Changes in multi-modality management of acromegaly in a tertiary centre over 2 decades

PURPOSE

Acromegaly is a rare disease associated with chronic multisystem complications. New therapeutic strategies have emerged in the last decades, combining pituitary transsphenoidal surgery (TSS), radiotherapy or radiosurgery (RXT) and medical treatments.

METHODS

This retrospective monocentric study focused on presentation, management and outcome of acromegaly patients diagnosed between 2000 and 2020, still followed up in 2020, with a minimum follow-up of 1 year, and comparison of the first vs. second decade of the study.

RESULTS

275 patients were included, 50 diagnosed before 2010 and 225 after 2010. 95% of them had normal IGF-1 levels (with or without treatment) at the last follow-up. Transsphenoidal surgery was more successful after 2010 (75% vs. 54%; p < 0.01), while tumor characteristics remained the same over time. The time from first treatment to biochemical control was shorter after 2010 than before (8 vs. 16 months; p = 0.03). Since 2010, RT was used less frequently (10% vs. 32%; p < 0.01) but more rapidly after surgery (26 vs. 53 months; p = 0.03). In patients requiring anti-secretory drugs after TSS, the time from first therapy to biochemical control was shorter after 2010 (16 vs. 29 months; p < 0.01). Tumor size, tumor invasiveness, baseline IGF-1 levels and Trouillas classification were identified as predictors of remission.

CONCLUSION

The vast majority of patients with acromegaly now have successful disease control with a multimodal approach. They reached biochemical control sooner in the most recent half of the study period. Future work should focus on those patients who are still uncontrolled and on the sequelae of the disease.

3D volume growth rate evaluation in the EORTC-BTG-1320 clinical trial for recurrent WHO grade 2 and 3 meningiomas

BACKGROUND

We previously reported that tumor 3D volume growth rate (3DVGR) classification could help in the assessment of drug activity in patients with meningioma using three main classes and a total of five subclasses: class 1: decrease; 2: stabilization or severe slowdown; 3: progression. The EORTC-BTG-1320 clinical trial was a randomized phase II trial evaluating the efficacy of trabectedin for recurrent WHO 2 or 3 meningioma. Our objective was to evaluate the discriminative value of 3DVGR classification in the EORTC-BTG-1320.

METHODS

All patients with at least one available MRI before trial inclusion were included. 3D volume was evaluated on consecutive MRI until progression. 2D imaging response was centrally assessed by MRI modified Macdonald criteria. Clinical benefit was defined as neurological or functional status improvement or steroid decrease or discontinuation.

RESULTS

Sixteen patients with a median age of 58.5 years were included. Best 3DVGR classes were: 1, 2A, 3A and 3B in 2 (16.7%), 4 (33.3%), 2 (16.7%) and 4 (33.3%) patients, respectively. All patients with progression-free survival longer than 6 months had best 3DVGR class 1 or 2. 3DVGR classes 1 and 2 (combined) had a median overall survival of 34.7 months versus 7.2 months for class 3 (p=0.061). All class 1 patients (2/2), 75% of class 2 patients (3/4) and only 10% of class 3 patients (1/10) had clinical benefit.

CONCLUSIONS

Tumor 3DVGR classification may be helpful to identify early signals of treatment activity in meningioma clinical trials.

Innovative treatments for meningiomas

Multi-recurrent high-grade meningiomas remain an unmet medical need in neuro-oncology when iterative surgeries and radiation therapy sessions fail to control tumor growth. Nevertheless, the last 10years have been marked by multiple advances in the comprehension of meningioma tumorigenesis via the discovery of new driver mutations, the identification of activated intracellular signaling pathways, and DNA methylation analyses, providing multiple potential therapeutic targets. Today, Anti-VEGF and mTOR inhibitors are the most used and probably the most active drugs in aggressive meningiomas. Peptide radioactive radiation therapy aims to target SSTR2A receptors, which are strongly expressed in meningiomas, but have an insufficient effect in most aggressive meningiomas, requiring the development of new techniques to increase the dose applied to the tumor. Based on the multiple potential intracellular targets, multiple targeted therapy clinical trials targeting Pi3K-Akt-mTOR and MAP kinase pathways as well as cell cycle and particularly, cyclin D4-6 are ongoing. Recently discovered driver mutations, SMO, Akt, and PI3KCA, offer new targets but are mostly observed in benign meningiomas, limiting their clinical relevance mainly to rare aggressive skull base meningiomas. Therefore, NF2 mutation remains the most frequent mutation and main challenging target in high-grade meningioma. Recently, inhibitors of focal adhesion kinase (FAK), which is involved in tumor cell adhesion, were tested in a phase 2 clinical trial with interesting but insufficient activity. The Hippo pathway was demonstrated to interact with NF2/Merlin and could be a promising target in NF2-mutated meningiomas with ongoing multiple preclinical studies and a phase 1 clinical trial. Recent advances in immune landscape comprehension led to the proposal of the use of immunotherapy in meningiomas. Except in rare cases of MSH2/6 mutation or high tumor mass burden, the activity of PD-1 inhibitors remains limited; however, its combination with various radiation therapy modalities is particularly promising. On the whole, therapeutic management of high-grade meningiomas is still challenging even with multiple promising therapeutic targets and innovations.

Contribution of nuclear medicine to the diagnosis and management of primary brain tumours

Positron emission tomography (PET) is a powerful tool that can help physicians manage primary brain tumours at diagnosis and follow-up. In this context, PET imaging is used with three main types of radiotracers: ¹⁸F-FDG, amino acid radiotracers, and ⁶⁸Ga conjugated to somatostatin receptor ligands (SSTRs). At initial diagnosis, ¹⁸F-FDG helps to characterize primary central nervous system (PCNS) lymphomas and high-grade gliomas, amino acid radiotracers are indicated for gliomas, and SSTR PET ligands are indicated for meningiomas. Such radiotracers provide information on tumour grade or type, assist in directing biopsies and help with treatment planning. During follow-up, in the presence of symptoms and/or MRI modifications, the differential diagnosis between tumour recurrence and post-therapeutic changes, in particular radiation necrosis, may be challenging, and there is strong interest in using PET to evaluate therapeutic toxicity. PET may also contribute to identifying specific complications, such as postradiation therapy encephalopathy, encephalitis associated with PCNS lymphoma, and stroke-like migraine after radiation therapy (SMART) syndrome associated with glioma recurrence and temporal epilepsy, originally illustrated in this review. This review summarizes the main contribution of PET to the diagnosis, management, and follow-up of brain tumours, specifically gliomas, meningiomas, and primary central nervous system lymphomas.

Meningiomas in patients with long-term exposition to progestins: Characteristics and outcome

OBJECTIVE

The aim of this study was to describe progestin-associated meningiomas' characteristics, outcome and management.

MATERIAL AND METHODS

We included 53 patients operated on and/or followed in the department for meningioma with progestin intake longer than one year and with recent drug discontinuation.

RESULTS

Cyproterone acetate (CPA), nomegestrol acetate (NomA), and chlormadinone acetate (ChlA) were involved in most cases. Mean duration of progestin drugs intake was 17.5 years. Tumors were multiple in 66% of cases and were located in the anterior and the medial skull base in 71% of cases. Transitional subtype represented 16/25 tumors; 19 meningiomas were WHO grade I and 6 were grade II. The rate of transitional subtype and skull base location was significantly higher compared to matched operated meningioma general population. No difference was observed given WHO classification. But Ki67 proliferation index tends to be lower and 5/6 of the WHO grade II meningiomas were classified as WHO grade II because of brain invasion. Strong progesterone receptors expression was observed in most cases. After progestin discontinuation, a spontaneous visual recovery was observed in 6/10 patients. Under CPA (n=24) and ChlA/NomA (n=11), tumor volume decreased in 71% and 18% of patients, was stabilized in 25% and 64% of patients, and increased in 4% and 18% of patients, respectively. Volume outcome was related to meningioma location.

CONCLUSIONS

Outcome at progestins discontinuation is favorable but different comparing CPA versus ChlA-NomA and comparing tumor location. Long-term follow-up is required. In most cases, simple observation is recommended and surgery should be avoided.

Management of patients suffering from hemorrhagic intracranial metastases: Propositions to help the neurosurgeon in emergency situations based on a literature review

INTRODUCTION

Brain metastases are the most common intracranial neoplasm in adult patients, and one of the fearsome complications proves to be intratumoral hemorrhage. The neurosurgical management of patients harboring a bleeding brain metastasis is not fully established and there is still today an ongoing debate on the optimal management of these patients. The aim of this article is to provide the neurosurgeons with practical tools to assist in their decision-making process in the management of BMs.

METHODS

We conducted a literature review of the relevant Pubmed, Cochrane, and Google scholar-indexed articles published between 2000 and 2019. The following key words were entered in the Pubmed search engine: [metastasis], [metastases], [brain metastases], [brain metastasis], [hemorrhage], [hematoma], [blood clot], [intracerebral hemorrhage], [intracranial hemorrhage]. The review was performed in accordance with the PRISMA recommendations.

RESULTS

Based on PubMed, Cochrane, and Google scholar, 459 articles were retained, 392 were then removed because of their non-adequacy with the topic and, 9 articles were removed because they were not written in English language. So, 58 articles were analyzed. Radiological evaluation is crucial, but few traps exist. The frequency of overall brain tumor-related with intracranial hematoma is 7.2%, with a higher frequency for secondary tumors. The local recurrence rate after resection of a hemorrhagic metastasis seems to be better probably because of an easier "en bloc" resection thanks to the hematoma. An atypical presentation is reported in up to 4% in patients with chronic or acute subdural hematoma. Patients with subarachnoid hemorrhage and epidural hematoma are rare. A clear-cut correlation between the incidence of bleeding event in brain mets and prior stereotactic radiosurgery was not established.

CONCLUSION

The current literature pertaining to the neurosurgical management of acute bleeding in brain metastasis is scant and the level of evidence remains low (experts 'opinions; class C). Herein we suggest a flowchart to assist in dealing with those difficult patients.

The interest of intraoperative scanner coupled to neuronavigation in traumatic or oncologic fractures of the cervical and upper thoracic spine requiring vertebral body height restoring procedures

OBJECT

In recent years, the classical vertebroplasty has tended to be replaced by vertebral augmentation procedures. This article discusses the reliability of vertebral augmentation procedures using balloon kyphoplasty or a spine jack system, with intraoperative CT scan control coupled with the neuronavigation system as a treatment option for cervical and upper thoracic spine lesions.

METHODS

In our neurosurgical department, in the past two years, 11 patients underwent either a kyphoplasty or a vertebral augmentation by a Spine Jack via a transpedicular route, under perioperative 3D imaging, for a total of 15 cervical/upper thoracic lesions. For these patients, we evaluated the clinical symptoms before and after surgery, the intraoperative and postoperative complications as well as the radiation exposure and the duration of their hospitalisation.

RESULTS

We noted for all of the patients an improvement of the mean Karnofsky index, which improved from 50 to 80, and of the VAS that decreased from a mean of 75 to 15, as they were clearly alleviated after the operation. The radiation was lower for patients that were treated for 2 or more vertebrae, and much lower for the medical staff. The intraoperative complications rate (4 cement leakages for 15 vertebrae, 26%), was low and completely asymptomatic in all cases. The radiological follow-up examinations were satisfactory for all the patients.

CONCLUSIONS

Our results suggest that percutaneous transpedicular vertebral augmentation techniques using intraoperative CT scan are a viable treatment for secondary lesions or traumatic compression fractures of the cervical and upper thoracic spine.

Minimally invasive posterior fixation and anterior debridement-fusion for thoracolumbar spondylodiscitis: A 40-case series and review of the literature

INTRODUCTION

Pyogenic spondylodiscitis is a rare disease, but incidence is increasing. Reported failure rates following conservative management range from 12% to 18%. The purpose of this study was to determine the safety and efficacy of posterior percutaneous pedicle screw fixation combined with anterior debridement and fusion (ADF) for infective spondylodiscitis in the thoracic and/or lumbar spine.

METHODS

The retrospective study cohort comprised all patients without neurological deficit who underwent minimally invasive posterior and anterior surgery between April 2008 and April 2016 for thoracic and/or lumbar spondylodiscitis.

RESULTS

Forty patients were eligible (16 female: 40%). The lumbar region was affected in 31 cases (77.5%). Source of infection was identified in only 22 cases (55%) and bacteriological identification was obtained in 32 cases (80%). Mean hospital stay was 14.8 days (range, 6-39 days). Complete recovery was achieved in 39 patients (97.5%) at 3 months' follow-up. Mean preoperative local kyphosis angle was 16.1^o, versus 14^o at 1-year (P>0.05). 36 patients (90%) had at least 1 year's follow-up, and fusion was obtained for all these cases.

CONCLUSION

Two-stage minimally invasive surgery is effective and safe for the treatment of single or two-level thoracolumbar spondylodiscitis. It could be an alternative to conventional open surgery or conservative treatment.

Acromegaly in Carney complex

PURPOSE

Carney complex (CNC) is a rare autosomal dominant syndrome, characterized by mucocutaneous pigmentation, cardiac, cutaneous myxomas and endocrine overactivity. It is generally caused by inactivating mutations in the PRKAR1A (protein kinase cAMP-dependent type I regulatory subunit alpha) gene. Acromegaly is an infrequent manifestation of CNC, reportedly diagnosed in 10% of patients.

METHODS

We here report the case of a patient who was concomitantly diagnosed with Carney complex, due to a new mutation in PRKAR1A ((NM_002734.3:c.80_83del, p.(Ile27Lysfs*101 in exon 2), and acromegaly. In parallel, we conducted an extensive review of published case reports of acromegaly in the setting of CNC.

RESULTS

The 43-year-old patient was diagnosed with an acromegaly due to a GH-secreting pituitary microadenoma resistant to somatostatin analogs. He underwent transsphenoidal surgery in our tertiary referral center, which found a pure GH-secreting adenoma. In the literature, we identified 57 cases (24 men, 33 women) of acromegaly in CNC patients. The median age at diagnosis was 28.8 ± 12 year and there were 6 cases of gigantism. Acromegaly revealed CNC in only 4 patients. 24 patients had a microadenoma and two carried pituitary hyperplasia and/or multiple adenomas, suggesting that CNC may result in a higher proportion of microadenoma as compared to non-CNC acromegaly.

CONCLUSIONS

Although it rarely reveals CNC, acromegaly is diagnosed at a younger age in this setting, with a higher proportion of microadenomas.

P13.09 Genomic analysis of paired IDHwt glioblastoma (GB) reveals recurrent alterations of MPDZ at relapse after radiotherapy and temozolomide (RTCT)

BACKGROUND

GB are highly aggressive tumors which systematically relapse. Our objective was to identify disease progression mechanisms and genomic drivers of GB treatment resistance.

MATERIAL AND METHODS

Ten paired frozen tumors from initial and recurrent surgery after RTCT were screened by CGH Array. Next, NGS of the selected genes was performed on 19 paired tumors (38 samples). Molecular alterations were correlated with patient data. TCGA was used to characterize the molecular profile of MPDZ.

RESULTS

Nineteen IDHwt GB patients with a median age of 54.5 years (37.2–72.8) were included. Using CGH array, unsupervised analysis clustered the whole samples by paired of initial and recurrent tumors. However only 44% of CGH Array alterations were shared between initial and recurrent tumors (amplifications: 55%; deletions: 30%). The new alterations detected at relapse were amplifications in 25% and deletions in 23% of tumors. Two regions corresponding to 171 genes were lost at relapse (p=0.03): 19q13.33 and 19q13.41. Using DAVID genome, 3/171 genes (related to neutrophil chemotactic factors) were identified: FPR1, FPR2, FPR3. Moreover, 24 genes were lost (including MPDZ) and 2 genes were gained in 20% of recurrent tumors. Totally, 29 genes were analyzed by NGS and 4 genes showed pathogenic mutations shared by initial and recurrent tumors: FPR2, REL, TYRP1 and MPDZ. Only MPDZ showed, at relapse, an increasing rate of mutated variants and a new mutation affecting the splicing site. These alterations were independent from classical prognostic factors (age, sexe, karnofsky performans status, MMS and MGMT status) and from patient survivals. To explore MPDZ expression, we used TCGA initial dataset and observed that a lower RNA expression of MPDZ was associated with IDHwt (p<0.001) and grade IV (p<0.001) gliomas, reinforcing the potential pejorative impact of MPDZ loss.

CONCLUSION

Our results suggest that MPDZ is frequently altered at initial diagnosis with increased alterations in recurrent IDHwt GB after RTCT, suggesting that MPDZ impairment could contribute to the resistance/relapse mechanisms. Further investigations are needed to validate these results. Our results suggest that MPDZ is frequently altered at initial diagnosis with increased alterations in recurrent IDHwt GB after RTCT, suggesting that MPDZ impairment could contribute to the resistance/relapse mechanisms. Further investigations are needed to validate these results.

OS8.7 Targeting Pi3k-Akt-mTOR and MAPKinase pathways in aggressive meningiomas: in vitro study

BACKGROUND

Recurrent and aggressive meningiomas remain an unmet medical need in neuro-oncology. In our preclinical model on meningioma primary cell culture, the combination of the mTOR inhibitor, everolimus and the somatostatin analog, octreotide decreased cell viability and proliferation without inducing apoptosis. The interest of the combined treatment everolimus plus octreotide were clinically validated by the CEVOREM clinical trial demonstrating a decrease in growth rate of meningiomas in most treated patients.

Nevertheless, everolimus induced an increase in Akt activity in vitro, which probably limited everolimus efficiency. We hypothesized that targeting Pi3K could prevent this positive feedback on Akt phosphorylation, induced by mTOR inhibition. The involvement of MAPKinase pathway in meningioma tumorigenesis was recently demonstrated. Our aim was to decipher the effect of the Pi3k α inhibitor Alpelisib (BYL719) and the specific inhibitor of MEK1,2 Mekinist (Trametinib) alone or in combination, in comparison to the mTor inhibitor everolimus on human meningioma primary cell cultures.

MATERIAL AND METHODS

The impact of the drugs was studied on 40 meningiomas, well characterized at clinical, histological and molecular level. The cell viability, cell proliferation and apoptosis were analyzed under drugs.

RESULTS

BYL719 induced a dose dependent decrease in cell viability (maximal effect -90%, IC50 10-6M) in all tested meningiomas (n=30). This effect was stronger than those of everolimus (maximal effect -50%, n=24, IC50 10-8M). 22 tumors were sensitive to Trametinib (maximal effect <-50%, IC50 10–5 M), 14 were partially sensitive (maximal effect between -20 and -40% IC50 10–5 M) and 3 were resistant. An apoptotic effect was observed under BYL719 in 6/18 tested tumors whereas no apoptosis was observed under Trametinib and Everolimus. Combination of BYL719 and Trametinib induced a significant stronger decrease in cell viability than each drug alone. Correlation analysis between these functional results, the tumor genomic profile and the activation of ERK/MEK kinase pathway is ongoing.

CONCLUSION

PI3K-Akt-mTOR and ERK/MEK kinase pathways constitute relevant targets in aggressive meningioma therapy. In our preclinical model, previously validated by CEVOREM clinical trial, co-targeting Pi3k-Akt-mTOR and MAPkinase pathways improved cell proliferation inhibition in comparison to the target of each pathway alone. BYL719 induced apoptosis which was not achieved by everolimus. These results support the ongoing clinical trial ALTREM combining Alpelisib and Trametinib on patients harboring aggressive recurrent meningiomas.

Pre-surgical medical treatment, a major prognostic factor for long-term remission in acromegaly

PURPOSE

To determine whether pre-surgical medical treatment (PSMT) using long-acting Somatostatin analogues in acromegaly may improve long-term surgical outcome and to determine decision making criteria.

METHODS

This retrospective study included 110 consecutive patients newly diagnosed with acromegaly, who underwent surgery in a reference center (Marseille, France). The mean long-term follow-up period was 51.4 ± 36.5 (median 39.4) months. Sixty-four patients received PSMT during 3-18 (median 5) months before pituitary surgery. Remission was defined at early (3 months) evaluation and at last follow-up by GH nadir after oral glucose tolerance test < 0.4 µg/L and normal IGF-1.

RESULTS

Pretreated and non-pretreated groups were comparable for the main confounding factors except for higher IGF-1 at diagnosis in PSMT patients. Remission rates were significantly different in pretreated or not pretreated groups (61.1% vs. 36.6%, respectively at long-term evaluation). In multivariate analysis, PSMT was significantly linked to 3 months (p < 0.01) and long-term remission (p < 0.01). Duration of PSMT was not significantly different in cured or non-cured patients, at both evaluation times. PSMT appeared to be more beneficial for patients with an invasive tumor. No patient with a tumor greater than 18 mm or mean GH level exceeding 35 ng/mL at diagnosis was cured by surgery alone (vs. 8 and 9 patients in the pretreated group, respectively). Patients with PSMT showed more transient mild hyponatremia after surgery.

CONCLUSIONS

PSMT significantly improved short and long-term remission in patients with acromegaly, independent of its duration, especially in invasive adenomas.

Active cushing syndrome patients have increased ectopic fat deposition and bone marrow fat content compared to cured patients and healthy subjects: a pilot 1H-MRS study

OBJECTIVE

Glucocorticoid excess is one of the most important causes of bone disorders. Bone marrow fat (BMF) has been identified as a l new mediator of bone metabolism. Cushing syndrome (CS), is a main regulator of adipose tissue distribution but its impact on BMF is unknown. The objective of the study was to evaluate the effect of chronic hypercortisolism on BMF.

DESIGN

This was a cross-sectional study. Seventeen active and seventeen cured ACTH-dependent CS patients along with seventeen controls (matched with the active group for age and sex) were included.

METHODS

the BMF content of the femoral neck and L3 vertebrae were measured by 1H-MRS on a 3-Tesla wide-bore magnet. BMD was evaluated in patients using dual-energy X-ray absorptiometry.

RESULTS

Active CS patients had higher BMF content both in the femur (82.5±2.6%) and vertebrae (70.1±5.1%) compared to the controls (70.8±3.6%, p=0.013 and 49.0±3.7% p=0.005, respectively). In cured CS patients (average remission time of 43 months), BMF content was not different from controls at both sites (72.3±2.9% (femur) and 46.7%±5.3% (L3)). BMF content was positively correlated with age, fasting plasma glucose, HbA1c, triglycerides and visceral adipose tissue in the whole cohort and negatively correlated with BMD values in the CS patients .

CONCLUSIONS

Accumulation of BMF is induced by hypercortisolism. In remission patients BMF reached values of controls. Further studies are needed to determine whether this increase in marrow adiposity in CS is associated with bone loss.

Circumferential minimally invasive approach for low-grade isthmic spondylolisthesis: A clinical and radiological study of 43 patients

INTRODUCTION

Circumferential fusion for lumbar low-grade isthmic spondylolisthesis (LGIS) provides the best spinal stability and highest fusion rates. The aim of this study is to investigate results of minimal invasive management of LGIS and correlations between Intervertebral Foramen Surface (IFS) and other parameters.

METHODS

We retrospectively reviewed cases of 43 patients who underwent a minimally invasive circumferential fusion (Anterior lumbar interbody fusion followed by percutaneous posterior pedicle screw fixation) for LGIS between January 2010 and December 2014 in our institution. Inclusion criteria were one-level (L4-L5 or L5-S1) LGIS with low back and/or radicular pain. Pre- and postoperative radiographic evaluations were performed at 6, 12 and 24months. Measurements (Percentage of anterior displacement, degree of slip angle, height of the intervertebral space and the IFS) were obtained using Surgimap^®.

RESULTS

Nineteen patients (44.2%) were males. Mean age was 43 years old (19-72years). The mean follow-up of the series was 18.3months (3-72months). Mean preoperative Visual Analogy Scale (VAS) for low back pain decreased from 70mm to 20mm and from 80mm to 10mm as to radicular pain. Anterior displacement was reduced from 18% to 7% (p<0.01), degree of slippage were increased from 9.8° to 15.2° (p<0.01), intervertebral height was restored from 4.4mm to 8.5mm (p<0.01) and increase of the IFS was calculated 48.8%.

CONCLUSION

One stage circumferential fixation for adults' LGIS without decompression, allows restoration of intervertebral height permitting good reduction of the slippage, an increasing of the IFS and liberation of nerve roots.

Lack of functional remission in Cushing's syndrome

INTRODUCTION

Hypercortisolism leads to severe clinical consequences persisting after the onset of remission. These physical sequelae of cortisol exposure are known to profoundly impact the patient's quality of life. As psychological factors may be correlated with this quality of life, our objective was to determine the specific weight of psychological determinants of quality of life in patients in remission from hypercortisolism.

PATIENTS AND METHODS

In an observational study, 63 patients with hypercortisolism in remission were asked to complete exhaustive self-administered questionnaires including quality of life (WHOQoL-BREF and Cushing QoL), depression, anxiety, self-esteem, body image, and coping scales. Multivariate analyses were performed. Psychological variables relevant to the model were: anxiety, depression, self-esteem, body image, and positive thinking dimension of the Brief-COPE. Cortisol deficiency was defined as a potential confounder.

RESULTS

The median time since remission was 3 years. Patients had significantly lower quality of life and body satisfaction score than the French population and patients with chronic diseases. Depression significantly impaired all WHOQoL and Cushing QoL domains. A low body satisfaction score significantly impaired social relationships quality of life score. In total, 42.9% of patients still needed working arrangements, 19% had disability or cessation of work.

CONCLUSION

Patients in biological remission of hypercortisolism can rarely be considered as functionally cured: this is evidenced by altered quality of life, working arrangements, and chronic depression. A multidisciplinary management of these patients is thus mandatory on a long-term basis.

Adjacent level spondylodiscitis in a patient with thoracic spondylodiscitis: A case report and review of the literature

INTRODUCTION

Adjacent level spondylodiscitis (ALS) after primary surgery for thoracic spondylodiscitis is a very rare condition.

CASE REPORT

We report the case of a 76-year-old man with this pathology. A first posterior minimally invasive approach combined with anterior approach to the thoracic spine was safely performed for thoracic spondylodiscitis. More than a year later, exploration of recurrent symptoms with ¹⁸FDG PET scan helped to diagnose ALS. Further surgery was performed. At 3-year follow-up examination showed no recurrence of the infection.

DISCUSSION

ALS should be suspected during recurrent symptoms after spinal fusion surgery. Evaluation should be based on the results of ¹⁸FDG PET scan and surgery.

CONCLUSION

Bacterial and histopathological analyses combined with an increase of spine fixation and adapted antimicrobial therapy are a safe management for ALS.

Trends in the surgical management of odontoid fractures in patients above 75 years of age: Retrospective study of 70 cases

BACKGROUND

Odontoid fractures are the most common upper cervical spine fracture in adults over 70 years of age. Hence, treatment of these fractures has public health implications.

OBJECTIVES

Evaluate the early complications, bone healing and mortality in patients above 75 years of age who undergo surgical treatment of an odontoid fracture. Compare the results between patients operated with the Harms technique or anterior screw fixation.

METHODS

This was a retrospective study of 70 patients with an odontoid fracture who were treated surgically between 2000 and 2015 at the Hôpital de la Timone in France. The age at the time of diagnosis, comorbidities, ASA score and autonomy were evaluated. Bone healing was determined using computed tomography.

RESULTS

In the cohort, 22 patients underwent anterior screw fixation, 38 were treated using the Harms technique and 10 with other procedures. The average age was 85.1 years. Fifty-four percent of patients had an ASA score above 3. The average follow-up was 23.4 months. An Anderson type II fracture was present in 80.6% of patients. In the anterior screw fixation group, the operative time was significantly shorter than in the Harms group and no blood transfusions were needed. However, 13.6% of these patients had to be re-operated because the initial construct was unstable; no patients in the Harms group underwent revision surgery. There were more complications in the anterior screw fixation group than in the Harms group: 41% versus 13.2% (P<0.02). The fractures had healed in all patients reviewed after 1 year. The 3-month survival in the anterior screw fixation group was 64.7% and it was 81.3% in the Harms group. These rates were stable at 1 year with no statistical differences between groups.

CONCLUSION

Surgical treatment of odontoid fractures in the elderly results in an excellent union rate. The mortality rate is stable after 3 months. In our experience, the Harms technique has a lower risk of complications and better mechanical stability than anterior screw fixation. Despite the steep learning curve, we believe the Harms technique is probably the best choice for treating odontoid fractures in the elderly.

LEVEL OF EVIDENCE

IV.

Surgical management of post-traumatic atlantoaxial rotatory fixation due to C2 facet fracture: 5 clinical cases

PURPOSE

Report the results of surgical treatment of post-traumatic atlantoaxial rotatory fixation (AARF) due to C2 articular facet fracture in adults.

MATERIAL AND METHODS

The records of five patients treated since 2009 for AARF due to a C2 articular facet fracture were analyzed retrospectively. Three women and two men with an average age of 60 years (27-82) were included, one of whom initially had neurological deficits. In all cases, the surgical strategy consisted of posterior fixation: Harms-type in four cases and trans-articular with hooks in one case.

RESULTS

Dislocations due to fracture of the C2 articular facet are rare in adults; various treatment strategies have been described. In our experience, posterior screw fixation leads to satisfactory clinical and radiological outcomes. Fusion is not necessary in these cases because the dislocation is related to an asymmetric fracture without ligament damage.

CONCLUSION

Posterior fixation provides satisfactory reduction of these injuries and leads to satisfactory bone union. This surgical treatment can be performed early on after the trauma and is an interesting alternative to conservative treatment.

Impact of surgical correction of a U-shaped sacral fracture on sagittal spino-pelvic alignment: Regarding one case

U-shaped sacral fractures are uncommon and are mostly the consequence of a high-energy kinetic trauma. The sacrum is a crucial element for sagittal alignment in a standing position as it determines the value of the pelvic incidence, which is a fixed and unchanging parameter for a given individual. We report the case of a 21-year-old man who underwent corrective surgery for a type II U-shaped fracture of the sacrum (according to the Roy-Camille classification), associated with a S1-S2 dislocation and sacral kyphosis that modified the patient's pelvic incidence. At one-year follow-up, radiographic examinations revealed solid bony fusion and stable results after removal of the implants. The surgery was managed for neurological decompression, stabilization of the fracture and correction of sacral kyphosis. The restoration of the theoretical pelvic incidence depended on the estimated lumbar lordosis. The aim of this study was to highlight the particularities in the management of a sacral U-shaped fracture and their relationship with the sagittal alignment.

[Minimal invasive circumferential fusion in the management of kyphotic thoracolumbar lesions: Technical note]

INTRODUCTION

Management of spinal kyphotic deformities remains challenging in order to achieve a complete correction of the deformity, stabilize the spine and restore a satisfactory sagittal alignment. The aim of this study was to report the results of a technique combining, during the same operative session: a percutaneous osteosynthesis (with or without decompression) and a minimal invasive corpectomy using an anterior approach.

METHODS

Twelve patients (mean age 54 years old) were included in this single center retrospective study. Kyphotic deformity was related to a trauma in 9 cases, to a tumor in 2 cases and was infectious in the last case. The level involved was L1 in 7 cases, T12 in 3 cases, T10 and L4 in 1 case each. First step of the surgical strategy was a routine posterior percutaneous osteosynthesis. In 5 cases, a complementary minimal invasive decompression was performed using tubular retractors. During the second step, an anterior corpectomy was performed and the vertebral reconstruction was done using telescopic vertebral body prosthesis. Once the last correction was achieved, final locking of the posterior instrumentation was performed.

RESULTS

In the entire series, a short construct was done in 2 cases and a long construct was decided for the 10 other cases depending on the lesion. Mean surgical time was 246 min [173-375] and postoperative blood transfusion was not necessary. Patients were discharged from the hospital on average at day 8 [4-25] according to associated lesions. Based on radiographic analyses, a significant restoration of the vertebral kyphosis (average 17°, P<0.001) and vertebral body height (27% on average, P<0.001) were obtained.

CONCLUSION

Combination of these two minimal invasive techniques allows a circumferential spinal fixation with a low rate of complications and a satisfactory restoration of local sagittal deformity. This strategy is, in our experience, a valuable alternative to conventional techniques. Further studies with a longer follow-up will therefore needed in order to confirm these results.

Metastatic odontoid fracture management by anterior screw fixation and kyphoplasty

We report the case of a patient diagnosed with a pathological fracture of the odontoid dens related to a renal carcinoma metastasis and treated by an original technique. In order to achieve correct stabilization of the fracture and to preserve rotational neck mobility, an anterior approach combining an odontoid screw fixation and a balloon kyphoplasty was performed. This minimal invasive strategy provided satisfactory clinical and radiological results for this unstable lesion. To our knowledge, this technique has not been previously reported and could be a valuable alternative approach in the management of craniocervical metastatic lesions for these fragile patients.

Adult symptomatic and growing arachnoid cyst successfully treated by ventriculocystostomy: a new insight on adult arachnoid cyst history

BACKGROUND

Adult arachnoid cysts are known to be stable and asymptomatic but their history remains undefined.

CASE DESCRIPTION

The authors report the case of an 81-year-old woman with progressive hemiplegia and aphasia. CT scan revealed a voluminous left frontotemporal arachnoid cyst with a major mass effect on the midline and contralateral blocked hydrocephalus. Endoscopic ventriculocystostomy was performed with a spectacular neurological improvement.

DISCUSSION AND CONCLUSIONS

Symptomatic adult arachnoid cysts are extremely rare. To our knowledge, no similar clinical case of a growing arachnoid cyst in elderly patients has yet been reported in the literature. The mechanisms of cyst enlargement and decompensation still remain undefined and debated. The possibility of adult arachnoid cyst growth has to be considered in clinical practice. Endoscopic ventriculocystostomy is as effective as in paediatric cases.

[Acute decompensation of os odontoideum in the elderly. Case report]

Os odontoideum is a lesion of the second cervical vertebra, usually revealed by a neurological decompensation due to a neck injury in young adults. We report the exceptional case of an os odontoideum decompensation in a 81-year-old patient, who became quadriplegic after a fall. Subsequent surgical treatment resulted in complete neurological recovery. Os odontoideum can decompensate at all ages, and the authors recommend preventive surgical treatment in cases of instability, including in the elderly.

Superior sagittal sinus reconstruction using a femoral venous graft after total removal of a meningioma. Case report

OBJECTIVE

Resection of a parasagittal meningioma invading the superior sagittal sinus (SSS) needs the reconstruction of the sinus by a patch or a venous graft depending of sinus invasion degree.

METHOD

We present here a case of a 21-year-old man who underwent radical removal of a radio-induced parasagittal meningioma totally invading the posterior third of the sinus. For its reconstruction, we used the patient's left superficial femoral vein without valves as an autograft, by realizing two end-to-end anastomoses between the sinus and the graft after an en-bloc removal of the meningioma and the invaded sinus.

RESULTS

Two years after surgery, clinical examination of the patient was strictly normal and the femoral venous graft was still patent on CT angiograms.

CONCLUSION

The superficial femoral vein without valves seems to be convenient for SSS reconstruction.