An Overview of Systemic Targeted Therapy in Renal Cell Carcinoma, with a Focus on Metastatic Renal Cell Carcinoma and Brain Metastases

The most commonly diagnosed malignancy of the urinary system is represented by renal cell carcinoma. Various subvariants of RCC were described, with a clear-cell type prevailing in about 85% of all RCC tumors. Patients with metastases from renal cell carcinoma did not have many effective therapies until the end of the 1980s, as long as hormonal therapy and chemotherapy were the only options available. The outcomes were unsatisfactory due to the poor effectiveness of the available therapeutic options, but then interferon-alpha and interleukin-2 showed treatment effectiveness, providing benefits but only for less than half of the patients. However, it was not until 2004 that targeted therapies emerged, prolonging the survival rate. Currently, new technologies and strategies are being developed to improve the actual efficacy of available treatments and their prognostic aspects. This article summarizes the mechanisms of action, importance, benefits, adverse events of special interest, and efficacy of immunotherapy in metastatic renal cell carcinoma, with a focus on brain metastases.

Predictor factors for recurrence in atypical meningiomas

BACKGROUND AND OBJECTIVES

Atypical meningiomas (AMs), World Health Organization (WHO) grade 2, are a group of tumors with uneven and unpredictable clinical behavior. Our aim was to analyze possible tumor recurrence predictors, and to identify factors that improve progression-free survival (PFS).

PATIENTS, MATERIALS AND METHODS

Our retrospective study included 81 patients followed up in the Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iaşi, Romania, between 1 January 2010 and 31 December 2020. The histopathological specimens were reviewed according to the WHO 2021 criteria. Analyses included clinical, imaging, pathological and surgical factors.

RESULTS

The tumor recurred in 53.1% of the 81 cases within 60 months of surgery. Tumor location (p<0.000), tumor volume (p<0.010), extent of surgical resection (p<0.000) and dural sinus invasion (p<0.001) were predictive factors of recurrence. Gross total resection (Simpson grade I and II) was achieved in 59.2% of patients. Patients with the tumors located in the brain convexity and volume <26.4 cm³ had better survival rates up to recurrence. PFS showed a significant relationship between Simpson grade I-III and biopsy (p<0.000) and was statistically influenced by tumor volume and location, and dural sinus invasion.

CONCLUSIONS

AMs are a heterogeneous group of tumors, and we identified posterior fossa location, volume ≥26.4 cm³, Simpson grade III and IV resection and dural sinus invasion as predictive factors for relapse and a shorter PFS. Whereas certain characteristics provide some prognostic value, future molecular characterizations of AMs are necessary, which will support the clinical decision-making process.

Immunohistochemical evaluation of biomarkers with predictive role in acromegaly: a literature review

Acromegaly is a rare endocrine disorder, which despite the recent advances in diagnosis and management, remains a significant burden in terms of morbidity and mortality for patients because of the frequent aggressive evolution and lack of response to available first-line pharmacological therapy. A switch from the classical "trial and error" management to a personalized therapy approach has been proposed through early identification of biomarkers that could predict treatment response and biological behavior. Several such molecular markers have been extensively studied through immunohistochemistry (IHC), among them the somatostatin receptors type 2 (SSTR-2) and type 5 (SSTR-5), which are known to correlate with response to somatostatin analogues treatment, the SSTR-2 negative tumors usually being resistant to first-generation analogues, while SSTR-5 potentially being a predictive marker for the novel agent, Pasireotide. Based on cytokeratin (CK) immunostaining pattern, somatotropinomas have been classified into densely granulated adenomas (DGAs), which present a milder evolution and favorable outcomes after therapy, and sparsely granulated adenomas (SGAs), known to be more aggressive and frequently resistant to first-line treatment options. Other novel markers, such as the E-cadherin cell-adhesion protein, the aryl hydrocarbon receptor-interacting protein (AIP), the cytoskeleton molecule filamin A (FLNA) and the Ki-67 nuclear antigen have also been the highlight of IHC studies on growth hormone (GH)-producing tumors, with promising results regarding their predictive roles for the outcome of acromegalic patients. In this review, we aimed to summarize the current knowledge on the role of IHC for acromegaly, highlighting the most important biomarkers that could offer valuable information for predicting treatment response, biological behavior, and prognosis.

Mass effect: a plethora of symptoms caused by an otherwise benign transitional pituitary meningioma. Case report

Meningiomas are among the most commonly encountered tumors of the central nervous system, being more frequent in females. We present the case of a dyslipidemic male patient, previously diagnosed with coronary artery disease for which he previously underwent percutaneous coronary intervention with the placement of two bare metal stents on the left anterior descending artery. He was presented to the emergency department for atypical angina and a seven-day history of dizziness when switching from clino- to orthostatism, reduced visual acuity, diplopia and vomiting. Electrocardiogram (ECG), both at rest and exercise test were suggestive for myocardial ischemia. Echocardiography revealed myocardial hypokinesia in the territory of the right coronary artery and of the left descending artery, while coronarography showed insignificant intra-stent stenosis. Imaging techniques revealed a frontobasal extraneuraxial mass, creating a compressive effect on both middle cerebral arteries and on the optic chiasm as well as thickening of the dura mater adjacent to the mass. Endocrinology blood tests showed hypocortisolemia, hyperprolactinemia and low levels of free thyroxine (fT4), suggesting secondary combined pituitary hormone deficiency. The patient underwent surgery and total resection of the tumor was performed. Definite diagnosis - transitional meningioma - was obtained through histological examination and immunohistochemistry. The key feature of this case was the extra-cardiac cause of angina accompanied by ECG abnormalities in a patient with stable coronary heart disease, in whom the clinical presentation was secondary to blood pressure variations in the context of pituitary and adrenal deficiency.

AN UNUSUAL CASE OF CEREBELLAR VENOUS ANGIOMA ASSOCIATED WITH TEMPORAL CAVERNOMA – PATHOPHYSIOLOGICAL, DIAGNOSTIC, AND SURGICAL CONSIDERATIONS

Cerebral vascular malformations are hamartomas, classified into four distinct groups:arteriovenous malformations, cavernous malformations, capillary telangiectasias, anddevelopmental venous anomalies. These abnormal vascular entities have distinct histopathological, radiological, and clinical features, which make them different from one another. We report a case of a 37-year-old man, who presented with headaches, generalized grand mal seizures, and an episode of loss of consciousness, due to a left temporal cavernoma. Gadolinium-enhanced T1-weighted MR images showed a left temporal “popcorn-like” lesion, with heterogeneousenhancement, measuring 15/17/18 mm, suggestive of a cavernoma (angiographically occultmalformation). The T2-weighted MRI showed a right cerebellar venous plexus, draining into alarger central vein and the angiogram revealed the pathognomonic caput medusae aspect of avenous angioma. Microsurgical resection of the left temporal cavernous malformation wasperformed using a left frontal temporal approach. The venous angioma was spared to avoid venousinfarction and cerebral edema with devastating vital consequences. The intra- and postoperativecourses were uneventful with total recovery. The seizures remitted under anticonvulsant therapy,and the postoperative computer tomography investigation were within normal limits. The venous angioma was situated in the right cerebellar hemisphere, rather than near the cavernoma, its location making this the particular aspect of this case.