Prolonged Stabilization of Multiple and Single Brain Metastases from Breast Cancer with Tamoxifen. Report of Three Cases

Cancer frequently metastasizes to the brain, and such lesions, whether multiple or solitary, have a poor prognosis, despite all efforts to treat them. There have been recent sporadic reports of brain metastases from breast cancer responding for some years to antiestrogens (particularly tamoxifen) or bromocryptine. We report three cases of brain metastasis from cancer – two multiple and one a solitary lesion. The long survival of the patients – two for 5 years and one for 6 years, with more than an acceptable quality of life – should prompt therapeutic trials to test tamoxifen and designed to assess its effects on a sizable number of patients.

Transsphenoidal adenomectomy for GH-, PRL- and ACTH-secreting pituitary tumours: outcome analysis in a series of 125 patients

Transsphenoidal surgery (TSS) is a well recognised treatment for secreting pituitary adenomas, however a very wide variation of clinical outcomes and recurrence rates has been reported, depending on the different criteria used to define the cure. We reported the clinical outcome of a large series of patients operated on for a secreting pituitary adenoma according to the most recent stringent criteria of biochemical remission nowadays accepted. One hundred and twenty-five consecutive patients with a secreting pituitary adenoma (42 PRL-, 67 GH- and 16 ACTH-secreting adenomas) who were operated on by the two same neurosurgeons were considered for the study. Biochemical remission of disease was achieved in 56% of patients; 78% for patients with microadenoma and 47% for patients with macroadenomas, respectively. No cases of mortality or major immediate postoperative complications were observed. Tumour size, high hormone levels and dural invasion were significantly correlated to a poor surgical outcome. The recurrence rates ranged between 0 and 24%, being higher for PRL-secreting tumours. In conclusion, TSS is safe and effective in secreting pituitary tumours. It is still the first treatment for GH- and ACTH-secreting adenomas, whereas in patients with prolactinomas, surgery should be reserved for cases of resistance or intolerance to dopamine agonists.

Solitary Brain Metastases from Uterus Carcinoma: Report of Three Cases

Solitary brain metastases from uterine carcinoma are uncommon. Intracranial metastases from uterus usually occur in widely disseminated disease. We report three cases of solitary brain metastasis from uterine cancer. In one of these patients metastasis was detected prior to diagnosis of primitive cancer. In a review of the literature only seven cases of solitary brain metastasis preceding the diagnosis of uterine cancer have been documented.

Temozolomide in radio-chemotherapy combined treatment for newly-diagnosed glioblastoma multiforme: phase II clinical trial

BACKGROUND

Continuous research into new strategies and chemotherapy agents for the treatment of malignant high-grade gliomas have led to the synthesis of a new chemotherapy drug, temozolomide (TMZ), with a lower toxicity profile compared to conventional chemotherapy agents, such as nitrosoureas. Temozolomide is an oral alkylating chemotherapy agent licensed for the treatment of recurrent high-grade gliomas, anaplastic astrocytoma (AA) and glioblastoma multiforme (GBM). Because of its favorable pharmacokinetic and pharmacodynamic properties and improved tolerability, TMZ is now under investigation for concomitant use with radiotherapy in patients with newly-diagnosed GBM. We present a phase II clinical trial investigating the efficacy and safety of radio-chemotherapy combined treatment using TMZ, followed by six cycles of adjuvant chemotherapy with TMZ, in patients with newly-diagnosed GBM who have undergone debulking surgery or biopsy only.

PATIENTS AND METHODS

Twenty-one patients with newly histologically-diagnosed GBM were enrolled into this phase II clinical trial. In phase I of the study, TMZ (75 mg/m2/day per 7 days/wk for 6 weeks) was orally administered to patients concomitantly with radiotherapy (RT) (2 Gy per fraction once daily, per 5 days/wk for 6 weeks). In phase II of the study, four weeks after completion of RT, a monochemotherapy using TMZ was administered at the dosage of 200 mg/m2/day per 5 days every 28 days for 6 cycles. Primary end-points were the safety and tolerability profile of this two-phase combined treatment and secondary end-points were the objective response and survival rates at twelve months and eighteen months from study entry.

RESULTS

The one-year survival rate of patients treated with the investigated multimodality treatment was 58% and median survival time was 15.7 months. Concomitant RT plus TMZ (phase I) followed by adjuvant TMZ (phase 2) were well-tolerated; indeed, nonhematological adverse events were rare and mild to moderate in severity; grade 3 and 4 neutropenia and thrombocytopenia were the major-related hematological side-effects observed in only 2 and 3 of all patients in phase I and 4 patients in phase II. We found that the combination of radio- and chemo-therapy, in phase I of the study did not significantly increase the incidence and severity of hematological toxicity caused by the adjuvant TMZ-based chemotherapy administered in phase II of the study.

CONCLUSION

The investigated multimodality treatment regimen was well-tolerated and prolonged survival while improving patients' quality of life.

Use of spiral computerized tomography angiography in patients with cerebral aneurysm. Our experience

BACKGROUND

The purpose is to highlight the usefulness of CT angiography (CTA) in the diagnosis and surgical treatment of cerebral aneurysms.

METHODS

Thirty-one patients with subarachnoid haemorrhages were subjected to CT angiography and in those cases where this test did not reveal the aneurysm or did not supply sufficient information relating to it, subsequently a digital subtraction angiography was also performed. Each aneurysm-positive CTA was re-processed using the 3-D techniques, with the neuro-radiologist and the neuro-surgeon working in close co-operation.

RESULTS

In 27 cases the CTA diagnosed an aneurysm, and in the 4 cases where no vascular malformations were revealed, also the traditional angiography did not show any pathology. In 17 out of 18 cases operated on in order to clip the aneurysm, the CTA supplied all the information needed for the surgery and it was possibile to reconstruct images similar to those of the surgical field. This led to improvement in the programming of the surgical intervention; in 1 case only was it also necessary to perform the DSA before the operation.

CONCLUSIONS

CT angiography, because it is non-invasive, easy to perform, diagnostically reliable, and because the 3-D re-constructions offer the chance to create images of the possible operating field, is the first-choice test to be adopted in the treatment of subarachnoid haemorrhages, even though in some cases the use of the traditional angiography is still necessary and should be carried out whenever the CTA does not reveal vascular malformations.

Frontotemporal orbitozygomatic craniotomy to exposure the cavernous sinus and its surrounding regions. Microsurgical anatomy

BACKGROUND

The microsurgical anatomy of the cavernous sinus and its surrounding regions were examined via frontotemporal orbitozygomatic (FTOZ) craniotomy. Combined with other deep osteotomies, the possibility of exposing the petroclival region and basilar artery was also explored.

METHODS

The study was made on 20 sides of 10 cadaveric specimens fixed with formalin, with the help of the surgical microscope (magnification 5-15).

RESULTS

The FTOZ was performed with frontotemporal and orbitozygomatic flaps. Extradurally, V2, V3, the trigeminal ganglion, the posterior vertical segment of the intracavernous ICA and the VI nerve were exposed by FTOZ craniotomy. By further removal of the petrous apex (Kawase's triangle), exposure could be extended to the petroclival region; with anterior modification of the microscopic light, in 50% of the specimens, exposure reached as low as the convergence of the vertebral arteries. The anterior part of the cavernous sinus and the orbital apex were examined by removing the anterior clinoid process, orbital roof and unroofing the optic canal. Intradurally, the intrapeduncular fossa (upper 1/3 of the clivus) was examined. The intracavernous cranial nerves and vessels were studied via lateral and superior wall approaches. By removing both the anterior and posterior clinoid processes together, in 80% of the specimens, the exposure could be carried as far as the midpoint of the basilar artery.

CONCLUSIONS

FTOZ craniotomy could be used to treat lesions involving the cavernous sinus and its surrounding regions. Incorporated with the petrous apectomy, it could be used to expose the petroclival region and, in selected cases, exposure could be extended to the convergence of the vertebral arteries. Combined with anterior and posterior clinoidectomies, it could also be used to treat midpoint regions of the basilar artery.

Cavernous angiomas of the nervous system in Italy: clinical and genetic study

We performed a clinical and genetic study of patients affected by cavernous angiomas (CA) of the nervous system. We examined initial signs and symptoms in sporadic and familial cases. We obtained clinical, neuroimaging and genetic data on 15 Italian patients with CA of the nervous system with positive, doubtful or apparently negative family history. Genetic markers surrounding three different gene regions (7q, 3q and 7p) were analysed. In one small family, genetic linkage was consistent with all chromosome loci. In another family with the unusual association of cerebral and spinal CA, linkage with chromosome 7q and, likely, 7p was excluded, while linkage with locus 3q was possible. Our results indicate that Italian families with CA may show genetic heterogeneity. Non-specific and subtle onset symptoms hide the presence of CA within families. Patients with multiple CA may have silent cerebral lesions confirming the low penetrance of clinical signs in spite of radiological ones.

Total removal of an intramedullary cavernous angioma by transthoracic approach

Intramedullary cavernous angiomas are rare vascular malformations; all published cases have been surgically approached posteriorly by standard laminectomy. We describe the case of a 63-year-old man with an intramedullary cavernous angioma, anteriorly located in the thoracic spinal cord. The angioma was operated on by transthoracic approach and totally removed.

[Epidermoid cyst of the cranial vault. Neuroradiological and therapeutic considerations]

AIM

Intradiploic epidermoid cyst is a slow-growing tumor affecting only rarely the cranial bones.

PATIENT

The authors describe a case of intradiploic epidermoid cyst of the cranial vault in which there was a predominantly intracranial extension. Roentgenographic and CT findings do not permit a differential diagnosis. Complete removal of the cyst and its capsule was accomplished, with complete recovery.

CONCLUSION

Total removal oft the tumor and its capsule is associated with a very good long-term prognosis without recurrences.

[Intramedullary cervical neurinoma. A case report and review of the literature]

A case of intramedullary neurinoma of the cervical spinal cord in a patient with no sign of von Recklinghausen's disease is reported. It was diagnosed by computed tomography and magnetic resonance imaging and treated surgically. Discussion examines etiology, role of diagnostic procedures and surgical treatment of this rare tumor.

Prognostic factors in intramedullary astrocytomas

This report presents a retrospective prognostic study of 65 patients with intramedullary astrocytoma surgically treated between 1953 and 1990. Median survival and statistical survival at 5 years were assessed in relation to clinical, histological and therapeutic factors for each patient. Results showed that factors positively influencing the prognosis are low histological grade of the tumour and good pre- and post-operative general conditions. Among the grade II astrocytomas, the fibrillary and protoplasmatic types presented longer survival times regardless of the type of removal performed. In anaplastic astrocytomas the simultaneous presence of certain morphological features indicative of higher malignancy negatively influenced survival. The degree of resection did not influence average survival within each histological grade.

Osteoblastoma of the calvaria: report of two cases diagnosed with MRI and clinical review

The authors describe 2 cases of osteoblastoma of the calvaria and review the clinical features of the 28 cases reported in the world literature. Benign osteoblastoma is a rare tumor that effects young patients, most frequently at temporal level. On the basis of its neuroradiological appearance, it is difficult to formulate a differential diagnosis against other osteoblastic tumors or against osteoid osteoma. In only a few cases MRI findings are reported. In our cases, MRI was more effective than CT scans and radiographs for evaluating the intracranial and intraosseous extension of the tumor. The definitive diagnosis was obtained by combining the histopathological features of the tumor with the clinical and radiological data. The prognosis of this tumor is very good regardless of the type of treatment performed, although both relapse and, more rarely, malignant tumor evolution are possible.

Intramedullary astrocytomas and ependymomas in the pediatric age group: a retrospective study

A series of 45 pediatric patients underwent surgery for intramedullary astrocytoma or ependymoma at the Cook County Hospital or the Children's Memorial Hospital of Chicago (Northwestern University) and the Neurosurgical Department of Rome "La Sapienza" University. Results showed that intramedullary astrocytomas and ependymomas in children differ from one another in terms of prognosis, and particularly as regards surgical strategy as an element of therapeutic management. Gross total removal of 70% of the ependymomas was achieved, in comparison to 33% of the astrocytomas. In astrocytomas the extent of resection did not significantly influence prognosis. Neurological condition on admission, regardless of oncotype, was found to be extremely influential: patients operated in good condition tended to remain neurologically stable or improve in the long term, while those operated on while in poor condition did not show any improvement at all. No definitive conclusions were possible regarding the value of radiotherapy, because it was only performed in 6 of the 45 cases. The authors limited its use to highly malignant lesions in view of the well-known sensitivity of the spinal cord to radiation, especially in children.

Intramedullary cavernous angiomas of the spinal cord: report of six cases

The authors report six cases of intramedullary cavernoma. Symptoms evolved by episodes of stepwise neurologic deterioration or slow progression. All patients had preoperative and postoperative magnetic resonance imaging (MRI). Removal of the cavernoma was total in all cases and in one a transthoracic approach was performed because of the ventral and superficial position of the lesion. At follow-up, ranging from 6 to 18 months, two patients improved, two were unchanged, and one had deteriorated. Prognosis was influenced by the length of clinical history and the severity of preoperative symptoms. The principal clinical and therapeutic aspects of cavernoma are discussed in light of the published data.

Spontaneous drainage of syringomyelia. Report of two cases

Two cases are reported of Arnold-Chiari type I malformation associated with syringomyelia, in which magnetic resonance (MR) imaging revealed spontaneous decompression of the syrinx. In one case axial MR imaging sections showed a communication between the syrinx and the spinal subarachnoid space, which supports the hypothesis that fissuring of the cord parenchyma is instrumental in the spontaneous resolution of syringomyelia. The MR imaging changes were not accompanied by variations in the patients' clinical course.

Meningiomas of Meckel's cave

A series of 16 patients with meningiomas of Meckel's cave is reported. Trigeminal neuralgia, typical or atypical, was the initial symptom in 10 patients (62.5%). At admission, trigeminal signs and symptoms were present in 15 patients (93.7%); in 7 patients (43.7%), trigeminal dysfunction was combined with the impairment of other cranial nerves. On retrospective analysis, these patients fall into two clinical groups that differ also in prognosis. Group 1 comprises eight patients with trigeminal signs and symptoms only. These patients had small meningiomas strictly affecting Meckel's cave. Total removal of the tumor was achieved in seven of eight patients, without adjunctive postoperative neurological deficits. In this group, there were no tumor recurrences. Group 2 comprises the other eight patients in whom trigeminal dysfunction was combined with impairment of other cranial nerves. These patients had large tumors arising from Meckel's cave and secondarily invading the cavernous sinus (five patients) or extending into the posterior fossa (two patients) or largely growing into the middle fossa (one patient). Total removal was achieved in only one patient, and a worsening of the preoperative neurological status was observed in four patients; there were three cases of tumor progression. A subtemporal intradural approach (used in the past in every case) is still used for the small tumors of Group 1 with good results. Since 1985, for tumors involving the cavernous sinus, we have employed a frontotemporal craniotomy with extradural clinoidectomy and superior and lateral approach to the cavernous sinus. When the tumor extends toward the posterior fossa, we use a combined temporosuboccipital-transpetrosal approach.(ABSTRACT TRUNCATED AT 250 WORDS)

Intramedullary metastasis of unknown origin: a case report

We report a case of cervicothoracic intramedullary metastasis with long survival. The patient is in satisfactory neurological condition 18 months after operation and has resumed her normal lifestyle. Despite meticulous examinations, the primary lesion could not be identified. We discuss the relevant published work.

[Aortic coarctation and intracranial aneurysm: an unusual association. Description of an unusual case and diagnostic-therapeutic considerations]

A case of double unruptured intracranial aneurysm associated with aortic coarctation is presented. The main characteristics of the unusual association, the diagnostic criteria and the surgical strategies are reviewed.

Brain oedema and intracranial hypertension treatment by GLIAS

The authors present their results regarding the use of a buffered solution of glycerol 30%-sodium ascorbate 20% (GLIAS) for the treatment of brain oedema and intracranial hypertension. GLIAS was perfused intravenously in 80 patients with several types of brain oedema. In every patients serum and urinary osmolarity, diuresis, main blood and urine parameters, and ICP were monitored. Following GLIAS infusion an increase in plasma osmolarity was observed, changing the average basal value plus 13.4% after 15 min., 10.5% after 30'. At the same time there was a reduction of ICP and improvement in cerebral compliance. In each case there was a decrease in intracranial hypertension and brain oedema without significant collateral effects.

Interhemispheric subdural hematoma (ISH). Case report

Interhemispheric subdural hematoma (ISH) is a rare form of post-traumatic intracranial hemorrhage. The Authors report a further case and review the relevant literature. ISH most frequently gives a clinical picture corresponding to the falx syndrome. The possibility of an interhemispheric hematoma evolving into a chronic subdural hematoma of the convexity is considered together with both surgical and medical therapeutic indications.

[Tumors of the central nervous system induced by ionizing radiation. Update on their pathology and presentation of a case]

Ionizing radiation-induced neoplasias are frequently described in literature but only 100 case about interested the central nervous system. The authors add a possible personal observation and line the main features of this association.