. VEGF-A and VEGF-R1 expression had no significant correlation with age and gender. Although peritumoral brain edema (PTBE) in astrocytoma was significantly associated with tumor stages, VEGF-A and VEGF-R1 were not correlated with PTBE in meningioma and metastasis.

CONCLUSION

VEGF-A is a valuable factor for the prognosis of PTBE and malignancy in astrocytoma and is helpful in monitoring treatment approaches.

Recurrent tumor and treatment-induced effects have different MR signatures in contrast enhancing and non-enhancing lesions of high-grade gliomas

BACKGROUND

Differentiating treatment-induced injury from recurrent high-grade glioma is an ongoing challenge in neuro-oncology, in part due to lesion heterogeneity. This study aimed to determine whether different MR features were relevant for distinguishing recurrent tumor from the effects of treatment in contrast-enhancing lesions (CEL) and non-enhancing lesions (NEL).

METHODS

This prospective study analyzed 291 tissue samples (222 recurrent tumor, 69 treatment-effect) with known coordinates on imaging from 139 patients who underwent preoperative 3T MRI and surgery for a suspected recurrence. 8 MR parameter values were tested from perfusion-weighted, diffusion-weighted, and MR spectroscopic imaging at each tissue sample location for association with histopathological outcome using generalized estimating equation models for CEL and NEL tissue samples. Individual cutoff values were evaluated using receiver operating characteristic curve analysis with 5-fold cross-validation.

RESULTS

In tissue samples obtained from CEL, elevated relative cerebral blood volume (rCBV) was associated with the presence of recurrent tumor pathology (P < 0.03), while increases in normalized choline (nCho) and choline-to-NAA index (CNI) were associated with the presence of recurrent tumor pathology in NEL tissue samples (P < 0.008). A mean CNI cutoff value of 2.7 had the highest performance, resulting in mean sensitivity and specificity of 0.61 and 0.81 for distinguishing treatment-effect from recurrent tumor within the NEL.

CONCLUSION

Although our results support prior work that underscores the utility of rCBV in distinguishing the effects of treatment from recurrent tumor within the contrast enhancing lesion, we found that metabolic parameters may be better at differentiating recurrent tumor from treatment-related changes in the NEL of high-grade gliomas.

Peritumoral Brain Edema in Meningiomas May Be Related to Glymphatic Dysfunction

The pathogenesis of peritumoral brain edema (PTBE) in meningiomas remains unclear. The glymphatic system is recently recognized as a pathway for waste clearance and maintaining fluid balance in the brain parenchymal interstitium. We aimed to investigate if the PTBE volume of meningiomas correlates with their glymphatic function. A total of 80 meningioma patients (mean age, 58.8 years; 37 men) and 44 normal subjects (mean age 53.3 years; 23 men) who had preoperative diffusion-tensor imaging for calculation of the analysis along the perivascular space (ALPS) index were retrospectively included. Information collected from each patient included sex, age, tumor grade, Ki-67 index, tumor location, tumor volume, PTBE volume and ALPS index. Comparisons of ALPS index among meningiomas without PTBE, meningiomas with PTBE, and normal subjects were performed using analysis of covariance with Bonferroni correction and adjustments for age and sex. Pearson correlation coefficient and multivariable linear regression analyses were performed to identify factors associated with PTBE volume. Group comparisons revealed that the ALPS index was significantly higher (P < 0.05) in meningiomas without PTBE vs. meningiomas with PTBE and normal subjects. On the other hand, ALPS index was not different between meningiomas with PTBE and normal subjects. On Pearson correlation and multivariable linear regression analyses, the ALPS index was the only factor significantly (P < 0.05) associated with PTBE volume. In conclusion, PTBE volume inversely correlated with ALPS index in meningiomas. PTBE formation in meningiomas may be related to glymphatic dysfunction.

Association of Isocitrate Dehydrogenase (IDH) Status With Edema to Tumor Ratio and Its Correlation With Immune Infiltration in Glioblastoma

Purpose

The extent of preoperative peritumoral edema in glioblastoma (GBM) has been negatively correlated with patient outcome. As several ongoing studies are investigating T-cell based immunotherapy in GBM, we conducted this study to assess whether peritumoral edema with potentially increased intracranial pressure, disrupted tissue homeostasis and reduced local blood flow has influence on immune infiltration and affects survival.

Methods

A volumetric analysis of preoperative imaging (gadolinium enhanced T1 weighted MRI sequences for tumor size and T2 weighted sequences for extent of edema (including the infiltrative zone, gliosis etc.) was conducted in 144 patients using the Brainlab® software. Immunohistochemical staining was analyzed for lymphocytic- (CD 3+) and myelocytic (CD15+) tumor infiltration. A retrospective analysis of patient-, surgical-, and molecular characteristics was performed using medical records.

Results

The edema to tumor ratio was neither associated with progression-free nor overall survival (p=0.90, p=0.74). However, GBM patients displaying IDH-1 wildtype had significantly higher edema to tumor ratio than patients displaying an IDH-1 mutation (p=0.01). Immunohistopathological analysis did not show significant differences in lymphocytic or myelocytic tumor infiltration (p=0.78, p=0.74) between these groups.

Conclusion

In our cohort, edema to tumor ratio had no significant correlation with immune infiltration and outcome. However, patients with an IDH-1wildtype GBM had a significantly higher edema to tumor ratio compared to their IDH-1 mutated peer group. Further studies are necessary to elucidate the underlying mechanisms.

Reuse of Molecules for Glioblastoma Therapy

Glioblastoma multiforme (GBM) is a highly malignant primary brain tumor. The current standard of care for GBM is the Stupp protocol which includes surgical resection, followed by radiotherapy concomitant with the DNA alkylator temozolomide; however, survival under this treatment regimen is an abysmal 12-18 months. New and emerging treatments include the application of a physical device, non-invasive 'tumor treating fields' (TTFs), including its concomitant use with standard of care; and varied vaccines and immunotherapeutics being trialed. Some of these approaches have extended life by a few months over standard of care, but in some cases are only available for a minority of GBM patients. Extensive activity is also underway to repurpose and reposition therapeutics for GBM, either alone or in combination with the standard of care. In this review, we present select molecules that target different pathways and are at various stages of clinical translation as case studies to illustrate the rationale for their repurposing-repositioning and potential clinical use.

Gold nanoparticles carrying or not anti-VEGF antibody do not change glioblastoma multiforme tumor progression in mice

Aims

Glioblastoma multiforme (GBM) is the most devastating malignant primary brain tumor known. Life expectance is around 15 months after diagnosis. Several events contribute to the GBM progression such as uncontrolled genetic cancer cells proliferation, angiogenesis (mostly vascular endothelial growth factor (VEGF)-mediated), tissue invasion, glioma stem cell activity, immune system failure, and a hypoxic and inflammatory tumor microenvironment. Tumor cells antiproliferative effect of 20 nm citrate-covered gold nanoparticles (cit-AuNP) has been reported, along with anti-inflammatory and anti-oxidative effects. We aimed to test whether either chronic treatment with 20 nm cit-AuNP or anti-VEGF antibody (Ig)-covered AuNP could reduce GBM progression in mice.

Main methods

Effect of the gold nanoparticles on the GL261 glioblastoma cells proliferation in vitro, and on the GL261-induced glioblastoma cell growth in C57BL/6 mice in vivo were tested. Besides, fluorophore-conjugated gold nanoparticles penetration through the GL261 plasma cell membrane, gold labelling in brain parenchyma of glioblastoma-carrying mice, and VEGF expression into the tumor were evaluated.

Key findings

We observed cit-AuNP did no change the GL261 cells proliferation. Similarly, we demonstrated chronic treatment with either cit-AuNP or anti-VEGF Ig-covered AuNP did not modify the GL261 cells-induced GBM progression in mice. By the end, we showed AuNPs did not trespass in appreciable amount both the GL261 plasma cell membrane and the tumoral blood brain barrier (BBB), and did not change the VEGF expression into the tumor.

Significance

20 nm cit-AuNP or anti-VEGF Ig covered-AuNP are not good tools to reduce GBM in mice, probably because they do not penetrate both tumor cells and BBB in enough amount to reduce tumor growing.

Pathophysiology of Cerebral Edema—A Comprehensive Review

Cerebral edema is a condition where an excess of cerebral water accumulates due to primary neurological or non-neurological causes. Cerebral edema complicates many brain pathologies causing additional injury often in excess of the original neurological insult. Classic descriptions divide cerebral edema into cytotoxic, vasogenic, interstitial, and osmotic subtypes. The interplay of different mechanisms is important in the clinical manifestations. Recent research has advanced our understanding of the molecular pathophysiology of cerebral edema, exposing the central role of aquaporins and specific ion channels. The aim of this review is to provide a comprehensive overview of the molecular pathophysiology of cerebral edema including unique disease specific mechanisms.

Impact of Peritumoral Edema During Tumor Treatment Field Therapy: A Computational Modelling Study

BACKGROUND

Tumor treatment fields (TTFie-lds) are an approved adjuvant therapy for glioblastoma (GBM). The magnitude of applied electrical field has been shown to be related to the anti-tumoral response. However, peritumoral edema may result in shunting of electrical current around the tumor, thereby reducing the intra-tumoral electric field. In this study, we systematically address this issue with computational simulations.

METHODS

Finite element models are created of a human head with varying amounts of peritumoral edema surrounding a virtual tumor. The electric field distribution was simulated using the standard TTFields electrode montage. Electric field magnitude was extracted from the tumor and related to edema thickness. Two patient specific models were created to confirm these results.

RESULTS

The inclusion of peritumoral edema decreased the average magnitude of the electric field within the tumor. In the model considering a frontal tumor and an anterior-posterior electrode configuration, ≥6 mm of peritumoral edema decreased the electric field by 52%. In the patient specific models, peritumoral edema decreased the electric field magnitude within the tumor by an average of 26%. The effect of peritumoral edema on the electric field distribution was spatially heterogenous, being most significant at the tissue interface between edema and tumor.

CONCLUSIONS

The inclusion of peritumoral edema during TTFields modelling may have a dramatic effect on the predicted electric field magnitude within the tumor. Given the importance of electric field magnitude for the anti-tumoral effects of TTFields, the presence of edema should be considered both in future modelling studies and when planning TTField therapy.

Effect of Methylprednisolone on Experimental Brain Edema in Magnetic Resonance Imaging

Magnetic resonance imaging has been used for evaluating of a brain edema in experimental animals to assess cytotoxic and vasogenic edema by the apparent diffusion coefficient (ADC) and T2 imaging. This paper brings information about the effectiveness of methylprednisolone (MP) on experimental brain edema. A total of 24 rats were divided into three groups of 8 animals each. Rats with cytotoxic/intracellular brain edema induced by water intoxication were assigned to the group WI. These rats also served as the additional control group CG when measured before the induction of edema. A third group (WIMP) was intraperitoneally administered with methylprednisolone 100 mg/kg during water intoxication treatment. The group WI+MP was injected with methylprednisolone 50 mg/kg into the carotid artery within two hours after the water intoxication treatment. We evaluated the results in four groups. Two control groups (CG, WI) and two experimental groups (WIMP, WI+MP). Rats were subjected to MR scanning 24 h after edema induction. We observed significantly increased ADC values in group WI in both evaluated areas – cortex and hippocampus, which proved the occurrence of experimental vasogenic edema, while ADC values in groups WIMP and WI+MP were not increased, indicating that the experimental edema was not developed and thus confirming the protective effect of MP.

[Modern standards for magnetic resonance imaging of the brain tumors]

Neuroimaging is essential in survey of patients with brain tumors. An important objectives of neuroimaging are highly reliable non-invasive diagnosis, treatment planning and evaluation of treatment outcomes. Magnetic resonance imaging (MRI) is one of the modern neuroimaging methods. This technique ensures analysis of structural cerebral changes, vascular and metabolic characteristics of brain tumors. It is necessary to standardize imaging parameters and unify protocols and methods considering a widespread use of MRI for brain tumors. In our practice, we use our own experience, world literature data and evidence-based international guidelines on the diagnosis of various brain diseases. The purpose of this review is to study the modern principles of magnetic resonance imaging in adults with brain tumors in neurosurgical practice.

Transcriptomic Hallmarks of Tumor Plasticity and Stromal Interactions in Brain Metastasis

The brain is a major site of relapse for several cancers, yet deciphering the mechanisms of brain metastasis remains a challenge because of the complexity of the brain tumor microenvironment (TME). To define the molecular landscape of brain metastasis from intact tissue in vivo, we employ an RNA-sequencing-based approach, which leverages the transcriptome of xenografts and distinguishes tumor cell and stromal gene expression with improved sensitivity and accuracy. Our data reveal shifts in epithelial and neuronal-like lineage programs in malignant cells as they adapt to the brain TME and the reciprocal neuroinflammatory response of the stroma. We identify several transcriptional hallmarks of metastasis that are specific to particular regions of the brain, induced across multiple tumor types, and confirmed in syngeneic models and patient biopsies. These data may serve as a resource for exploring mechanisms of TME co-adaptation within, as well as across, different subtypes of brain metastasis.

Prediction of IDH Status Through MRI Features and Enlightened Reflection on the Delineation of Target Volume in Low-Grade Gliomas

Isocitrate dehydrogenase mutational status defines distinct biologic behavior and clinical outcomes in low-grade gliomas. We sought to determine magnetic resonance imaging characteristics associated with isocitrate dehydrogenase mutational status to evaluate the predictive roles of magnetic resonance imaging features in isocitrate dehydrogenase mutational status and therefore their potential impact on the determination of clinical target volume in radiotherapy. Forty-eight isocitrate dehydrogenase-mutant and 28 isocitrate dehydrogenase–wild-type low-grade gliomas were studied. Isocitrate dehydrogenase mutation was related to more frequency of cortical involvement compared to isocitrate dehydrogenase–wild-type group (34/46 vs 6/24, P = .0001). Peritumoral edema was less frequent in isocitrate dehydrogenase–mutant tumors (32.6% vs 58.3% for isocitrate dehydrogenase–wild-type tumors, P = .0381). Isocitrate dehydrogenase–wild-type tumors were more likely to have a nondefinable border, while isocitrate dehydrogenase–mutant tumors had well-defined borders (66.7% vs 39.1%, P = .0287). Only 8 (17.4%) of 46 of the isocitrate dehydrogenase–mutant tumors demonstrated marked enhancement, while this was 66.7% in isocitrate–wild-type tumors (P < .0001). Choline–creatinine ratio for isocitrate dehydrogenase–wild-type tumors was significantly higher than that for isocitrate dehydrogenase–mutant tumors. In conclusion, frontal location, well-defined border, cortical involvement, less peritumoral edema, lack of enhancement, and low choline–creatinine ratio were predictive for the definition of isocitrate dehydrogenase–mutant low-grade gliomas. Magnetic resonance imaging can provide an advantage in the detection of isocitrate dehydrogenase status indirectly and indicate the need to explore new design for treatment planning in gliomas. Choline–creatinine ratio in magnetic resonance spectroscopy could be a potential more reasonable reference for the new design of delineation of target volume in low-grade gliomas.

Provider views on perioperative steroid use for patients with newly diagnosed pediatric brain tumors

PURPOSE

Cerebral edema from brain tumors can cause neurological impairment. Steroids treat edema but with possible adverse effects. We surveyed providers regarding steroid use in newly diagnosed patients with brain tumors to determine if practices are standard or markedly variable.

METHODS

An anonymous voluntary online survey was sent to members of neuro-oncology consortiums. Four clinical scenarios were provided and questions regarding initiation of steroids, type, dose, formulation, and duration were asked. Demographic information was collected.

RESULTS

369 providers received the survey, 76 responded (20.6% response rate). The proportion of providers who would start steroids significantly differed among scenarios (scenario 1 vs 2, p < 0.001; 2 vs 3, p < 0.001; 1 vs 3, p < 0.001). 75 (98.7%) providers would start steroids for vasogenic edema (scenario 1) and 55 (72.4%) for obstructive hydrocephalus (scenario 2). 16 (21.1%) would start steroids for vasogenic edema but not obstructive hydrocephalus. The odds of choosing to start steroids in patients with obstructive hydrocephalus were 7.59 times more (95% CI: 2.29, 25.13) if providers felt symptoms would improve within 24 h. All would use dexamethasone. A significant difference was seen between the proportion of providers who would give a loading dose if vasogenic edema with neurological deficits were noted versus vasogenic edema alone (57.9% vs 43.4%; p = 0.002).

CONCLUSIONS

These results suggest that providers recommend dexamethasone for patients with vasogenic edema and obstructive hydrocephalus. Variability remains with dosing schedule. Further studies are needed to identify the most appropriate use of steroids for newly diagnosed CNS tumor patients with the goal to create steroid management guidelines.

Metformin as Potential Therapy for High-Grade Glioma

Metformin (MET), 1,1-dimethylbiguanide hydrochloride, is a biguanide drug used as the first-line medication in the treatment of type 2 diabetes. The recent years have brought many observations showing metformin in its new role. The drug, commonly used in the therapy of diabetes, may also find application in the therapy of a vast variety of tumors. Its effectiveness has been demonstrated in colon, breast, prostate, pancreatic cancer, leukemia, melanoma, lung and endometrial carcinoma, as well as in gliomas. This is especially important in light of the poor options offered to patients in the case of high-grade gliomas, which include glioblastoma (GBM). A thorough understanding of the mechanism of action of metformin can make it possible to discover new drugs that could be used in neoplasm therapy.

Lymphatic outflow of cerebrospinal fluid is reduced in glioma

Glioblastoma is a malignant brain tumor with mean overall survival of less than 15 months. Blood vessel leakage and peritumoral edema lead to increased intracranial pressure and augment neurological deficits which profoundly decrease the quality of life of glioblastoma patients. It is unknown how the dynamics of cerebrospinal fluid (CSF) turnover are affected during this process. By monitoring the transport of CSF tracers to the systemic blood circulation after infusion into the cisterna magna, we demonstrate that the outflow of CSF is dramatically reduced in glioma-bearing mice. Using a combination of magnetic resonance imaging (MRI) and near-infrared (NIR) imaging, we found that the circulation of CSF tracers was hindered after cisterna magna injection with reduced signals along the exiting cranial nerves and downstream lymph nodes, which represent the major CSF outflow route in mice. Due to blockage of the normal routes of CSF bulk flow within and from the cranial cavity, CSF tracers were redirected into the spinal space. In some mice, impaired CSF clearance from the cranium was compensated by a lymphatic outflow from the sacral spine.

Identification of distinctive features in human intracranial tumors by label-free nonlinear multimodal microscopy

Nonlinear multimodal microscopy offers a series of label-free techniques with potential for intraoperative identification of tumor borders in situ using novel endoscopic devices. Here, we combined coherent anti-Stokes Raman scattering, two-photon excited fluorescence (TPEF) and second harmonic generation imaging to analyze biopsies of different human brain tumors, with the aim to understand whether the morphological information carried by single field of view images, similar to what delivered by present endoscopic systems, is sufficient for tumor recognition. We imaged 40 human biopsies of high and low grade glioma, meningioma, as well as brain metastases of melanoma, breast, lung and renal carcinoma, in comparison with normal brain parenchyma. Furthermore, five biopsies of schwannoma were analyzed and compared with nonpathological nerve tissue. Besides the high cellularity, the typical features of tumor, which were identified and quantified, are intracellular and extracellular lipid droplets, aberrant vessels, extracellular matrix collagen and diffuse TPEF. Each tumor type displayed a particular morphochemistry characterized by specific patterns of the above-mentioned features. Nonlinear multimodal microscopy performed on fresh unprocessed biopsies confirmed that the technique has the ability to visualize tumor structures and discern normal from neoplastic tissue likewise in conditions close to in situ.

Glioma surgery: From preservation of motor skills to conservation of cognitive functions

The first step of glioma treatment is surgery. Extent of resection (EOR) improves patient survival if surgery does not negatively impair a patient's neurological status. However, how surgery affects the patient's quality of life (QOL) has been less studied, especially as regards cognitive aspects. In our study, we retrospectively analyzed our cases with awake surgery. In all patients, surgical excision was stopped when active functions were intraoperatively identified. A neuropsychological assessment was performed both before and after surgery (5 days and 1 month after). Writing, motor speech, comprehension, expression, reading, pragmatics, attention, memory, problem solving and visuoperceptive functions were evaluated and scored with the NOMS scale. We found no differences in the median values of writing and motor speech, while there was a difference in the following variables: comprehension, expression, reading, pragmatics, attention, memory, problem solving and visuoperceptive functions. Moreover, the Dunn test did not show any difference between preoperative evaluation and evaluation performed 30 days after surgery regarding comprehension, expression, reading, pragmatics, attention, problem solving and visuoperceptive functions. However, there was a difference between preoperative and postoperative evaluation for memory. This retrospective study shows that awake surgery could be a reasonable possibility to preserve a patient's QOL achieving an EOR >82% of the Total Tumor Volume (Fluid-attenuated inversion recovery (FLAIR) hyperintense region in low-grade gliomas and enhancing nodules plus FLAIR hyperintense region in high-grade gliomas). In this series memory was the only aspect that had an impairment after surgery without a complete recovery at one month after surgery.

Early postoperative delineation of residual tumor after low-grade glioma resection by probabilistic quantification of diffusion-weighted imaging

OBJECTIVE

In WHO grade II low-grade gliomas (LGGs), early postoperative MRI (epMRI) may overestimate residual tumor on FLAIR sequences. Consequently, MRI at 3-6 months follow-up (fuMRI) is used for delineation of residual tumor. This study sought to evaluate if integration of apparent diffusion coefficient (ADC) maps permits an accurate estimation of residual tumor early on epMRI.

METHODS

From a consecutive cohort, 43 cases with an initial surgery for an LGG, and complete epMRI (< 72 hours after resection) and fuMRI including ADC maps, were retrospectively identified. Residual FLAIR hyperintense tumor was manually segmented on epMRI and corresponding ADC maps were coregistered. Using an expectation maximization algorithm, residual tumor segments were probabilistically clustered into areas of residual tumor, ischemia, or normal white matter (NWM) by fitting a mixture model of superimposed Gaussian curves to the ADC histogram. Tumor volumes from epMRI, clustering, and fuMRI were statistically compared and agreement analysis was performed.

RESULTS

Mean FLAIR hyperintensity suggesting residual tumor was significantly larger on epMRI compared to fuMRI (19.4 ± 16.5 ml vs 8.4 ± 10.2 ml, p < 0.0001). Probabilistic clustering of corresponding ADC histograms on epMRI identified subsegments that were interpreted as mean residual tumor (7.6 ± 10.2 ml), ischemia (8.1 ± 5.9 ml), and NWM (3.7 ± 4.9 ml). Therefore, mean tumor quantification error between epMRI and fuMRI was significantly reduced (11.0 ± 10.6 ml vs -0.8 ± 3.7 ml, p < 0.0001). Mean clustered tumor volumes on epMRI were no longer significantly different from the fuMRI reference (7.6 ± 10.2 ml vs 8.4 ± 10.2 ml, p = 0.16). Correlation (Pearson r = 0.96, p < 0.0001), concordance correlation coefficient (0.89, 95% confidence interval 0.83), and Bland-Altman analysis suggested strong agreement between both measures after clustering.

CONCLUSIONS

Probabilistic segmentation of ADC maps facilitates accurate assessment of residual tumor within 72 hours after LGG resection. Multiparametric image analysis detected FLAIR signal alterations attributable to surgical trauma, which led to overestimation of residual LGG on epMRI compared to fuMRI. The prognostic value and clinical impact of this method has to be evaluated in larger case series in the future.

Dexamethasone in Glioblastoma Multiforme Therapy: Mechanisms and Controversies

Glioblastoma multiforme (GBM) is the most common and malignant of the glial tumors. The world-wide estimates of new cases and deaths annually are remarkable, making GBM a crucial public health issue. Despite the combination of radical surgery, radio and chemotherapy prognosis is extremely poor (median survival is approximately 1 year). Thus, current therapeutic interventions are highly unsatisfactory. For many years, GBM-induced brain oedema and inflammation have been widely treated with dexamethasone (DEX), a synthetic glucocorticoid (GC). A number of studies have reported that DEX also inhibits GBM cell proliferation and migration. Nevertheless, recent controversial results provided by different laboratories have challenged the widely accepted dogma concerning DEX therapy for GBM. Here, we have reviewed the main clinical features and genetic and epigenetic abnormalities underlying GBM. Finally, we analyzed current notions and concerns related to DEX effects on cerebral oedema, cancer cell proliferation and migration and clinical outcome.

Nanomedicine for Spontaneous Brain Tumors: A Companion Clinical Trial

Nanoparticles' enhanced permeation and retention (EPR) variations due to tumor heterogeneity in naturally occurring brain tumors are commonly neglected in preclinical nanomedicine studies. Recent pathological studies have shown striking similarities between brain tumors in humans and dogs, indicating that canine brain tumors may be a valuable model to evaluate nanoparticles' EPR in this context. We recruited canine clinical cases with spontaneous brain tumors to investigate nanoparticles' EPR in different brain tumor pathologies using surface-enhanced Raman spectroscopy (SERS). We used gold nanoparticles due to their surface plasmon effect that enables their sensitive and microscopic resolution detection using the SERS technique. Raman microscopy of the resected tumors showed heterogeneous EPR of nanoparticles into oligodendrogliomas and meningiomas of different grades, without any detectable traces in necrotic parts of the tumors or normal brain. Raman observations were confirmed by scanning electron microscopy (SEM) and X-ray elemental analyses, which enabled localization of individual nanoparticles embedded in tumor tissues. Our results demonstrate nanoparticles' EPR and its variations in clinically relevant, spontaneous brain tumors. Such heterogeneities should be considered alongside routine preoperative imaging and histopathological analyses in order to accelerate clinical management of brain tumors using nanomedicine approaches.

Neoplastic and Non-Neoplastic Causes of Acute Intracerebral Hemorrhage on CT : The Diagnostic Value of Perihematomal Edema

OBJECTIVE

The aim of this study was to investigate the diagnostic value of perihematomal edema (PHE) volume in non-enhanced computed tomography (NECT) to discriminate neoplastic and non-neoplastic causes of acute intracerebral hemorrhage (ICH).

METHODS

In this retrospective study, from 560 patients with acute ICH 91 patients fulfilled the inclusion criteria and were classified into neoplastic and non-neoplastic ICH. For each patient, ICH and total hemorrhage volume (ICH + PHE) were segmented semiautomatically. The PHE volume and relative PHE were further calculated and all parameters were compared between the different groups. Additionally, hematoma density was measured and compared between the groups.

RESULTS

The PHE volume and relative PHE on NECT were significantly higher in neoplastic vs. the non-neoplastic ICH (p = 0.003 and p < 0.001, respectively). Absolute ICH volume, symptom time onset to CT and ICH localization showed no significant difference between the two groups (p > 0.1). Univariate receiver operating characteristics (ROC) analysis revealed a high diagnostic performance for relative PHE in the discrimination of neoplastic and non-neoplastic ICH with an optimal cut-off of 0.50 (area under the curve, AUC 0.81, 60.0% sensitivity, 91.8% specificity), followed by PHE (AUC 0.69) and hematoma density (AUC 0.68).

CONCLUSION

Relative PHE with a cut-off of >0.50 is a specific and simple indicator for neoplastic causes of acute ICH and a potential tool for clinical implementation. This observation needs to be validated in an independent patient cohort.

Heterogeneity of glioblastoma with gliomatosis cerebri growth pattern on diffusion and perfusion MRI

BACKGROUND AND PURPOSE

Gliomatosis cerebri (GC) is a rare growth pattern of glioblastoma whose diffuse nature is reflected by unspecific, relatively uniform findings on conventional MRI. In the present study we sought to evaluate the additional value of diffusion (DWI) and perfusion weighted (PWI) MRI for a more detailed characterization.

METHODS

We analyzed the MRI findings in patients with histologically proven glioblastoma with GC growth pattern with a specific emphasis on T2 lesion pattern, volume, relative apparent diffusion coefficient (rACD), and relative cerebral blood volume (rCBV) and compared these to age-/gender-matched patients with localized glioblastoma.

RESULTS

Overall, 16 patients (median age 59.5 years, 4 male) were included in the study. Of these, 8 patients had a glioblastoma with GC growth pattern, and 8 a classical localized growth pattern. While the median rADC (1.27 [IQR 1.12-1.41]) within the T2 lesion was significant lower in glioblastoma with GC growth pattern compared to localized glioblastoma (1.74 [IQR 1.45-1.96]; p = 0.003), the median T2 lesion volume and rCBV within the T2 lesion did not differ significantly. Furthermore, six patients with glioblastoma with GC growth pattern showed focal areas with significantly reduced rADC (p = 0.043), and/or increased rCBV (p = 0.028).

CONCLUSIONS

Lower rADC in glioblastoma with GC growth pattern might reflect the diffuse tumor cell infiltration whereas focal areas with decreased rADC and/or increased rCBV probably indicate high tumor cell density and/or abnormal tumor vessels which may be useful for biopsy guidance.

Deciphering mechanisms of brain metastasis in melanoma - the gist of the matter

Metastasis to distant organs and particularly the brain still represents the most serious obstacle in melanoma therapies. Melanoma cells acquire a phenotype to metastasize to the brain and successfully grow there through complex mechanisms determined by microenvironmental than rather genetic cues. There do appear to be some prerequisites, including the presence of oncogenic BRAF or NRAS mutations and a loss of PTEN. Further mediators of the brain metastatic phenotype appear to be the high activation of the PI3K/AKT or STAT3 pathway or high levels of PLEKHA5 and MMP2 in metastatic cells. A yet undefined subset of brain metastases exhibit a high level of expression of CD271 that is associated with stemness, migration and survival. Hence, CD271 expression may determine specific properties of brain metastatic melanoma cells. Environmental cues - in particular those provided by brain parenchymal cells such as astrocytes - seem to help specifically guide melanoma cells that express CCR4 or CD271, potential "homing receptors". Upon entering the brain, these cells interact with brain parenchyma cells and are thereby reprogrammed to adopt a neurological phenotype. Several lines of evidence suggest that current therapies may have a negative effect by activating a program that drives tumor cells toward stemness and metastasis. Yet significant improvements have expanded the therapeutic options for treating brain metastases from melanoma, by combining potent BRAF inhibitors such as dabrafenib with checkpoint inhibitors or stereotactic surgery. Further progress toward developing new therapeutic strategies will require a more profound understanding of the mechanisms that underlie brain metastasis in melanoma.

Edema of the optic tract in patients with tumors of the sellar region: clinical and visual implications in the pediatric population

OBJECTIVE Tumor-related edema of the optic tract (EOT) corresponds to a preferential posterior distribution of peritumoral edema along the white matter tract of the visual system. To date, the consequences of EOT have never been evaluated specifically in the pediatric population. In this study, the authors attempted to identify clinical and radiological features associated with the development of EOT and the specific influence of this edema on visual function. METHODS A retrospective review was performed of data collected from patients younger than 18 years who underwent surgery for a tumor in the sellar region at the authors' institution between January 2005 and January 2016. Data were collected on patient characteristics, ophthalmological evaluations, and neuroimaging findings. To evaluate and compare visual function impairment, ophthalmological data were converted to a global visual function score, which took into account visual acuity, visual field evaluations, and laterality deficiencies. The visual acuity score was defined according to the International Classification of Diseases, 10th Revision. Visual field deficiencies were converted to a score of 0-2. Two opposing groups were then distinguished according to the presence or absence of EOT. Visual acuity, visual field results, and global scores were compared between groups before and after treatment. RESULTS Twenty-six patients were included in the study: 17 patients with craniopharyngioma, 3 patients with pilocytic astrocytoma, 2 patients with ganglioglioma, 2 patients with germ cell tumor, 1 patient with macroprolactinoma, and 1 patient with Rathke's cleft cyst. There were 11 children in the group with edema and 15 children in the group without edema. None of the following criteria were statistically different between the 2 groups: age, sex, clinical symptoms at presentation (endocrine deficiency or intracranial hypertension signs), incidence of hydrocephalus, compression of the optic tracts and mass effect on the optic chiasm, tumor size and localization, presence of intratumoral cysts, treatment, type of tumor, or recurrence. The median global visual function and visual acuity scores were not significantly different between the groups either at presentation or at final evaluation. The visual field score was lower (i.e., more deficiency) in the group with edema than in the group without edema (p < 0.05); 89% of the patients with edema had severe or mild visual field impairment versus only 40% of the patients without edema. At the final examination after treatment, the visual field scores were not different between the 2 groups. Although not significant, the number of patients with optic disc pallor was greater in the group without edema both at diagnosis and at final examination. CONCLUSIONS This study confirms that EOT in the context of sellar region tumor in children is not necessarily associated with a less-favorable visual prognosis.