Facilitating Repeat Intracarotid Injections in Mouse Models by a Novel Injection Site Repair Technique

Given recent advances in the delivery of novel antitumor therapeutics using endovascular selective intraarterial delivery methods in neuro-oncology, there is an urgent need to develop methods for intracarotid injections in mouse models, including methods to repair the carotid artery in mice after injection to allow for subsequent injections. We developed a method of intracarotid injection in a mouse model to deliver therapeutics into the internal carotid artery (ICA) with two alternative procedures. During injection, the needle is inserted into the common carotid artery (CCA) after tying a suture around the external carotid artery (ECA) and injected therapeutics are delivered into the ICA. Following injection, the common carotid artery (CCA) can be ligated, which limits the number of intracarotid injections to one. The alternative procedure described in this article includes a modification where intracarotid artery injection is followed by injection site repair of the CCA, which restores blood flow within the CCA and avoids the complication of cerebral ischemia seen in some mouse models. We also compared the delivery of bone marrow-derived human mesenchymal stem cells (BM-hMSCs) to intracranial tumors when delivered through intracarotid injection with and without injection site repair following the injection. Delivery of BM-hMSCs does not differ significantly between the methods. Our results demonstrate that injection site repair of the CCA allows for repeat injections through the same artery and does not impair the delivery and distribution of injected material, thus providing a model with greater flexibility that more closely emulates intracarotid injection in humans.

Intraoperative language mapping guided by real-time visualization of gamma band modulation electrocorticograms: Case report and proof of concept

Background

Electrocorticography (ECoG) language mapping is often performed extraoperatively, frequently involves offline processing, and relationships with direct cortical stimulation (DCS) remain variable. We sought to determine the feasibility and preliminary utility of an intraoperative language mapping approach guided by real-time visualization of electrocorticograms.

Methods

A patient with astrocytoma underwent awake craniotomy with intraoperative language mapping, utilizing a dual iPad stimulus presentation system coupled to a real-time neural signal processing platform capable of both ECoG recording and delivery of DCS. Gamma band modulations in response to 4 language tasks at each electrode were visualized in real-time. Next, DCS was conducted for each neighboring electrode pair during language tasks.

Results

All language tasks resulted in strongest heat map activation at an electrode pair in the anterior to mid superior temporal gyrus. Consistent speech arrest during DCS was observed for Object and Action naming tasks at these same electrodes, indicating good correspondence with ECoG heat map recordings. This region corresponded well with posterior language representation via preoperative functional MRI.

Conclusions

Intraoperative real-time visualization of language task-based ECoG gamma band modulation is feasible and may help identify targets for DCS. If validated, this may improve the efficiency and accuracy of intraoperative language mapping.

Ureteroscopy Versus Double J Stenting in Emergency Treatment of Obstructive Lithiasis

Objective: Ureteroscopy (URS) is a commonly used procedure for the management of ureteral stones. While elective URS has been extensively studied, the literature on emergency URS remains limited. The aim of the present study is to evaluate the efficacy and safeness of URS performed in emergency settings and to determine the ideal candidates for this type of intervention. Methods:Patients who underwent URS for ureteral stones in a single healthcare unit, "Saint John" Emergency Clinical Hospital, Bucharest, Romania, were included in a retrospective investigation between April 2022 and March 2023. The study group was divided into two subgroups: group A (138 patients who underwent semirigid URS in an emergency setting) which was subdivided into group A1 (95 patients with stone on the distal ureter) and group A2 (43 patients with stone on the proximal ureter), and group B (151 patients who underwent a double J stent insertion). The success rate defined as stone fragmentation and resolution of renal obstruction, along with intraoperative and postoperative complications were assessed. A URS procedure was considered unsuccessful if either the instrument could not be passed to access the stone or it was deemed unsafe to perform the URS. In such cases, patients were managed by inserting a ureteric stent and scheduled for a subsequent procedure. Results:It could be observed that most complications occurred in emergency ureteroscopy on distal ureter (95 cases) and the most severe ones on proximal ureter (two cases - Clavien 4). Double J stenting provided a reduced number of complications (51 cases). It should be mentioned that patients with emergency semirigid ureteroscopy had more complications than those with double J stent for every group of BMI, while most of the complications were observed in the groups with the highest BMI. The success of the URS procedure was determined based on complete stone fragmentation and extraction, and it was of 91.3% for cases with emergency ureteroscopy. Conclusion:Patients who underwent URS for ureteral stones at a single facility, "Saint John" Emergency Clinical Hospital, Bucharest, Romania, were included in a retrospective investigation. The success rates and complication rates of emergency URS were comparable to those of elective URS, providing valuable insights for clinical decision-making.

MD Anderson Phase III Randomized Preoperative Stereotactic Radiosurgery (SRS) vs. Postoperative SRS for Brain Metastases Trial

PURPOSE/OBJECTIVE(S)

Postoperative stereotactic radiation therapy/radiosurgery (SRT/SRS) is being evaluated in comparison to Preoperative SRT for brain metastases (mets) in a limited number of prospective clinical trials. Our objective is to address the significant knowledge gap concerning the logistics of preoperative SRT in comparison to postoperative SRT in a randomized controlled study.

MATERIALS/METHODS

Patients with brain mets with at least 1 surgically operable met were randomized (1:1) to Preop vs Postop SRT. In this abstract, we present non-primary endpoint data on the trial concept and logistics of treatment for this data safety monitoring board reviewed study. Patients enrolled had 1-2 lesions resected and <15 lesions treated at time of SRT to best reflect the standard population that receive SRT and surgery at our institution.

RESULTS

From 12/2018 to 12/2022, 99 patients with 1-2 operable brain mets were enrolled and randomized to Preop (n = 49) or Postop (n = 50) SRT. Males represented 56% of the cohort compared to females, and <25% were age 18-49 years, while 27%, 29, and 19% respectively were 50-59, 60-69, and > = 70. The most frequent histologies enrolled were lung (29%), renal cell (15%), melanoma (14%), and breast (11%) cancers. The majority of patients (83%) had 1-4 brain mets on their baseline MRI and 91% subsequently had a single lesion resected. Seventy-nine patients completed both SRT and surgery, while 9% received no therapy due to drop out before study therapy initiation. Among patients receiving both therapies in the combined cohort, 68% received a non-invasive stereotactic radiosurgery instrument to the randomized cavity lesion compared to 32% receiving LINAC based SRT. Treatment of the lesion or cavity with single fraction SRT was 51% in the Preop arm vs 31% in the Postop arm. Multi-fraction (3-5 SRT) was 67% in the Postop cohort in contrast to 47% in the Preop cohort. Time from randomization to RT was 5.6 days and 33.7 days in the Preop and Postop cohorts respectively, and for surgery was 10.2 days vs 12.9 days in the Postop vs Preop cohorts. The average time from RT to surgery was 7.3 days in the Preop arm and 23.5 days in the Postop arm (to allow for incisional healing time).

CONCLUSION

In one of the early initiated randomized prospective cohorts of Preop vs Postop SRT, we demonstrated logistical feasibility with an efficient clinical trial workflow for study treatment. Differences in Preop vs Postop logistics reflect clinical practice differences in time-to-treatment. Therapy with various modalities reflected real-world practice and possibly provider preferences in technique when addressing the nature of delineating cavities and changes in cavity volume with regard to fractionation. Independent of the primary outcomes, our data provides insights in the practical management of patients receiving these two modalities of therapy, and further data at the completion of trial will address relevant primary outcomes.

Semirigid vs Flexible Ureteroscopy in the Management of Ureteral Stones - Review

Ureteral stones are a major clinical problem in urology that require effective and safe therapeutic options. Semirigid and flexible ureteroscopy ar two well-established procedures for treating these stones. The present review provides an outline of the advantages and disadvantages of these approaches. Semirigid ureteroscopy, which uses a rigid straight instrument, provides excellent stone visualisation and successful fragmentation. It is especially useful for proximal and bigger stones, frequently resulting in high stone-free rates and reduced procedure times. Nonetheless, its stiffness can make it difficult to navigate the delicate ureteral anatomy and increase the risk of mucosal injury. On the other hand, flexible ureteroscopy employs a more adjustable flexible scope, allowing access to complicated ureteral configurations while reducing the risk of ureteral trauma. It excels at treating distal and difficult stones but has a lower efficacy with larger stones and often requires longer procedure times. The choice between semirigid and flexible ureteroscopy is determined by patient-specific factors such as stone characteristics or anatomical considerations and the surgeon's skill. A customised approach that uses the capabilities of both treatments as needed can improve stone management outcomes while reducing potential problems. The continued advancement of technology and methodological modifications is predicted to improve the field of ureteroscopic stone management.

The Management of Reno-Ureteral Lithiasis - from Emergency Presentation to Definitive Treatment

Introduction: The aim of our study was to retrospectively evaluate the stone-free rate after the second intervention for every performed procedure (semirigid ureteroscopy, flexible ureteroscopy, semirigid plus flexible ureteroscopy and percutaneous nephrolithotomy). Materials and methods: A total of 149 patients, who came to the emergency room of "Saint John" Emergency Clinical Hospital, Bucharest, Romania, with acute renal pathology suggesting the presence of renal and/or ureteral lithiasis confirmed by imagining (x-ray, ultrasonography or computer tomography), were included in this retrospective study, which was conducted between September 2021 and September 2022. All selected patients had an indication of emergency surgical intervention that consisted of a double-J stent mounting. We analyzed the stone-free rate after the secondary intervention, which was one of the following procedures: semirigid ureteroscopy, flexible ureteroscopy, combined semirigid and flexible ureteroscopy (F-URS), and percutaneous nephrolithotomy (PCNL). Patients came back for the secondary intervention and were reevaluated using imaging techniques. Results:Endoscopic procedures were performed by 14 surgeons over a time period of two to six weeks after the initial stenting procedure. Encrusted stents were encountered in four cases and in five cases the patients were admitted with obstruction of previously inserted stents. From the total of 149 patients, 68 (45,6%) subjects underwent semirigid ureteroscopy, with a stone-free rate of 86% (59 cases), 32 (21,4%) F-URS, with a stone-free rate of 90,6% (30 cases), 41 (27,5%) combined flexible and semirigid ureteroscopy, with a stone-free rate of 90,24% (37 cases), and eight (5,3%) patients received PCNL, with a stone-free rate of 75% (six cases). Overall stone-free rate for all procedures was 90,06%. The mean operative time was 23 minutes. No major incidents or complications occurred during the procedures. Conclusion:The emergency pre-stenting before the definitive treatment of reno-ureteral lithiasis is a safe procedure. Flexible ureteroscopy was the most successful secondary intervention, with the highest rate of achieving stone-free status.

NIMG-64. INTRAOPERATIVE LANGUAGE MAPPING USING GAMMA-BAND MODULATIONS OF ELECTROCORTICOGRAM (ECOG) INDUCED BY WORD/SOUND CATEGORIZATION TASK: VALIDATION WITH REPRODUCIBLE SPEECH ARRESTS DURING LINGUISTIC TASKS

OBJECTIVE

Determination of the correlation between gamma-band modulations of electrocorticogram (ECoG) induced by linguistic tasks and reproducible speech arrests caused by bipolar direct cortical stimulations (DCS).

METHODS

3 subjects (age 39, 56, 64 years) with left temporal lobe glioma underwent surgery involving awake craniotomy. A 4x8 ECoG electrode grid (2.3mm contact exposure, 1cm contact spacing) was placed above the respective tumor area. A MATLAB-Simulink based real-time software system running on a portable laptop computer was used to map gamma-band modulations as a 2D heat map while the subjects engaged in different linguistic tasks: word/sound categorization by pressing a button, object naming, action naming, written descriptive naming, and auditory descriptive naming. Auditory stimulus was applied during word/sound categorization task (duration 300 – 500ms), auditory descriptive naming ( &gt; 1s); other tasks involved visual stimulus only. The subjects repeated the four naming tasks while bipolar DCS (2/4/6 mA, 60Hz, 2s) was applied at different electrode pairs.

RESULTS

The electrodes having stronger gamma-band modulations were distinct for different tasks. Reproducible speech arrests occurred during object, action, auditory naming tasks while stimulating specific electrode pairs, even though not all these electrodes had strong activations during these tasks. Across all subjects these electrodes had strong activations consistently during word/sound categorization tasks, starting as early as 250ms and lasting even after the auditory stimuli were terminated (~ 650ms). The longer activations can be associated with word recognition process. The subjects self-reported about having difficulty in comprehension rather than speech production during speech arrests. 3D brain rendering using MRI images showed that the speech arrest electrodes were identically located on the superior temporal gyrus, inferior to central sulcus for all 3 subjects.

CONCLUSION

Intraoperative language mapping guided by gamma-band ECoG modulations induced by word/sound categorization tasks can be utilized to localize eloquent cortex associated with auditory processing.

NCOG-14. INTRAOPERATIVE COGNITIVE-LINGUISTIC MAPPING GUIDED BY VISUALIZATION OF GAMMA BAND MODULATION ELECTROCORTICOGRAMS: PROOF OF CONCEPT IN A PATIENT WITH LEFT TEMPORAL AND OCCIPITAL LOW-GRADE ASTROCYTOMA

OBJECTIVE

Determine the feasibility and preliminary utility of a novel approach to intraoperative brain mapping guided by visualization of electrocorticography (ECoG) heat maps.

METHODS

A 39-year-old male with a biopsy-proven left posterior temporal and occipital WHO grade II IDH-mutant astrocytoma underwent awake craniotomy with intraoperative language mapping. Language mapping utilized a dual iPad stimulus presentation system (NeuroMapper) coupled to a portable real-time neural signal processing system capable of both recording cortical activity and delivering direct cortical stimulation in a closed-loop fashion. An ECoG grid (4x8 with 1cm pitch) which covered the majority of the left temporal lobe was used to assess oscillatory cortical activity during administration of language paradigms including object, action, auditory descriptive, and written descriptive naming. ECoG recording and cortical stimulation were synchronized with stimulus presentation via a photosensor attached to the patient-facing tablet. Gamma band modulations in response to language paradigms at each electrode were processed in real-time and visualized as heat maps in MATLAB/Simulink. Following recording and visualization, bipolar direct cortical stimulation from the grid was conducted for each neighboring electrode pair (up to an intensity of 6 mA) during administration of language tasks.

RESULTS

Despite mild fluent aphasia, a large set of reliable baseline stimuli were obtained for the language mapping paradigms. All naming paradigms resulted in strongest heat map activation at electrode 12 located in the anterior to mid superior temporal gyrus. During stimulation, consistent speech arrest was observed across all paradigms when stimulating electrode pair 11-12, indicating good correspondence with ECoG heat map recordings. Additionally, this region corresponded well with posterior language network representation via resting-state fMRI.

CONCLUSION

Intraoperative real-time visualization of task-based ECoG gamma band modulation is feasible and may help identify targets for direct cortical stimulation. If validated, this may improve the efficiency and accuracy of intraoperative language mapping.

Transcranial magnetic stimulation tractography and the facilitation of gross total resection in a patient with a motor eloquent glioblastoma: illustrative case

BACKGROUND

In patients with perieloquent tumors, neurosurgeons must use a variety of techniques to maximize survival while minimizing postoperative neurological morbidity. Recent publications have shown that conventional anatomical features may not always predict postoperative deficits. Additionally, scientific conceptualizations of complex brain function have shifted toward more dynamic, neuroplastic theories instead of traditional static, localizationist models. Functional imaging techniques have emerged as potential tools to incorporate these advances into modern neurosurgical care. In this case report, we describe our observations using preoperative transcranial magnetic stimulation data combined with tractography to guide a nontraditional surgical approach in a patient with a motor eloquent glioblastoma.

OBSERVATIONS

The authors detail the use of preoperative functional and structural imaging to perform a gross total resection despite tumor infiltration of conventionally eloquent anatomical structures. The authors resected the precentral gyrus, specifically the paracentral lobule, localized using intraoperative mapping techniques. The patient demonstrated mild transient postoperative weakness and made a full neurological recovery by discharge 1 week later.

LESSONS

Preoperative functional and structural imaging has potential to not only optimize patient selection and surgical planning, but also facilitate important intraoperative decisions. Innovative preoperative imaging techniques should be optimized and used to identify safely resectable structures.

Transcranial magnetic stimulation (TMS) seeded tractography provides superior prediction of eloquence compared to anatomic seeded tractography

Background

For patients with brain tumors, maximizing the extent of resection while minimizing postoperative neurological morbidity requires accurate preoperative identification of eloquent structures. Recent studies have provided evidence that anatomy may not always predict eloquence. In this study, we directly compare transcranial magnetic stimulation (TMS) data combined with tractography to traditional anatomic grading criteria for predicting permanent deficits in patients with motor eloquent gliomas.

Methods

We selected a cohort of 42 glioma patients with perirolandic tumors who underwent preoperative TMS mapping with subsequent resection and intraoperative mapping. We collected clinical outcome data from their chart with the primary outcome being new or worsened motor deficit present at 3 month follow up, termed “permanent deficit”. We overlayed the postoperative resection cavity onto the preoperative MRI containing preoperative imaging features.

Results

Almost half of the patients showed TMS positive points significantly displaced from the precentral gyrus, indicating tumor induced neuroplasticity. In multivariate regression, resection of TMS points was significantly predictive of permanent deficits while the resection of the precentral gyrus was not. TMS tractography showed significantly greater predictive value for permanent deficits compared to anatomic tractography, regardless of the fractional anisotropic (FA) threshold. For the best performing FA threshold of each modality, TMS tractography provided both higher positive and negative predictive value for identifying true nonresectable, eloquent cortical and subcortical structures.

Conclusion

TMS has emerged as a preoperative mapping modality capable of capturing tumor induced plastic reorganization, challenging traditional presurgical imaging modalities.

Perfusion-guided endovascular super-selective intra-arterial infusion for treatment of malignant brain tumors

BACKGROUND

Survival for glioblastoma remains very poor despite decades of research, with a 5-year survival of only 5%. The technological improvements that have revolutionized treatment of ischemic stroke and brain aneurysms have great potential in providing more precise and selective delivery of cancer therapeutic agents to brain tumors.

METHODS

We describe for the first time the use of perfusion guidance to enhance the precision of endovascular super-selective intra-arterial (ESIA) infusions of mesenchymal stem cells loaded with Delta-24 (MSC-D24) in the treatment of glioblastoma (NCT03896568).

RESULTS

MRI imaging, which best defines the location of the tumor, is co-registered and fused with the patient's position using cone beam CT, resulting in optimal vessel selection and confirmation of targeted delivery through volumetric perfusion imaging.

CONCLUSIONS

This technique of perfusion guided-ESIA injections (PG-ESIA) enhances our ability to perform targeted super-selective delivery of therapeutic agents for brain tumors.

Predictors of mortality and tumor recurrence in desmoplastic infantile ganglioglioma and astrocytoma-and individual participant data meta-analysis (IPDMA)

PURPOSE

Desmoplastic infantile astrocytoma (DIA) and desmoplastic infantile ganglioglioma (DIG) are classified together as grade I neuronal and mixed neuronal-glial tumor of the central nervous system by the World Health Organization (WHO). These tumors are rare and have not been well characterized in terms of clinical outcomes. We aimed to identify clinical predictors of mortality and tumor recurrence/progression by performing an individual patient data meta-analysis (IPDMA) of the literature.

METHODS

A systematic literature review from 1970 to 2020 was performed, and individualized clinical data for patients diagnosed with DIA/DIG were extracted. Aggregated data were excluded from collection. Outcome measures of interest were mortality and tumor recurrence/progression, as well as time-to-event (TTE) for each of these. Participants without information on these outcome measures were excluded. Cox regression survival analyses were performed to determine predictors of mortality and tumor recurrence / progression.

RESULTS

We identified 98 articles and extracted individual patient data from 188 patients. The cohort consisted of 58.9% males with a median age of 7 months. The majority (68.1%) were DIGs, while 24.5% were DIAs and 7.5% were non-specific desmoplastic infantile tumors; DIAs presented more commonly in deep locations (p = 0.001), with leptomeningeal metastasis (p = 0.001), and was associated with decreased probability of gross total resection (GTR; p = 0.001). Gender, age, and tumor pathology were not statistically significant predictors of either mortality or tumor recurrence/progression. On multivariate survival analysis, GTR was a predictor of survival (HR = 0.058; p = 0.007) while leptomeningeal metastasis at presentation was a predictor of mortality (HR = 3.27; p = 0.025). Deep tumor location (HR = 2.93; p = 0.001) and chemotherapy administration (HR = 2.02; p = 0.017) were associated with tumor recurrence/progression.

CONCLUSION

Our IPDMA of DIA/DIG cases reported in the literature revealed that GTR was a predictor of survival while leptomeningeal metastasis at presentation was associated with mortality. Deep tumor location and chemotherapy were associated with tumor recurrence / progression.

Subtemporal, Transapical, and Transcavernous Approach to Clip Low-Lying Basilar Tip Aneurysm: 2-Dimensional Operative Video

Basilar tip aneurysm clipping is technically challenging because of the depth of operative corridor, rarity in presentation, and important perforators supplying deep, critical structures. Two major approaches to basilar tip aneurysms include (1) a frontotemporal (transorbital) trans-sylvian approach for most aneurysms and (2) a modified subtemporal approach for aneurysms with low-lying necks. A 53-yr-old woman presented to our institution with a large unruptured basilar tip aneurysm notable for a low, broad neck (6.4 mm). After discussion of risks and benefits of endovascular vs surgical options, the patient consented to operative intervention. She underwent a right frontotemporal craniotomy with zygomatic osteotomy, intradural petrous apicectomy, elective sectioning of the fourth cranial nerve (CN IV), and intracavernous removal of the dorsum sellae and posterior clinoid process to provide more space for aneurysm dissection. After temporary clipping of the basilar artery, the perforating arteries were dissected free from the aneurysm and the aneurysm occluded with 2 fenestrated clips. Important technical nuances of the approach include (1) achieving ample working room for temporary occlusion aneurysm dissection, (2) careful dissection of the perforators and contralateral P1, and (3) utilization of 2 fenestrated clips to accommodate and preserve the ipsilateral P1 segment. Postoperative angiogram showed complete aneur-ysmal occlusion. Postoperatively, the patient demonstrated mild cognitive impairment and a right CN IV palsy. At 6-wk follow-up, cognition recovered to normalcy. More recently, at 12-mo follow-up, the patient noted intermittent diplopia. Formal neuro-ophthalmologic assessment confirmed persistence of a CN IV palsy treated with prism lenses but no other neurological deficits.

Stochastic growth pattern of untreated human glioblastomas predicts the survival time for patients

Glioblastomas are highly malignant brain tumors. Knowledge of growth rates and growth patterns is useful for understanding tumor biology and planning treatment logistics. Based on untreated human glioblastoma data collected in Trondheim, Norway, we first fit the average growth to a Gompertz curve, then find a best fitted white noise term for the growth rate variance. Combining these two fits, we obtain a new type of Gompertz diffusion dynamics, which is a stochastic differential equation (SDE). Newly collected untreated human glioblastoma data in Seattle, US, re-verify our model. Instead of growth curves predicted by deterministic models, our SDE model predicts a band with a center curve as the tumor size average and its width as the tumor size variance over time. Given the glioblastoma size in a patient, our model can predict the patient survival time with a prescribed probability. The survival time is approximately a normal random variable with simple formulas for its mean and variance in terms of tumor sizes. Our model can be applied to studies of tumor treatments. As a demonstration, we numerically investigate different protocols of surgical resection using our model and provide possible theoretical strategies.

RNAi technology targeting the FGFR3-TACC3 fusion breakpoint: an opportunity for precision medicine

BACKGROUND

Fusion genes form as a result of abnormal chromosomal rearrangements linking previously separate genes into one transcript. The FGFR3-TACC3 fusion gene (F3-T3) has been shown to drive gliomagenesis in glioblastoma (GBM), a cancer that is notoriously resistant to therapy. However, successful targeting of F3-T3 via small molecular inhibitors has not revealed robust therapeutic responses, and specific targeting of F3-T3 has not been achieved heretofore. Here, we demonstrate that depleting F3-T3 using custom siRNA to the fusion breakpoint junction results in successful inhibition of F3-T3+ GBMs, and that exosomes can successfully deliver these siRNAs.

METHODS

We engineered 10 unique siRNAs (iF3T3) that specifically spanned the most common F3-T3 breakpoint with varying degrees of overlap, and assayed depletion by qPCR and immunoblotting. Cell viability assays were performed. Mesenchymal stem cell-derived exosomes (UC-MSC) were electroporated with iF3T3, added to cells, and F3-T3 depletion measured by qPCR.

RESULTS

We verified that depleting F3-T3 using shRNA to FGFR3 resulted in decreased cell viability and improved survival in glioma-bearing mice. We then demonstrated that 7/10 iF3T3 depleted F3-T3, and importantly, did not affect levels of wild-type (WT) FGFR3 or TACC3. iF3T3 decreased cell viability in both F3T3+ GBM and bladder cancer cell lines. UC-MSC exosomes successfully delivered iF3T3 in vitro, resulting in F3-T3 depletion.

CONCLUSION

Targeting F3-T3 using siRNAs specific to the fusion breakpoint is capable of eradicating F3T3+ cancers without toxicity related to inhibition of WT FGFR3 or TACC3, and UC-MSC exosomes may be a plausible vehicle to deliver iF3T3.

PATH-07. MITOTIC INDEX THRESHOLDS DO NOT PREDICT CLINICAL OUTCOME FOR IDH-MUTANT ASTROCYTOMA

Current histological grading recommendations for isocitrate dehydrogenase (IDH)-mutant astrocytoma are imprecise and not reliably predictive of patient outcome, while somatic copy number alterations are emerging as important prognostic biomarkers. One explanation for this relative underperformance of histological grading is that current criteria to distinguish World Health Organization (WHO) grade III anaplastic astrocytomas from lower-grade diffuse astrocytomas (WHO grade II) are vague (‘increased mitotic activity’). This qualitative approach ensures diagnostic uncertainty and a broad ‘gray zone’ where both diffuse and anaplastic designations can reasonably be assigned. Thus, we hypothesized that interobserver variability and lack of defined mitotic thresholds for IDH-mutant astrocytomas underlies poor predictive accuracy of current histologic grading approaches. To test this hypothesis, we quantified total mitotic figures and maximum mitotic activity per ten high-powered fields in an institutional cohort of IDH-mutant astrocytomas. In our cohort, there was no mitotic activity threshold that was reflective of clinical progression-free or overall survival. Furthermore, in a multivariate Cox regression model consisting of mitotic activity, molecular markers, and clinical characteristics, only CDKN2A deletion was identified as a relevant variant for poor overall survival. We conclude that lack of defined mitotic figure thresholds may not contribute to underperformance of histological grading for IDH-mutant astrocytomas. This study supports the shift towards ‘molecular grading’ to replace traditional histological grading for IDH-mutant astrocytomas.

Mitotic Index Thresholds Do Not Predict Clinical Outcome for IDH-Mutant Astrocytoma

Current histological grading recommendations for isocitrate dehydrogenase (IDH)-mutant astrocytoma are imprecise and not reliably predictive of patient outcome, while somatic copy number alterations are emerging as important prognostic biomarkers. One explanation for this relative underperformance of histological grading is that current criteria to distinguish World Health Organization (WHO) grade III anaplastic astrocytomas from lower-grade diffuse astrocytomas (WHO grade II) are vague (“increased mitotic activity”). This qualitative approach ensures diagnostic uncertainty and a broad “gray zone” where both diffuse and anaplastic designations can reasonably be assigned. Thus, we hypothesized that interobserver variability and lack of defined mitotic thresholds for IDH-mutant astrocytomas underlies poor predictive accuracy of current histologic grading approaches. To test this hypothesis, we quantified total mitotic figures and maximum mitotic activity per 10 high-powered fields in an institutional cohort of IDH-mutant astrocytomas. In our cohort, there was no mitotic activity threshold that was reflective of progression-free or overall survival (OS). Furthermore, in a multivariate Cox regression model consisting of mitotic activity, molecular markers, and clinical characteristics, only CDKN2A homozygous deletion was identified as a relevant variant for poor OS. We conclude that lack of defined mitotic figure thresholds may not contribute to underperformance of histological grading for IDH-mutant astrocytomas.

Arming oHSV with ULBP3 drives abscopal immunity in lymphocyte-depleted glioblastoma

Oncolytic viruses induce local tumor destruction and inflammation. Whether virotherapy can also overcome immunosuppression in noninfected tumor areas is under debate. To address this question, we have explored immunologic effects of oncolytic herpes simplex viruses (oHSVs) in a genetically engineered mouse model of isocitrate dehydrogenase (IDH) wild-type glioblastoma, the most common and most malignant primary brain tumor in adults. Our model recapitulates the genomics, the diffuse infiltrative growth pattern, and the extensive macrophage-dominant immunosuppression of human glioblastoma. Infection with an oHSV that was armed with a UL16-binding protein 3 (ULBP3) expression cassette inhibited distant tumor growth in the absence of viral spreading (abscopal effect) and yielded accumulation of activated macrophages and T cells. There was also abscopal synergism of oHSVULBP3 with anti-programmed cell death 1 (anti-PD-1) against distant, uninfected tumor areas; albeit consistent with clinical trials in patients with glioblastoma, monotherapy with anti-PD-1 was ineffective in our model. Arming oHSV with ULBP3 led to upregulation of antigen processing and presentation gene sets in myeloid cells. The cognate ULBP3 receptor NKG2D, however, is not present on myeloid cells, suggesting a noncanonical mechanism of action of ULBP3. Overall, the myeloid-dominant, anti-PD-1-sensitive abscopal effect of oHSVULBP3 warrants further investigation in patients with IDH wild-type glioblastoma.

Desmoplastic Infantile Ganglioglioma/Astrocytoma (DIG/DIA) Are Distinct Entities with Frequent BRAFV600 Mutations

Desmoplastic infantile ganglioglioma (DIG) and desmoplastic infantile astrocytoma (DIA) are extremely rare tumors that typically arise in infancy; however, these entities have not been well characterized in terms of genetic alterations or clinical outcomes. Here, through a multi-institutional collaboration, the largest cohort of DIG/DIA to date is examined using advanced laboratory and data processing techniques. Targeted DNA exome sequencing and DNA methylation profiling were performed on tumor specimens obtained from different patients (n = 8) diagnosed histologically as DIG/DIGA. Two of these cases clustered with other tumor entities, and were excluded from analysis. The remaining 16 cases were confirmed to be DIG/DIA by histology and by DNA methylation profiling. Somatic BRAF gene mutations were discovered in 7 instances (43.8%); 4 were BRAFV600E mutations, and 3 were BRAFV600D mutations. Three instances of malignant transformation were found, and sequencing of the recurrence demonstrated a new TP53 mutation in one case, new ATRX deletion in one case, and in the third case, the original tumor harbored an EML4-ALK fusion, also present at recurrence. DIG/DIA are distinct pathologic entities that frequently harbor BRAFV600 mutations. Complete surgical resection is the ideal treatment, and overall prognosis is excellent. While, the small sample size and incomplete surgical records limit a definitive conclusion about the risk of tumor recurrence, the risk appears quite low. In rare cases with wild-type BRAF, malignant progression can be observed, frequently with the acquisition of other genetic alterations.Implications: DIG/DIA are a distinct molecular entity, with a subset frequently harboring either BRAF V600E or BRAF V600D mutations. Mol Cancer Res; 16(10); 1491-8. ©2018 AACR.

Natural history of cerebral cavernous malformations

Cerebral cavernous malformations (CCM) are vascular abnormalities of the central nervous system with an incidence of 0.4-0.5% and an annual rate of hemorrhage ranging from 0.7% to 1%. Most lesions are located in the cerebral hemisphere but some occur in deeper locations such as the basal ganglia and pons. The most common symptoms during presentation are headache, seizures, and focal neurologic deficits. Surgery remains the most effective treatment modality for symptomatic CCM, while the management of incidental CCM remains controversial. Factors associated with increased risk of hemorrhage include being female and less than 40 years old. This finding, however, is not consistent in all natural history studies evaluated. During follow-up, the most important and consistent risk factor for rebleed was a prior hemorrhage. Here, we provide an indepth but concise review of the literature regarding the natural history of CCMs.

The Influence of NBI Vision Over the First Follow-up Cystoscopy Outcomes in Newly Diagnosed NMIBC Patients

BACKGROUND

A retrospective study was aimed to establish the eventual impact of narrow band imaging (NBI) cystos copy over the short term residual tumors’ rate determined during the first follow-up endoscopic control in newly determined non-muscle invasive bladder cancer (NMIBC) cases.

METHODS

68 patients were found with NMIBC by means of both white light cystoscopy (WLC) and NBI. A follow-up using both investigation modalities was performed at 3 months from the initial procedure in 67 cases (one was lost from follow-up). RESULTS concerning the short termer currences were retrospectively compared to those obtain ending a similar series of 67 patients previously diagnosed and treated by means of classical WLC and resection only.

RESULTS

The short term residual tumors’ rate established during the first follow-up cystoscopy was lower in the study group initially benefiting from the NBI mode by comparison to the WLC control series (4.5% versus 11.9%). When drawing a parallel with the tumor map location outlined during the initial procedure, the most important differences were emphasized concerning other site recurrences (3%versus 8.95%).

CONCLUSIONS

NBI cystoscopy and resection displayed a substantially favorable influence over the short termoncologic outcome in newly diagnosed NMIBC cases when compared to the standard protocol.

ABBREVIATIONS

NBI â€" narrow band imaging; NMIBC â€"non-muscle invasive bladder cancer; WLC â€" white light cystoscopy; TURBT â€" transurethral resection of bladdertumors; CIS â€" carcinoma in situ.

NBI - plasma vaporization hybrid approach in bladder cancer endoscopic management

OBJECTIVES

A prospective study was performed aiming to evaluate the surgical efficacy, perioperative safety profile, diagnostic accuracy and medium term results of a multi-modal approach consisting in narrow band imaging (NBI) cystoscopy and bipolar plasma vaporization (BPV) when compared to the standard protocol represented by white light cystoscopy (WLC) and transurethral resection of bladder tumors (TURBT).

MATERIALS & METHODS

A total of 260 patients with apparently at least one bladder tumor over 3 cm were included in the trial. In the first group, 130 patients underwent conventional and NBI cystoscopy followed by BPV, while in a similar number of cases of the second arm, classical WLC and TURBT were applied. In all non-muscle invasive bladder tumors' (NMIBT) pathologically confirmed cases, standard monopolar Re-TUR was performed at 4-6 weeks after the initial intervention, followed by one year' BCG immunotherapy. The follow-up protocol included abdominal ultrasound, urinary cytology and WLC, performed every 3 months for a period of 2 years.

RESULTS

The obturator nerve stimulation, bladder wall perforation, mean hemoglobin level drop, postoperative bleeding, catheterization period and hospital stay were significantly reduced for the plasma vaporization technique by comparison to conventional resection. Concerning tumoral detection, the present data confirmed the NBI superiority when compared to standard WLC regardless of tumor stage (95.3% vs. 65.1% for CIS, 93.3% vs. 82.2% for pTa, 97.4% vs. 94% for pT1, 95% vs. 84.2% overall). During standard Re-TUR the overall (6.3% versus 17.4%) and primary site (3.6% versus 12.8%) residual tumors' rates were significantly lower for the NBI-BPV group. The 1 (7.2% versus 18.3%) and 2 (11.5% versus 25.8%) years' recurrence rates were substantially lower for the combined approach.

CONCLUSIONS

NBI cystoscopy significantly improved diagnostic accuracy, while bipolar technology showed a higher surgical efficiency, lower morbidity and faster postoperative recovery. The combined technique offered a reduced rate of residual tumors at Re-TUR, both globally as well as for orthotopic tumors. Substantially lower recurrence rates were found at 1 and 2 years among the NBI-BPV cases.

NBI cystoscopy in routine urological practice - from better vision to improve therapeutic management

OBJECTIVES

A single centre, retrospective trial was performed trying to assess the impact of NBI cystoscopy in cases of non-muscle invasive bladder tumors (NMIBT) by comparison to the standard approach. Our goal was to determine the superiority of the new method in terms of detection rates and subsequent postoperative treatment changes.

MATERIALS AND METHODS

A total of 320 NMIBT suspected consecutive cases were enrolled in the study. The inclusion criteria were represented by hematuria, positive urinary cytology and/or ultrasound suspicion of bladder tumors. All patients underwent WLC and NBI cystoscopy. Standard transurethral resection of bladder tumors (TURBT) was performed for all lesions visible in WL and NBI guided resection for solely NBI observed tumors.

RESULTS

The overall NMIBT and CIS patients' detection rates were significantly improved for the NBI evaluation ((94.9% versus 88.1% and 95.7% versus 65.2%). Also, on a lesions' related basis, NBI cystoscopy emphasized a significantly superior diagnostic accuracy concerning the CIS, pTa and overall NMIBT formations ((95.2% versus 60.3%, 92.8% versus 83.9% and 94.1% versus 82%). Additional tumors were diagnosed by NBI in a significantly higher proportion of CIS, pTa, pT1 and NMIBT patients (56.6% versus 8.7%, 28% versus 10.3%, 30.3% versus 10.6% and 31.6% versus 9.4%). As a result of these supplementary findings, the postoperative treatment was significantly improved in a substantial proportion of cases (15.4% versus 5.1%).

CONCLUSIONS

NBI cystoscopy represents a valuable diagnostic alternative in NMIBT patients, with significant improvement of tumor visual accuracy as well as detection rates. This approach provided a substantial amelioration to the risk category stratification and subsequent bladder cancer therapeutic management.

"Tips and tricks" in secondary bladder neck sclerosis' bipolar plasma vaporization approach

INTRODUCTION

Secondary bladder neck sclerosis (BNS) represents a common late complication of prostate surgery, however so far insufficiently assessed in the available literature. More over, the previously attempted and analyzed therapeutic modalities failed to achieve acknowledgement as standard treatment for this particular pathology.

METHODS

The bipolar plasma vaporization (BPV) was introduced as a viable mean of removing the obstructing scar formation in a gradual fashion. Several "tips and tricks" were described as particularly useful in optimizing the plasma corona vaporization effect. The proper BPV technique is simple and safe while closely relying on certain surgical steps, the simultaneous vaporization and coagulation processes and a superior endoscopic vision. Recent technological advances created the premises for further improvements.

RESULTS

The plasma-button vaporization is characterized by a satisfactory surgical speed, remote intraoperative bleeding risks, high-quality endoscopic visibility as well as the achievement of a complete sclerotic tissue removal. Within a short learning curve, a superior final aspect of the prostatic fossa and bladder neck is obtained at the end of surgery. The continuous plasma vaporization mode provides additional technical advantages. The previously described drawbacks of transurethral incision or resection seem to have been overcome by the practical features of the plasma vaporization process.

CONCLUSIONS

The BPV technique outlines a promising modality of efficiently ablating the obstructing fibrous tissue in secondary BNS patients. The simplicity and safety of the bipolar vaporization approach, together with the thorough obstructing scar removal in a radical fashion, create the premises for a favorable long term BPV clinical outcome.

NBI cystoscopy and bipolar electrosurgery in NMIBC management - An overview of daily practice

INTRODUCTION

The standard non-muscle invasive bladder cancer (NMIBC) endoscopic diagnosis suffers from the frequently unsatisfactory white light evaluation accuracy leading to residual lesions being left behind. Monopolar transurethral resection of bladder tumors (TURBT) is marked by a substantial morbidity rate requiring further amelioration.

METHODS

Small size tumors (under 1 cm) are feasible for "en bloc" resection. Bipolar TURBT was defined as being able to challenge the gold-standard status of monopolar resection due to the reduced complication rates. Plasma-button vaporization was introduced as a promising large bladder tumors' ablation modality. Narrow band imaging (NBI) cystoscopy became an increasingly popular method of enhancing tumor detection.

RESULTS

The "en bloc" resection of small size or thin pedicle tumors provides the conditions for avoiding tumoral tissue scattering. Bipolar resection is characterized by decreased perioperative bleeding risks and faster patient recovery. Plasma-button vaporization gained confirmation as an innovative approach, able to dispose large tumor bulks under complete control while minimizing the associated morbidity. NBI cystoscopy is a useful tool in identifying CIS lesions, small papillary tumors or extended margins of large tumor formations. As a cost-free technique, it may be extensively used both during the NMIBC initial diagnostic as well as during follow-up evaluation protocol.

CONCLUSIONS

Having in mind the various modalities of ameliorating the bladder cancer diagnostic and treatment, NMIBC management should be tailored in accordance with the particularities of each case.

Effect of brain- and tumor-derived connective tissue growth factor on glioma invasion

BACKGROUND

Tumor cell invasion is the principal cause of treatment failure and death among patients with malignant gliomas. Connective tissue growth factor (CTGF) has been previously implicated in cancer metastasis and invasion in various tumors. We explored the mechanism of CTGF-mediated glioma cell infiltration and examined potential therapeutic targets.

METHODS

Highly infiltrative patient-derived glioma tumor-initiating or tumor stem cells (TIC/TSCs) were harvested and used to explore a CTGF-induced signal transduction pathway via luciferase reporter assays, chromatin immunoprecipitation (ChIP), real-time polymerase chain reaction, and immunoblotting. Treatment of TIC/TSCs with small-molecule inhibitors targeting integrin β1 (ITGB1) and the tyrosine kinase receptor type A (TrkA), and short hairpin RNAs targeting CTGF directly were used to reduce the levels of key protein components of CTGF-induced cancer infiltration. TIC/TSC infiltration was examined in real-time cell migration and invasion assays in vitro and by immunohistochemistry and in situ hybridization in TIC/TSC orthotopic xenograft mouse models (n = 30; six mice per group). All statistical tests were two-sided.

RESULTS

Treatment of TIC/TSCs with CTGF resulted in CTGF binding to ITGB1-TrkA receptor complexes and nuclear factor kappa B (NF-κB) transcriptional activation as measured by luciferase reporter assays (mean relative luciferase activity, untreated vs CTGF(200 ng/mL): 0.53 vs 1.87, difference = 1.34, 95% confidence interval [CI] = 0.69 to 2, P < .001). NF-κB activation resulted in binding of ZEB-1 to the E-cadherin promoter as demonstrated by ChIP analysis with subsequent E-cadherin suppression (fold increase in ZEB-1 binding to the E-cadherin promoter region: untreated + ZEB-1 antibody vs CTGF(200 ng/mL) + ZEB-1 antibody: 1.5 vs 6.4, difference = 4.9, 95% CI = 4.8 to 5.0, P < .001). Immunohistochemistry and in situ hybridization revealed that TrkA is selectively expressed in the most infiltrative glioma cells in situ and that the surrounding reactive astrocytes secrete CTGF.

CONCLUSION

A CTGF-rich microenvironment facilitates CTGF-ITGB1-TrkA complex activation in TIC/TSCs, thereby increasing the invasiveness of malignant gliomas.

Epigenetic-mediated dysfunction of the bone morphogenetic protein pathway inhibits differentiation of glioblastoma-initiating cells

Despite similarities between tumor-initiating cells with stem-like properties (TICs) and normal neural stem cells, we hypothesized that there may be differences in their differentiation potentials. We now demonstrate that both bone morphogenetic protein (BMP)-mediated and ciliary neurotrophic factor (CNTF)-mediated Jak/STAT-dependent astroglial differentiation is impaired due to EZH2-dependent epigenetic silencing of BMP receptor 1B (BMPR1B) in a subset of glioblastoma TICs. Forced expression of BMPR1B either by transgene expression or demethylation of the promoter restores their differentiation capabilities and induces loss of their tumorigenicity. We propose that deregulation of the BMP developmental pathway in a subset of glioblastoma TICs contributes to their tumorigenicity both by desensitizing TICs to normal differentiation cues and by converting otherwise cytostatic signals to proproliferative signals.

Comparative cytogenetics and chromosomal characteristics of ribosomal DNA in the fish genus Vimba (Cyprinidae)

Karyotypic and cytogenetic characteristics of Vimba vimba and V. elongata were investigated using differential staining techniques (sequential C-banding, Ag- and CMA3-staining) and fluorescent in situ hybridization (FISH) with 28S rDNA probe. The diploid chromosome number in both species was 2n = 50 with 8 pairs of metacentrics, 14 pairs of submetacentrics to subtelocentrics and 3 pairs of subtelo- to acrocentrics. The largest chromosome pair of the complements was characteristically subtelo- to acrocentric. The nucleolar organizer regions (NORs) in both species were detected in the telomeres of a single, middle-sized subtelocentric chromosome pair, a pattern common in a number of other Leuciscinae. FISH with rDNA probe produced consistently positive hybridization signals detected in the same regions indicated by Ag-staining and CMA3-fluorescence. The distribution of C-positive heterochromatin was identical in both species, including a conspicuous size polymorphism of heterochromatic blocks in the largest metacentric and subtelo- to acrocentric chromosomal pairs. No heteromorphic sex chromosomes were detected. A single analyzed individual of V. melanops possessed the same karyotype and NOR phenotype as V. vimba and V. elongata. The apparent karyotype homogeneity and chromosomal characteristics of ribosomal DNA in all three species of the genus Vimba is consistent to that found in most other representatives of the European leuciscine cyprinid fishes.

Jejunal-rectal fistula as a complication of postoperative radiotherapy

We present the case of a patient with an unusual, complex enteric fistula with multiple tracts and associated abscesses. The fistula was a late complication of radiotherapy, administered three years earlier, after resection for carcinoma of the sigmoid colon. Most of the small bowel was involved in the radiation-induced disease. A wide resection was performed successfully. This report reviews current literature on intra-abdominal postradiotherapy injuries, particularly intestinal fistulae.

[Subarachnoid anesthesia with pethidine]

The authors present their experience about spinal anesthesia with pethidine as the sole medication. 713 patients whose mean age was 56.5 years received 1 mg . kg-1 of pethidine in 50 p. 100 aqueous solution administered by subarachnoid route. Indications were surgical procedures involving upper and lower abdomen, perineum and lower limbs. The set up of anesthesia is quite similar to those obtained with local anesthetics. Sensitivity disappears during the first three minutes in the area below the puncture site and in the following two or three minutes areflexia and paralysis is noted. The duration of the motor and sensory block is 90 to 120 minutes. Recovery appears to be in a reverse order. Spinal anaesthesia with pethidine exhibit the following characteristics: --sensory and motor blockade with minimal adverse reactions giving good and very good results in more than 90 per cent of cases, when involving perineum and lower limbs; --the most frequent adverse effect is a syndrome including hypotension, bradycardia and hypoxemia, appearing 20 to 30 minutes after injection, reversal is easily obtained by administration of pressure drugs and artificial ventilation. Neither delayed respiratory depression nor neurologic damage were noted; --a long lasting post-operative analgesia. In conclusion, this work demonstrates that: --1 mg . kg-1 of pethidine administered by subdural route realize a complete spinal anesthesia including motor, sensory and sympathetic blockade allowing surgical procedures in good conditions of security; --increasing the dosage of pethidine over 1 mg . kg-1 is not wise in order to avoid the occurrence of adverse side effects such as hypotension, bradycardia and bradypnaea; --this technic is only indicated for surgery in perineum and lower limbs.