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Weiss M, Dogan R, Eisenberg U, Velalakan A, Krüger J, Moritz I, Nistor-Gallo D, Flueh C, Janz C, Ahmadi R, Hakvoort K, Forster MT. Path to success: female leaders in German neurosurgery. Neurosurg Rev 2023; 46:269. [PMID: 37837541 PMCID: PMC10576670 DOI: 10.1007/s10143-023-02163-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 10/16/2023]
Abstract
Despite advances in gender equality, only 6% of German neurosurgical departments are currently led by women. With regard to their pioneering work and the importance of their role model effect, we aimed at reporting on the career pathways of the present and former female chairs of neurosurgical departments in Germany. We approached current and former female chairs in German neurosurgery and gathered descriptive information on their ways into leadership positions through structured interviews. Data were obtained from 16/22 (72.7%) female neurosurgical chairs, aged between 44 and 82 years. They completed their training within 6.5 ± 0.6 years, and it took them further 14.5 ± 5.9 years between training completion and chair acquisition. Having obtained their chair positions between 1993 and 2020, six (37.5%) of them have retired or changed career tracks. Of ten (62.5%) chairs still practicing, two are directors of university departments. Twelve (75.0%) hold professorships. Nine chairs (56.3%) are married, eight (50.0%) having children. Five chairs reported having experienced gender-based discrimination. Twelve had a male mentor or role model, two had a female role model, while only one had a female mentor. This study characterizes the to date small number of female neurosurgical chairs in Germany and their paths to neurosurgical leadership positions. In future, these should become historical in order to perceive the presence of women in leadership positions as self-evident normality, reflecting our society. However, further analyses comparing paths of both female and male neurosurgical chairs are necessary to explore gender-based differences in achieving neurosurgical leadership positions.
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Affiliation(s)
- Miriam Weiss
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Rabia Dogan
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | | - Aruni Velalakan
- Department of Neurosurgery, Ludwigsburg Hospital, Ludwigsburg, Germany
| | | | - Ina Moritz
- Department of Neurosurgery, MSB Medical School Berlin, Helios Klinikum Buch, Berlin, Germany
| | | | - Charlotte Flueh
- Department of Neurosurgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Claudia Janz
- Department of Neurosurgery, Solingen Municipal Hospital, Solingen, Germany
| | - Rezvan Ahmadi
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Karlijn Hakvoort
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Marie-Thérèse Forster
- Department of Neurosurgery, Goethe University, Schleusenweg 2-16, 60528, Frankfurt Am Main, Germany.
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Zeiner PS, Filipski K, Filmann N, Forster MT, Voss M, Fokas E, Herrlinger U, Harter PN, Steinbach JP, Ronellenfitsch MW. Sex-Dependent Analysis of Temozolomide-Induced Myelosuppression and Effects on Survival in a Large Real-life Cohort of Glioma Patients. Neurology 2022; 98:e2073-e2083. [DOI: 10.1212/wnl.0000000000200254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 02/04/2022] [Indexed: 11/15/2022] Open
Abstract
Objective:To investigate the association of radiochemotherapy-induced cytopenia with sex of glioma patients and its potential impact on survival.Methods:We retrospectively analyzed cytopenia during temozolomide-based concomitant radiochemotherapy (RCT) in 492 glioma patients. Histological grading, molecular pathology, surgical procedures, adjuvant chemotherapy subsequent to the RCT phase and overall survival (OS) were recorded. The extent of cytopenia was correlated with sex and outcome.Results:Treatment-induced severe cytopenia (leuko-, lympho-, neutro- and thrombocytopenia) was more frequent in women than men (44 vs. 18%, p-value 0.0002). In women with IDH-wildtype high-grade astrocytomas there was a negative correlation of severe cytopenia in general and thrombocytopenia in specific during temozolomide RCT with OS independent from other predictors (92 (77-111) vs. 73 (21-127) weeks, p-values <0.05). In men there was also a trend for this unfavorable effect. Additionally, severe cytopenia in all blood cell lineages correlated with reduced temozolomide dose exposure during RCT (all p-values <0.05 in the total cohort) and reduced dose exposure was independently associated with worse OS (hazard ratios for OS complete vs. reduced temozolomide dose in the total/female cohort: 0.66 (0.47-0.92) and 0.4 (0.24-0.69), p-values <0.05).Conclusions:Our analysis of treatment-induced cytopenia in a large cohort of glioma patients (i) confirms that women are at higher risk and (ii) demonstrates an association of cytopenia in women with shortened survival.Classification of Evidence:This study provides class II evidence that women with glioma treated with temozolomide-based concomitant radiochemotherapy have more frequent treatment-induced severe cytopenia than men and that severe myelosuppression correlates with worse OS in women.
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Urban H, Steidl E, Hattingen E, Filipski K, Meissner M, Sebastian M, Koch A, Strzelczyk A, Forster MT, Baumgarten P, Ronellenfitsch MW, Steinbach JP, Voss M. Immune Checkpoint Inhibitor-Induced Cerebral Pseudoprogression: Patterns and Categorization. Front Immunol 2022; 12:798811. [PMID: 35046955 PMCID: PMC8761630 DOI: 10.3389/fimmu.2021.798811] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/06/2021] [Indexed: 12/18/2022] Open
Abstract
Background The inclusion of immune checkpoint inhibitors (ICIs) in therapeutic algorithms has led to significant survival benefits in patients with various metastatic cancers. Concurrently, an increasing number of neurological immune related adverse events (IRAE) has been observed. In this retrospective analysis, we examine the ICI-induced incidence of cerebral pseudoprogression and propose a classification system. Methods We screened our hospital information system to identify patients with any in-house ICI treatment for any tumor disease during the years 2007-2019. All patients with cerebral MR imaging (cMRI) of sufficient diagnostic quality were included. cMRIs were retrospectively analyzed according to immunotherapy response assessment for neuro-oncology (iRANO) criteria. Results We identified 12 cases of cerebral pseudoprogression in 123 patients treated with ICIs and sufficient MRI. These patients were receiving ICI therapy for lung cancer (n=5), malignant melanoma (n=4), glioblastoma (n=1), hepatocellular carcinoma (n=1) or lymphoma (n=1) when cerebral pseudoprogression was detected. Median time from the start of ICI treatment to pseudoprogression was 5 months. All but one patient developed neurological symptoms. Three different patterns of cerebral pseudoprogression could be distinguished: new or increasing contrast-enhancing lesions, new or increasing T2 predominant lesions and cerebral vasculitis type pattern. Conclusion Cerebral pseudoprogression followed three distinct patterns and was detectable in 3.2% of all patients during ICI treatment and in 9.75% of the patients with sufficient brain imaging follow up. The fact that all but one of the affected patients developed neurological symptoms, which would be classified as progressive disease according to iRANO criteria, mandates vigilance in the diagnosis and treatment of ICI-induced cerebral lesions.
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Affiliation(s)
- Hans Urban
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
| | - Eike Steidl
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Elke Hattingen
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Katharina Filipski
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Institute of Neurology (Edinger Institute), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Markus Meissner
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Martin Sebastian
- Department of Medicine II, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Agnes Koch
- Department of Thoracic Surgery, Agaplesion Markuskrankenhaus, Frankfurt/Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (Cepter), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Marie-Thérèse Forster
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Peter Baumgarten
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Michael W Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (Cepter), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Joachim P Steinbach
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
| | - Martin Voss
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
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4
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Voss M, Wenger KJ, Fokas E, Forster MT, Steinbach JP, Ronellenfitsch MW. Single-shot bevacizumab for cerebral radiation injury. BMC Neurol 2021; 21:77. [PMID: 33596839 PMCID: PMC7888179 DOI: 10.1186/s12883-021-02103-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background Cerebral radiation injury, including subacute radiation reactions and later stage radiation necrosis, is a severe side effect of brain tumor radiotherapy. A protocol of four infusions of the monoclonal antibody bevacizumab has been shown to be a highly effective treatment. However, bevacizumab is costly and can cause severe complications including thrombosis, bleeding and gastrointestinal perforations. Methods We performed a retrospective analysis of patients treated in our clinic for cerebral radiation injury who received only a singular treatment with bevacizumab. Single-shot was defined as a singular administration of bevacizumab without a second administration during an interval of at least 6 weeks. Results We identified 11 patients who had received a singular administration of bevacizumab to treat cerebral radiation injury. Prior radiation had been administered to treat gliomas (ten patients) or breast cancer brain metastases (one patient). 9 of 10 patients with available MRIs showed a marked reduction of edema at first follow-up. Discontinuation of Dexamethasone was possible in 6 patients and a significant dose reduction could be achieved in all other patients. One patient developed pulmonary artery embolism 2 months after bevacizumab administration. The median time to treatment failure of any cause was 3 months. Conclusions Single-shot bevacizumab therefore has meaningful activity in cerebral radiation injury, but durable control is rarely achieved. In patients where a complete protocol of four infusions with bevacizumab is not feasible due to medical contraindications or lack of reimbursement, single-shot bevacizumab treatment may be considered.
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Affiliation(s)
- Martin Voss
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany. .,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany. .,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt/Main, Germany. .,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.
| | - Katharina J Wenger
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt/Main, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Emmanouil Fokas
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt/Main, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Department of Radiotherapy and Oncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Marie-Thérèse Forster
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt/Main, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Joachim P Steinbach
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt/Main, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
| | - Michael W Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt/Main, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
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5
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Senft C, Behrens M, Lortz I, Wenger K, Filipski K, Seifert V, Forster MT. The ability to return to work: a patient-centered outcome parameter following glioma surgery. J Neurooncol 2020; 149:403-411. [PMID: 32960402 PMCID: PMC7609423 DOI: 10.1007/s11060-020-03609-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND With refinements in diagnosis and therapy of gliomas, the importance of survival time as the sole outcome parameter has decreased, and patient-centered outcome parameters have gained interest. Pursuing a profession is an indispensable component of human happiness. The aim of this study was to analyze the professional outcomes besides their neuro-oncological and functional evaluation after surgery for gliomas in eloquent areas. METHODS We assessed neuro-oncological and functional outcomes of patients with gliomas WHO grades II and III undergoing surgery between 2012 and 2018. All patients underwent routine follow-up and adjuvant treatment. Treatment and survival parameters were collected prospectively. Repercussions of the disease on the patients' professional status, socio-economic situation, and neurocognitive function were evaluated retrospectively with questionnaires. RESULTS We analyzed data of 58 patients with gliomas (WHO II: 9; III: 49). Median patient age was 35.8 years (range 21-63 years). Awake surgery techniques were applied in 32 patients (55.2%). Gross total and subtotal tumor resections were achieved in 33 (56.9%) and 17 (29.3%) patients, respectively, whereas in 8 patients (13.8%) resection had to remain partial. Most patients (n = 46; 79.3%) received adjuvant treatment. Median follow up was 43.8 months (range 11-82 months). After treatment 41 patients (70.7%) were able to resume a working life. Median time until returning to work was 8.0 months (range 0.2-22.0 months). To be younger than 40 at the time of the surgery was associated with a higher probability to return to work (p < .001). Multivariable regression analysis showed that patient age < 40 years as well as occupational group and self-reported fatigue were factors independently associated with the ability to return to work. CONCLUSION The ability to resume professional activities following brain tumor surgery is an important patient-oriented outcome parameter. We found that the majority of patients with gliomas were able to return to work following surgical and adjuvant treatment. Preservation of neurological function is of utmost relevance for individual patients´ quality of life.
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Affiliation(s)
- Christian Senft
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany. .,University Cancer Center Frankfurt - UCT, Frankfurt, Germany.
| | - Marion Behrens
- Department of Neurology, Goethe-University Hospital, Frankfurt, Germany
| | - Irina Lortz
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Katharina Wenger
- Institute of Neuroradiology, Goethe-University Hospital, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany
| | - Katharina Filipski
- Neurological Institute (Edinger-Institute), Goethe-University, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Heidelberg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany
| | - Marie-Thérèse Forster
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany
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Voss M, Batarfi A, Steidl E, Wagner M, Forster MT, Steinbach JP, Rödel CM, Bojunga J, Ronellenfitsch MW. Adrenal Insufficiency in Patients with Corticosteroid-Refractory Cerebral Radiation Necrosis Treated with Bevacizumab. J Clin Med 2019; 8:jcm8101608. [PMID: 31623403 PMCID: PMC6832264 DOI: 10.3390/jcm8101608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/16/2022] Open
Abstract
Cerebral radiation necrosis is a common complication of the radiotherapy of brain tumours that can cause significant mortality. Corticosteroids are the standard of care, but their efficacy is limited and the consequences of long-term steroid therapy are problematic, including the risk of adrenal insufficiency (AI). Off-label treatment with the vascular endothelial growth factor A antibody bevacizumab is highly effective in steroid-resistant radiation necrosis. Both the preservation of neural tissue integrity and the cessation of steroid therapy are key goals of bevacizumab treatment. However, the withdrawal of steroids may be impossible in patients who develop AI. In order to elucidate the frequency of AI in patients with cerebral radiation necrosis after treatment with corticosteroids and bevacizumab, we performed a retrospective study at our institution's brain tumour centre. We obtained data on the tumour histology, age, duration and maximum dose of dexamethasone, radiologic response to bevacizumab, serum cortisol, and the need for hydrocortisone substitution for AI. We identified 17 patients with cerebral radiation necrosis who had received treatment with bevacizumab and had at least one available cortisol analysis. Fifteen patients (88%) had a radiologic response to bevacizumab. Five of the 17 patients (29%) fulfilled criteria for AI and required hormone substitution. Age, duration of dexamethasone treatment, and time since radiation were not statistically associated with the development of AI. In summary, despite the highly effective treatment of cerebral radiation necrosis with bevacizumab, steroids could yet not be discontinued due to the development of AI in roughly one-third of patients. Vigilance to spot the clinical and laboratory signs of AI and appropriate testing and management are, therefore, mandated.
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Affiliation(s)
- Martin Voss
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- University Cancer Center (UCT) Frankfurt, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- German Cancer Consortium (DKTK), 60590 Frankfurt am Main, Germany.
- Frankfurt Cancer Institute (FCI), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - AbdulAziz Batarfi
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Eike Steidl
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Marlies Wagner
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Marie-Thérèse Forster
- Department of Neurosurgery, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Joachim P Steinbach
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- University Cancer Center (UCT) Frankfurt, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- German Cancer Consortium (DKTK), 60590 Frankfurt am Main, Germany.
- Frankfurt Cancer Institute (FCI), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Claus M Rödel
- Department of Radiotherapy and Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Jörg Bojunga
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Michael W Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- University Cancer Center (UCT) Frankfurt, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- German Cancer Consortium (DKTK), 60590 Frankfurt am Main, Germany.
- Frankfurt Cancer Institute (FCI), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
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Voss M, Franz K, Steinbach JP, Fokas E, Forster MT, Filipski K, Hattingen E, Wagner M, Breuer S. Contrast enhancing spots as a new pattern of late onset pseudoprogression in glioma patients. J Neurooncol 2019; 142:161-169. [PMID: 30604393 DOI: 10.1007/s11060-018-03076-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/08/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Magnet resonance imaging (MRI) of gliomas is assessed by Response Assessment in Neuro-Oncology Criteria (RANO), which define new contrast-enhancing lesions as a sign for tumor recurrence. Pseudoprogression after radiotherapy may mimic tumor progression in MRI but is usually limited to the first months after irradiation. We noted a late onset pattern of new contrast-enhancing spots (NCES) appearing years after radiotherapy. METHODS We prospectively collected 23 glioma patients with 26 NCES (three patients had two separate NCES events) between 2014 and 2016 in our weekly tumor board without further selection by diagnosis, molecular markers or pretreatment. RESULTS Retrospective analysis revealed a homogeneous collective of young patients (median age of 49 years at NCES) with mainly IDH-mutated glioma (61%). Initial histology showed 26% glioblastoma, 52% grade III and 22% grade II glioma. NCES occurred at late follow-up with a median of 52 months after tumor diagnosis and 30 months after the last radiotherapy. The majority of NCES regressed spontaneously within a median of 10 months (n = 11) or remained stable without further therapy with a median follow-up of 26 months (n = 7). Only 4 NCES developed MRI morphologically into tumor recurrence. Two NCES were resected without any histopathological proof of tumor recurrence, and in 2 other cases NCES were defined as ischemic stroke or radionecrosis. CONCLUSION We hypothesize that the late onset phenomenon of NCES predominantly represents a form of radiation-induced vasculopathy that is different from early pseudoprogression and should be considered especially in younger patients with IDH-mutated glioma before initiation of new therapy.
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Affiliation(s)
- Martin Voss
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
| | - Kea Franz
- Departement of Neurosurgery, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Joachim P Steinbach
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Marie-Thérèse Forster
- Departement of Neurosurgery, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Katharina Filipski
- Institut of Neurology (Edinger-Institute), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Elke Hattingen
- Departement of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Marlies Wagner
- Departement of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Stella Breuer
- Departement of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Balermpas P, Stera S, Müller von der Grün J, Loutfi-Krauss B, Forster MT, Wagner M, Keller C, Rödel C, Seifert V, Blanck O, Wolff R. Repeated in-field radiosurgery for locally recurrent brain metastases: Feasibility, results and survival in a heavily treated patient cohort. PLoS One 2018; 13:e0198692. [PMID: 29874299 PMCID: PMC5991396 DOI: 10.1371/journal.pone.0198692] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 05/23/2018] [Indexed: 01/08/2023] Open
Abstract
Purpose Stereotactic radiosurgery (SRS) is an established primary treatment for newly diagnosed brain metastases with high local control rates. However, data about local re-irradiation in case of local failure after SRS (re-SRS) are rare. We evaluated the feasibility, efficacy and patient selection characteristics in treating locally recurrent metastases with a second course of SRS. Methods We retrospectively evaluated patients with brain metastases treated with re-SRS for local tumor progression between 2011 and 2017. Patient and treatment characteristics as well as rates of tumor control, survival and toxicity were analyzed. Results Overall, 32 locally recurrent brain metastases in 31 patients were irradiated with re-SRS. Median age at re-SRS was 64.9 years. The primary histology was breast cancer and non-small-cellular lung cancer (NSCLC) in respectively 10 cases (31.3%), in 5 cases malignant melanoma (15.6%). In the first SRS-course 19 metastases (59.4%) and in the re-SRS-course 29 metastases (90.6%) were treated with CyberKnife® and the others with Gamma Knife. Median planning target volume (PTV) for re-SRS was 2.5 cm3 (range, 0.1–37.5 cm3) and median dose prescribed to the PTV was 19 Gy (range, 12–28 Gy) in 1–5 fractions to the median 69% isodose (range, 53–80%). The 1-year overall survival rate was 61.7% and the 1-year local control rate was 79.5%. The overall rate of radiological radio-necrosis was 16.1% and four patients (12.9%) experienced grade ≥ 3 toxicities. Conclusions A second course of SRS for locally recurrent brain metastases after prior local SRS appears to be feasible with acceptable toxicity and can be considered as salvage treatment option for selected patients with high performance status. Furthermore, this is the first study utilizing robotic radiosurgery for this indication, as an additional option for frameless fractionated treatment.
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Affiliation(s)
- Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
- Saphir Radiosurgery Center, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK) partner site: Frankfurt am Main, Germany
- * E-mail:
| | - Susanne Stera
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Jens Müller von der Grün
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Britta Loutfi-Krauss
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Marie-Thérèse Forster
- Department of Neurosurgery, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Marlies Wagner
- Institute for Neuroradiology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Christian Keller
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
- Saphir Radiosurgery Center, Frankfurt, Germany
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK) partner site: Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center, Frankfurt, Germany
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center, Frankfurt, Germany
- Department of Neurosurgery, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
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9
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Zeiner PS, Zinke J, Kowalewski DJ, Bernatz S, Tichy J, Ronellenfitsch MW, Thorsen F, Berger A, Forster MT, Muller A, Steinbach JP, Beschorner R, Wischhusen J, Kvasnicka HM, Plate KH, Stefanović S, Weide B, Mittelbronn M, Harter PN. CD74 regulates complexity of tumor cell HLA class II peptidome in brain metastasis and is a positive prognostic marker for patient survival. Acta Neuropathol Commun 2018; 6:18. [PMID: 29490700 PMCID: PMC5831742 DOI: 10.1186/s40478-018-0521-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 02/18/2018] [Indexed: 12/30/2022] Open
Abstract
Despite multidisciplinary local and systemic therapeutic approaches, the prognosis for most patients with brain metastases is still dismal. The role of adaptive and innate anti-tumor response including the Human Leukocyte Antigen (HLA) machinery of antigen presentation is still unclear. We present data on the HLA class II-chaperone molecule CD74 in brain metastases and its impact on the HLA peptidome complexity.We analyzed CD74 and HLA class II expression on tumor cells in a subset of 236 human brain metastases, primary tumors and peripheral metastases of different entities in association with clinical data including overall survival. Additionally, we assessed whole DNA methylome profiles including CD74 promoter methylation and differential methylation in 21 brain metastases. We analyzed the effects of a siRNA mediated CD74 knockdown on HLA-expression and HLA peptidome composition in a brain metastatic melanoma cell line.We observed that CD74 expression on tumor cells is a strong positive prognostic marker in brain metastasis patients and positively associated with tumor-infiltrating T-lymphocytes (TILs). Whole DNA methylome analysis suggested that CD74 tumor cell expression might be regulated epigenetically via CD74 promoter methylation. CD74high and TILhigh tumors displayed a differential DNA methylation pattern with highest enrichment scores for antigen processing and presentation. Furthermore, CD74 knockdown in vitro lead to a reduction of HLA class II peptidome complexity, while HLA class I peptidome remained unaffected.In summary, our results demonstrate that a functional HLA class II processing machinery in brain metastatic tumor cells, reflected by a high expression of CD74 and a complex tumor cell HLA peptidome, seems to be crucial for better patient prognosis.
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Affiliation(s)
- P S Zeiner
- Edinger Institute (Institute of Neurology), Goethe-University, Heinrich-Hoffmann-Str. 7, D-60528, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neurooncology, Goethe-University, Frankfurt am Main, Germany
| | - J Zinke
- Edinger Institute (Institute of Neurology), Goethe-University, Heinrich-Hoffmann-Str. 7, D-60528, Frankfurt am Main, Germany
| | - D J Kowalewski
- Department of Immunology, Institute for Cell Biology, University of Tuebingen, Tuebingen, Germany
- Immatics Biotechnologies GmbH, Tübingen, Germany
| | - S Bernatz
- Edinger Institute (Institute of Neurology), Goethe-University, Heinrich-Hoffmann-Str. 7, D-60528, Frankfurt am Main, Germany
| | - J Tichy
- Dr. Senckenberg Institute of Neurooncology, Goethe-University, Frankfurt am Main, Germany
| | - M W Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, Goethe-University, Frankfurt am Main, Germany
| | - F Thorsen
- Department of Biomedicine, The Kristian Gerhard Jebsen Brain Tumour Research Center and The Molecular Imaging Center, University of Bergen, Bergen, Norway
| | - A Berger
- Institute for Virology, Goethe-University, Frankfurt am Main, Germany
| | - M T Forster
- Department of Neurosurgery, Goethe-University, Frankfurt am Main, Germany
| | - A Muller
- Department of Oncology, Luxembourg Institute of Health, Luxembourg, Luxembourg
| | - J P Steinbach
- Dr. Senckenberg Institute of Neurooncology, Goethe-University, Frankfurt am Main, Germany
- German Cancer Research Center DKFZ Heidelberg, Germany and German Cancer Consortium DKTK partner site, Frankfurt/Mainz, Germany
| | - R Beschorner
- Department of Pathology and Neuropathology, University of Tuebingen, Tuebingen, Germany
| | - J Wischhusen
- Department of Gynecology, University of Wuerzburg, Wuerzburg, Germany
| | - H M Kvasnicka
- Goethe-University, Dr. Senckenberg Institute for Pathology, Frankfurt am Main, Germany
| | - K H Plate
- Edinger Institute (Institute of Neurology), Goethe-University, Heinrich-Hoffmann-Str. 7, D-60528, Frankfurt am Main, Germany
- German Cancer Research Center DKFZ Heidelberg, Germany and German Cancer Consortium DKTK partner site, Frankfurt/Mainz, Germany
| | - S Stefanović
- Department of Immunology, Institute for Cell Biology, University of Tuebingen, Tuebingen, Germany
| | - B Weide
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany
| | - M Mittelbronn
- Edinger Institute (Institute of Neurology), Goethe-University, Heinrich-Hoffmann-Str. 7, D-60528, Frankfurt am Main, Germany
- German Cancer Research Center DKFZ Heidelberg, Germany and German Cancer Consortium DKTK partner site, Frankfurt/Mainz, Germany
- Luxembourg Centre of Neuropathology (LCNP), 3555, Dudelange, Luxembourg
- Laboratoire National de Santé, Department of Pathology, 3555, Dudelange, Luxembourg
- Luxembourg Centre for Systems Biomedicine (LCSB), University of Luxembourg, 4361, Esch-sur-Alzette, Luxembourg
- NORLUX Neuro-Oncology Laboratory, Department of Oncology, Luxembourg Institute of Health (L.I.H.), 1526, Luxembourg, Luxembourg
| | - P N Harter
- Edinger Institute (Institute of Neurology), Goethe-University, Heinrich-Hoffmann-Str. 7, D-60528, Frankfurt am Main, Germany.
- German Cancer Research Center DKFZ Heidelberg, Germany and German Cancer Consortium DKTK partner site, Frankfurt/Mainz, Germany.
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Gessler F, Forster MT, Duetzmann S, Mittelbronn M, Hattingen E, Franz K, Seifert V, Senft C. Combination of Intraoperative Magnetic Resonance Imaging and Intraoperative Fluorescence to Enhance the Resection of Contrast Enhancing Gliomas. Neurosurgery 2015; 77:16-22; discussion 22. [DOI: 10.1227/neu.0000000000000729] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Evidence suggests that extent of resection (EOR) is a prognostic factor for patients harboring gliomas. Recent studies have displayed the importance of intraoperative magnetic resonance imaging (iMRI) with 5-aminolevulinic acid (5-ALA) fluorescence-guidance in order to maximize EOR.
OBJECTIVE:
To compare iMRI and 5-ALA fluorescence-guidance and the impact on patient survival.
METHODS:
Thirty-two patients with contrast-enhancing gliomas undergoing intended gross total resection (GTR) were included in a prospective study. Surgeries were started under white-light conditions. When GTR was thought to be achieved, an iMRI scan was performed and a blue light turned on to search for unintentionally remaining tumor tissue. iMRI findings were compared with intraoperative fluorescence findings. Histological examination of tumor bulk and any additionally resected tissue was performed. All patients underwent early postoperative high-field MRI to determine EOR.
RESULTS:
In 13 patients (40.6%), iMRI and fluorescence unequivocally did not show residual tumor intraoperatively. In 19 patients (59.4%), resection was continued due to iMRI or fluorescence findings. In 9 of these (47.4%), iMRI and fluorescence findings were inconsistent regarding residual tumor. GTR according to postoperative MRI was achieved in all but 1 patient. Histological examination ruled out false positive findings in all additionally resected specimens. Sensitivity and specificity to detect residual tumor tissue were 75% and 100%, respectively, for iMRI and 70% and 100% for 5-ALA fluorescence.
CONCLUSION:
Use of iMRI as well as fluorescence-guidance are appropriate methods to improve the extent of resection in surgery of contrast-enhancing gliomas. Best results can be achieved by complementary use of both modalities.
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Affiliation(s)
- Florian Gessler
- Department of Neurosurgery, Goethe-University, Frankfurt, Germany
| | | | | | - Michel Mittelbronn
- Institute of Neurology (Edinger-Institute), Goethe-University, Frankfurt, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, Goethe-University, Frankfurt, Germany
| | - Kea Franz
- Department of Neurosurgery, Goethe-University, Frankfurt, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University, Frankfurt, Germany
| | - Christian Senft
- Department of Neurosurgery, Goethe-University, Frankfurt, Germany
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Forster MT, Limbart M, Seifert V, Senft C. Test-retest reliability of navigated transcranial magnetic stimulation of the motor cortex. Neurosurgery 2014; 10 Suppl 1:51-5; discussion 55-6. [PMID: 23842557 DOI: 10.1227/neu.0000000000000075] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Because navigated transcranial magnetic stimulation (nTMS) is increasingly used in neurosurgical research, interpretation of its results is of utmost importance. OBJECTIVE To evaluate the test-retest reliability of nTMS. METHODS Twelve healthy participants underwent nTMS at 2 different sessions separated by 10.3 ± 9.6 days. Investigated parameters included resting motor thresholds, hotspots, and centers of gravity calculated for the first dorsal interosseous, abductor pollicis brevis, extensor digitorum, tibial anterior, and abductor hallucis muscles. RESULTS Excellent reliability of resting motor thresholds was observed. Hotspots and centers of gravity showed moderate to excellent repeatability along the anteroposterior axis (intraclass correlation coefficient, 0.54-0.89), whereas the x coordinate presented mainly poor to moderate stability (intraclass correlation coefficient, 0.11-0.89). Movement of centers of gravity over sessions was 0.57 ± 0.32 cm, and hotspots laid 0.79 ± 0.47 cm apart. Calculation of coefficient of variation revealed high reliability of investigated parameters in upper extremities; in lower extremity muscles, high variation across sessions was observed. CONCLUSION nTMS can be considered a reliable tool, thus opening new fields of noninvasive investigations in neurosurgery. The results presented here should be considered in the interpretation of individual nTMS results.
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12
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Abstract
OBJECTIVE Surgical management of sphenoorbital meningiomas ranges among the most complex of intracranial tumors. We report on our experience of surgical technique, outcome, and tumor recurrence in sphenoorbital meningiomas. METHODS Between 2003 and 2013, surgical resections for sphenoorbital meningioma were performed in 18 patients (aged 49·6±9·8 years, only women), with two patients operated anew due to tumor recurrence. RESULTS Main symptom was proptosis (83·3%), followed by diminished visual acuity (38·9%), and dizziness (11·1%). In all patients the lateral orbital wall was resected, whereas the orbital roof and the zygoma were removed according to the extent of their tumorous infiltration. Unroofing of the optic canal was performed in 10 cases (55·6%) and unroofing of the optic foramen in two (11·1%). For reconstruction split calvarian bone and titanium mesh were used in six (33·3%) and seven patients (38·9%), respectively; in one patient both techniques were applied. In five patients (27·8%), no reconstruction was necessary. Complete tumor resection (Simpson grade 1 and 2) was achieved in 14 cases (77·7%). Postoperatively, proptosis improved in all patients. Median follow-up was 39·5±33·3 months (range 1-105) in 16 patients; 2 patients were lost to follow-up. No tumor recurrence was noted in five (27·8%) patients, whereas in nine (50%) patients tumor remnants proved stable over time. Two (11·1%) patients experienced progression of residual tumor, resulting in reoperation after 27 and 109 months, respectively. DISCUSSION Despite their delicate anatomical relations, surgery of sphenoorbital meningiomas is safe when combining modern techniques.
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13
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Forster MT, Senft C, Hattingen E, Lorei M, Seifert V, Szelényi A. Motor cortex evaluation by nTMS after surgery of central region tumors: a feasibility study. Acta Neurochir (Wien) 2012; 154:1351-9. [PMID: 22669201 DOI: 10.1007/s00701-012-1403-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 05/18/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Largely discussed during the past decade, motor cortex reorganization in brain tumor surgery has been investigated only by few studies. We therefore aimed to investigate cortical motor representation after resection of perirolandic WHO grade II and III gliomas using navigated transcranial magnetic stimulation (nTMS). METHODS Five patients were examined before neurosurgery and after a follow-up period of 17.7 ± 6.8 months. As a control, five healthy age-matched subjects were equally studied by nTMS in two sessions spaced 12.6 (range 2-35) days apart. Resting motor thresholds (RMT), hotspots and centers of gravity (CoG) were identified for the first dorsal interosseous (FDI), abductor pollicis brevis (APB), extensor digitorum (EXT), tibialis anterior (TA) and abductor hallucis (AH) muscles. Euclidian distances, coefficients of variance and intraclass correlation coefficients (ICC) were calculated. RESULTS Healthy subjects showed moderate to excellent reliability measurement of RMT (ICC = 0.69-0.94). Average displacement of CoGs across sessions was 0.68 ± 0.34 cm in the dominant and 0.76 ± 0.38 cm in the non-dominant hemisphere; hotspots moved 0.87 ± 0.51 cm and 0.83 ± 0.45 cm, respectively. In one patient these parameters differed significantly from the control group (p < 0.05 for both CoGs and hotspots). Overall, all patients' CoGs moved 1.12 ± 0.93 cm, and hotspots were 1.06 ± 0.7 cm apart. In both patients and healthy subjects, movement of assessed parameters was more important along the X- than the Y-axis. CONCLUSIONS nTMS allows evaluating cortical reorganization after brain tumor surgery. It may contribute to the understanding of neurofunctional dynamics, thus influencing therapeutic strategy.
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Affiliation(s)
- Marie-Thérèse Forster
- Department of Neurosurgery, Goethe University Hospital, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
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14
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Senft C, Forster MT, Bink A, Mittelbronn M, Franz K, Seifert V, Szelényi A. Optimizing the extent of resection in eloquently located gliomas by combining intraoperative MRI guidance with intraoperative neurophysiological monitoring. J Neurooncol 2012; 109:81-90. [PMID: 22528791 DOI: 10.1007/s11060-012-0864-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 03/29/2012] [Indexed: 10/28/2022]
Abstract
Several methods have been introduced to improve the extent of resection in glioma surgery. Yet, radical tumor resections must not be attempted at the cost of neurological deterioration. We sought to assess whether the use of an intraoperative MRI (iMRI) in combination with multimodal neurophysiological monitoring is suitable to increase the extent of resection without endangering neurological function in patients with eloquently located gliomas. Fifty-four patients were included in this study. In 21 patients (38.9 %), iMRI led to additional tumor resection. A radiologically complete resection was achieved in 31 patients (57.4 %), while in 12 of these, iMRI had depicted residual tumor tissue before resection was continued. The mean extent of resection was 92.1 % according to volumetric analyses. Postoperatively, 13 patients (24.1 %) showed new or worsening of pre-existing sensory motor deficits. They were severe in 4 patients (7.4 %). There was no correlation between the occurrence of either any new (P = 0.77) or severe (P = 1.0) sensory motor deficit and continued resection after intraoperative image acquisition. Likewise, tumor location, histology, and tumor recurrence did not influence complication rate on uni- and multivariate analysis. We conclude that the combination of iMRI guidance with multimodal neurophysiological monitoring allows for extended resections in glioma surgery without inducing higher rates of neurological deficits, even in patients with eloquently located tumors.
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Affiliation(s)
- Christian Senft
- Department of Neurosurgery, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528, Frankfurt, Germany.
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15
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Forster MT, Hattingen E, Senft C, Gasser T, Seifert V, Szelényi A. Navigated Transcranial Magnetic Stimulation and Functional Magnetic Resonance Imaging: Advanced Adjuncts in Preoperative Planning for Central Region Tumors. Neurosurgery 2011; 68:1317-24; discussion 1324-5. [DOI: 10.1227/neu.0b013e31820b528c] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Tumor resection in the vicinity of the motor cortex poses a challenge to all neurosurgeons. For preoperative assessment of eloquent cortical areas, functional magnetic resonance imaging (fMRI) is used, whereas intraoperatively, direct cortical stimulation (DCS) is performed. Navigated transcranial magnetic stimulation (nTMS) is comparable to DCS in activating cortical pyramidal neurons.
OBJECTIVE:
To evaluate the reliability of nTMS compared with fMRI and DCS for preoperative resection planning of centrally located tumors.
METHODS:
In a prospective series, 11 patients (ages, 20-63 years; mean, 41.9 ± 14.9 years, 2 women) with tumors located in or adjacent to the motor cortex were evaluated for surgery. fMRI and nTMS were applied for preoperative assessment of the extent of tumor resection. A 3-dimensional anatomic data set with superimposed fMRI data was integrated in the eXimia Navigated Brain Stimulation station for ensuing motor cortex mapping by nTMS. Responses from nTMS were evaluated by electromyographic response. During surgery, the coordinates of each DCS site were unambiguously defined and integrated into neuronavigation. A post hoc comparison of the coordinates of nTMS, fMRI, and DCS was performed.
RESULTS:
Distances from nTMS to DCS (10.5 ± 5.67 mm) were significantly smaller than those from fMRI to DCS (15.0 ± 7.6 mm).
CONCLUSION:
nTMS anticipates information usually only enabled by DCS and therefore allows surgical planning in eloquent cortex surgery.
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Affiliation(s)
- Marie-Thérèse Forster
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
| | - Elke Hattingen
- Department of Neuroradiology, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
| | - Christian Senft
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
| | - Thomas Gasser
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
| | - Andrea Szelényi
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
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Forster MT, Mathé AK, Senft C, Scharrer I, Seifert V, Gerlach R. The influence of preoperative anticoagulation on outcome and quality of life after surgical treatment of chronic subdural hematoma. J Clin Neurosci 2010; 17:975-9. [PMID: 20580997 DOI: 10.1016/j.jocn.2009.11.023] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 11/23/2009] [Accepted: 11/24/2009] [Indexed: 11/17/2022]
Abstract
The main aim of this study was to investigate the influence of perioperative anticoagulation on the clinical course and outcome of 144 patients who underwent surgery for chronic subdural hematoma (CSDH). The outcome was categorized according to the modified Rankin Scale (mRS), Barthel Index and postoperative quality of life (QoL) scale. There was a significant correlation between preoperative aspirin medication and reoperation (Mann-Whitney U-test, p<0.05). Moreover, dosage and duration of postoperative low-molecular-weight heparin (LMWH) administration were associated with a higher risk of reoperation (Mann-Whitney U-test, p<0.01) and a worse outcome on the mRS (Mann-Whitney U-test, p<0.05). Intraoperative treatment with prothrombin complex concentrate led to a poor outcome on the mRS (Craddock-Flood test, p<0.05). Reoperation is the strongest predictive factor of a poor QoL after surgical treatment of CSDH. Both preoperative and postoperative anticoagulation treatment may affect reoperation rate and, thus, postoperative QoL.
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Affiliation(s)
- M T Forster
- Department of Neurosurgery, Goethe University Frankfurt am Main, Schleusenweg 2-16, D-60528 Frankfurt am Main, Germany.
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Forster MT, Hattingen E, Gasser T, Senft C, Seifert V, Szelényi A. Navigated Transcranial Magnetic Stimulation and functional Magnetic Resonance Imaging – advanced adjuncts in preoperative planning for central region tumors. KLIN NEUROPHYSIOL 2010. [DOI: 10.1055/s-0030-1250971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Senft C, Schuster T, Forster MT, Seifert V, Gerlach R. Management and outcome of patients with acute traumatic subdural hematomas and pre-injury oral anticoagulation therapy. Neurol Res 2009; 31:1012-8. [PMID: 19570326 DOI: 10.1179/174313209x409034] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Acute subdural hematomas (aSDHs) are found in up to one-third of patients with severe traumatic brain injury and are associated with an unfavorable outcome in the majority of cases. Mortality ranges between 40 and 60%, but was reported to be even higher in patients undergoing oral anticoagulation therapy (OAT) at the time of injury. The objective of this study is to specifically report on the peri-operative management and outcome of patients with aSDH and pre-injury OAT. MATERIAL AND METHODS From June 2002 to June 2006, all patients with OAT who underwent surgical treatment of aSDH were retrospectively analysed. Results of pre-operative blood tests, the peri-operative and surgical management and the clinical courses were assessed. Patient outcome is reported according to the Glasgow Outcome Scale (GOS) at 6 months. RESULTS Eleven (10.3%) out of 107 patients with aSDH were on OAT. Patients with OAT were significantly older than patients without OAT (72.4 +/- 9.3 versus 59.9 +/- 17.5 years; p<0.05, Mann-Whitney U-test). Intensity of head trauma was moderate in four and severe in seven patients with a median pre-operative Glasgow Coma Scale (GCS) of 8. Median pre-treatment prothrombin time and international normalized ratio were 23% (range: 10-65%) and 3.3 (range: 1.5-10.6), respectively. Replacement therapy consisted of administration of prothrombin complex concentrates, vitamin K and FFP (fresh frozen plasma). In four patients, antithrombin was additionally given to prevent disseminated intravascular coagulation. Surgical treatment consisted of craniotomy (n=10) or craniectomy (n=1) and hematoma evacuation with intracranial pressure probe placement. Low molecular weight heparin was administered as pharmacological prophylaxis of thrombembolic events in an increasing dose post-operatively. At 6 months, six out of 11 patients survived with a median GOS of 4. All-cause mortality was 45.5%. A pre-operative GCS of < or = 8 was not associated with an increased risk of mortality (p>0.5, Fisher's exact test). No relevant rebleedings or thrombembolic complications were observed. The mortality rate of patients who did not undergo OAT was 50%. CONCLUSION A large number of patients with aSDH are on pre-injury OAT. Specific replacement therapy facilitates successful clot evacuation without bleeding complications. The overall outcome of these patients does not seem to differ from historical cohorts with aSDH without OAT, but a large prospective multicenter study is warranted to answer that question.
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Affiliation(s)
- Christian Senft
- Department of Neurosurgery, Goethe University, Frankfurt, Germany.
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Neubauer A, Wolfsberger S, Forster MT, Mroz L, Wegenkittl R, Bühler K. Advanced virtual endoscopic pituitary surgery. IEEE Trans Vis Comput Graph 2005; 11:497-507. [PMID: 16144247 DOI: 10.1109/tvcg.2005.70] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Endoscopy has recently been introduced to endonasal transsphenoidal pituitary surgery as a minimally invasive procedure for the removal of various kinds of pituitary tumors. To reduce morbidity and mortality with this new technique, the surgeon must be well-trained and well-prepared. Virtual endoscopy can be beneficial as a tool for training, preoperative planning, and intraoperative support. This paper introduces STEPS, a virtual endoscopy system designed to aid surgeons in getting acquainted with the endoscopic view of the anatomy, the handling of instruments, the transsphenoidal approach, and challenges associated with the procedure. STEPS also assists experienced surgeons in planning a real endoscopic intervention by getting familiar with the individual patient anatomy, identifying landmarks, planning the approach, and deciding upon the ideal target position of the actual surgical activity. The application provides interactive visualization, navigation, and perception aids and the possibility of simulating the procedure, including haptic feedback and simulation of surgical instruments.
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Affiliation(s)
- André Neubauer
- VRVis Research Center, Donaucitystrasse 1, 1220 Wien, Austria.
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