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Mamelak AN, Little AS, Gardner PA, Almeida JP, Recinos P, Soni P, Kshettry VR, Jane JA, Barkhoudarian G, Kelly DF, Dodd R, Mukherjee D, Gersey ZC, Fukuhara N, Nishioka H, Kim EH, Litré CF, Sina E, Mazer MW, Cui Y, Bonert V. A Prospective, Multicenter, Observational Study of Surgical vs Nonsurgical Management for Pituitary Apoplexy. J Clin Endocrinol Metab 2024; 109:e711-e725. [PMID: 37698130 DOI: 10.1210/clinem/dgad541] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/14/2023] [Accepted: 09/08/2023] [Indexed: 09/13/2023]
Abstract
CONTEXT Pituitary apoplexy (PA) has been traditionally considered a neurosurgical emergency, yet retrospective single-institution studies suggest similar outcomes among patients managed medically. OBJECTIVE We established a multicenter, international prospective registry to compare presentation and outcomes in PA patients treated with surgery or medical management alone. METHODS A centralized database captured demographics, comorbidities, clinical presentation, visual findings, hormonal status, and imaging features at admission. Treatment was determined independently by each site. Key outcomes included visual, oculomotor, and hormonal recovery, complications, and hospital length of stay. Outcomes were also compared based on time from symptom onset to surgery, and from admission or transfer to the treating center. Statistical testing compared treatment groups based on 2-sided hypotheses and P less than .05. RESULTS A total of 100 consecutive PA patients from 12 hospitals were enrolled, and 97 (67 surgical and 30 medical) were evaluable. Demographics, clinical features, presenting symptoms, hormonal deficits, and imaging findings were similar between groups. Severe temporal visual field deficit was more common in surgical patients. At 3 and 6 months, hormonal, visual, and oculomotor outcomes were similar. Stratifying based on severity of visual fields demonstrated no difference in any outcome at 3 months. Timing of surgery did not affect outcomes. CONCLUSION We found that medical and surgical management of PA yield similar 3-month outcomes. Although patients undergoing surgery had more severe visual field deficits, we could not clearly demonstrate that surgery led to better outcomes. Even without surgery, apoplectic tumor volumes regress substantially within 2 to 3 months, indicating that surgery is not always needed to reduce mass effect.
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Affiliation(s)
- Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Medical Center, Phoenix, AZ 85013, USA
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | | | - Pablo Recinos
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Pranay Soni
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - John A Jane
- Departments of Neurosurgery, Virginia Tech Medical Center, Roanoke, VA 24014, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Saint John's Medical Center, Santa Monica, CA 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Saint John's Medical Center, Santa Monica, CA 90404, USA
| | - Robert Dodd
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA 94305, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Eui-Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | | | - Elliott Sina
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Mia W Mazer
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Yujie Cui
- Biostatistic Core, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Vivien Bonert
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Kesari S, Wagle N, Carrillo JA, Sharma A, Nguyen M, Truong J, Gill JM, Nersesian R, Nomura N, Rahbarlayegh E, Barkhoudarian G, Sivakumar W, Kelly DF, Krauss H, Bustos MA, Hoon DSB, Anker L, Singh AS, Sankhala KK, Juarez TM. Pilot Study of High-Dose Pemetrexed in Patients with Progressive Chordoma. Clin Cancer Res 2024; 30:323-333. [PMID: 38047868 DOI: 10.1158/1078-0432.ccr-23-2317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/26/2023] [Accepted: 11/09/2023] [Indexed: 12/05/2023]
Abstract
PURPOSE Chordomas are ultrarare tumors of the axial spine and skull-base without approved systemic therapy. Most chordomas have negative expression of thymidylate synthase (TS), suggesting a potential for responding to the antifolate agent pemetrexed, which inhibits TS and other enzymes involved in nucleotide biosynthesis. We evaluated the therapeutic activity and safety of high-dose pemetrexed in progressive chordoma. PATIENTS AND METHODS Adult patients with previously treated, progressive chordoma participated in an open-label, single-institution, single-arm, pilot clinical trial of intravenous pemetrexed 900 mg/m2 every 3 weeks and supportive medications of folic acid, vitamin B12, and dexamethasone. The primary endpoint was objective response rate according to RECIST v1.1. Secondary endpoints included adverse events, progression-free survival (PFS), tumor molecular profiles, and alterations in tissue and blood-based biomarkers. RESULTS Fifteen patients were enrolled and the median number of doses administered was 15 (range, 4-31). One patient discontinued treatment due to psychosocial issues after four cycles and one contracted COVID-19 after 13 cycles. Of the 14 response-evaluable patients, 2 (14%) achieved a partial response and 10 (71%) demonstrated stable disease. Median PFS was 10.5 months (95% confidence interval: 9 months-undetermined) and 6-month PFS was 67%. Adverse events were expected and relatively mild, with one grade 3 creatinine increased, and one each of grade 3 and 4 lymphopenia. No grade 5 adverse events, unexpected toxicities, or dose-limiting toxicities were observed. Several patients reported clinical improvement in disease-related symptoms. CONCLUSIONS High-dose pemetrexed appears tolerable and shows objective antitumor activity in patients with chordoma. Phase II studies of high-dose pemetrexed are warranted.
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Affiliation(s)
- Santosh Kesari
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Naveed Wagle
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Jose A Carrillo
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Akanksha Sharma
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Minhdan Nguyen
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Judy Truong
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Jaya M Gill
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Raffi Nersesian
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Natsuko Nomura
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Elnaz Rahbarlayegh
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | | | - Daniel F Kelly
- Pacific Neuroscience Institute, Santa Monica, California
| | - Howard Krauss
- Pacific Neuroscience Institute, Santa Monica, California
| | - Matias A Bustos
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Dave S B Hoon
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Lars Anker
- Providence St. Joseph Hospital Orange, Orange, California
| | - Arun S Singh
- UCLA Health, Santa Monica Cancer Care, Santa Monica, California
| | - Kamalesh K Sankhala
- Cedars-Sinai Medical Center, Samuel Oschin Cancer Center, Los Angeles, California
| | - Tiffany M Juarez
- Pacific Neuroscience Institute, Santa Monica, California
- Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
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Juarez TM, Gill JM, Heng A, Carrillo JA, Wagle N, Nomura N, Nguyen M, Truong J, Dobrawa L, Sivakumar W, Barkhoudarian G, Kelly DF, Kesari S. A phase I dose-escalation study of pulsatile afatinib in patients with recurrent or progressive brain cancer. Neurooncol Adv 2024; 6:vdae049. [PMID: 38680990 PMCID: PMC11046985 DOI: 10.1093/noajnl/vdae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
Background Afatinib (BIBW2992; Gilotrif®) is a selective and irreversible inhibitor of the epidermal growth factor receptor (ErbB; EGFR) family. It inhibits EGFR, HER2, and HER4 phosphorylation, resulting in tumor growth inhibition and regression. This phase I dose-escalation trial of pulsatile afatinib examined the safety, drug penetration into the central nervous system, preliminary antitumor activity, and recommended phase II dose in patients with progressive or recurrent brain cancers. Methods Afatinib was taken orally once every 4 days or once every 7 days depending on dose cohort, until disease progression or unacceptable toxicity. Results A total of 24 patients received the investigational agent and were evaluable for safety analyses, and 21 patients were evaluable for efficacy. Dosing was administered at 80 mg every 4 days, 120 mg every 4 days, 180 mg every 4 days, or 280 mg every 7 days. A recommended phase II dose of pulsatile afatinib was established at 280 mg every 7 days as there were no dose-limiting toxicities in any of the dosing cohorts and all toxicities were deemed manageable. The most common drug-related toxicities were diarrhea, rash, nausea, vomiting, fatigue, stomatitis, pruritus, and limb edema. Out of the 21 patients evaluable for efficacy, 2 patients (9.5%) exhibited partial response based on Response Assessment in Neuro-Oncology criteria and disease stabilization was seen in 3 patients (14.3%). Conclusions Afatinib taken orally was safe and well-tolerated up to 280 mg every 7 days in brain cancer patients.
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Affiliation(s)
- Tiffany M Juarez
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neuro-Oncology, Santa Monica, California, USA
| | - Jaya M Gill
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neuro-Oncology, Santa Monica, California, USA
| | - Annie Heng
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neuro-Oncology, Santa Monica, California, USA
| | - Jose A Carrillo
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neuro-Oncology, Santa Monica, California, USA
| | - Naveed Wagle
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neuro-Oncology, Santa Monica, California, USA
| | - Natsuko Nomura
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neuro-Oncology, Santa Monica, California, USA
| | - Minhdan Nguyen
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neuro-Oncology, Santa Monica, California, USA
| | - Judy Truong
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neuro-Oncology, Santa Monica, California, USA
| | - Lucia Dobrawa
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neuro-Oncology, Santa Monica, California, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neurosurgery, Santa Monica, California, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neurosurgery, Santa Monica, California, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neurosurgery, Santa Monica, California, USA
| | - Santosh Kesari
- Pacific Neuroscience Institute and Saint John’s Cancer Institute at Providence Saint John’s Health Center, Neuro-Oncology, Santa Monica, California, USA
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Sivakumar W, Guan J, Langevin JP, Barkhoudarian G, Kelly DF, Martin N. Enhanced recovery after brain tumor surgery: pilot protocol implementation in a large healthcare system. Neurosurg Focus 2023; 55:E5. [PMID: 38039543 DOI: 10.3171/2023.9.focus23563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 09/28/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE Enhanced recovery after surgery (ERAS) protocols have been used in numerous specialties to improve the safety, efficiency, and cost of surgical interventions. Despite these successes, implementation of ERAS in cranial neurosurgery remains limited. In this study, a comprehensive ERAS protocol was implemented at two pilot sites within the Providence Health & Services system, and groundwork was laid for systemwide adoption. METHODS An enhanced recovery protocol was developed and implemented through an interdisciplinary team of clinicians, executive leadership, and clinical informatics professionals across preoperative, intraoperative, and postoperative domains. Outcomes including length of stay, discharge destination, and cost were collected through systemwide databases and compared with nonprotocolized sites. RESULTS During the study period, both pilot sites became top performers across the regional system in all evaluated metrics. The median length of stay for elective craniotomy at site 1 was reduced to 1.25 days, with a home discharge rate of > 90%. The cost per case at the pilot sites was nearly $7000 less on average than that of the nonprotocolized sites. CONCLUSIONS Implementation of enhanced recovery protocols for brain tumor surgery is feasible and effective, resulting in marked improvements in healthcare efficiency. Future studies, including implementation of the current protocol across the entire Providence system, are needed to maximize the potential benefits of enhanced recovery programs.
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Affiliation(s)
- Walavan Sivakumar
- 1Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
- 2Department of Neurosurgery and Neuroscience, Saint John's Cancer Institute, Santa Monica, California
| | - Jian Guan
- 1Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
- 2Department of Neurosurgery and Neuroscience, Saint John's Cancer Institute, Santa Monica, California
| | - Jean-Philippe Langevin
- 1Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
| | - Garni Barkhoudarian
- 1Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
- 2Department of Neurosurgery and Neuroscience, Saint John's Cancer Institute, Santa Monica, California
| | - Daniel F Kelly
- 1Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
- 2Department of Neurosurgery and Neuroscience, Saint John's Cancer Institute, Santa Monica, California
| | - Neil Martin
- 1Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California; and
- 2Department of Neurosurgery and Neuroscience, Saint John's Cancer Institute, Santa Monica, California
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Lopez Hernandez DW, Cantu R, Guskiewicz KM, Kelly DF, Swerdloff R, Woo E, Wright MJ. A - 151 Assessing the Role of Executive Function in the Memory Performances of Retired National Football League Players. Arch Clin Neuropsychol 2023; 38:1323. [PMID: 37807294 DOI: 10.1093/arclin/acad067.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVE We evaluated the relationship between retired National Football League players executive functioning (EF) abilities on verbal memory performance and subprocesses. METHOD Fifty-eight participants were divided into two groups: intact executive functioning (IEF) and deficit executive functioning (DEF). Participants completed the California Verbal Learning Test, Second Edition (CVLT-II) to evaluate verbal memory performance. Additionally, the Item Specific Deficit Approach (ISDA) was applied to the CVLT-II to quantify verbal memory subprocesses (i.e., encoding, consolidation, & retrieval). Next, we determined which ISDA indices predicted long-delayed free recall (LDFR) for both groups. We then computed hierarchal regressions to determine which ISDA indices were predictive of LDFR for each group. Next, we retained significant predictors from the ISDA and correlated them with measures of executive function in both groups with and without partialling out cognitive reserve (CR). RESULTS We found the IEF group outperformed the DEF group on the CVLT-II learning trials and LDFR, and demonstrated better encoding abilities. Hierarchical regression revealed that the ISDA was predictive of LDFR in both groups. The DEF group LDFR issues were only predicted by encoding problems. In contrast, LDFR deficits in the IEF were primarily driven by consolidation problems. The ISDA encoding index correlated with Trail Making Test part B and Phonemic Fluency Test. However, after partialling out the variance accounted for by CR, the associations between the encoding index and executive function were nonsignificant. CONCLUSIONS Our results suggest that greater executive function results in better memory performances in retired football players. Lastly, improved executive function is related to greater CR.
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Heinzerling KG, Sergi K, Linton M, Rich R, Youssef B, Bentancourt I, Bramen J, Siddarth P, Schwartzberg L, Kelly DF. Nature-themed video intervention may improve cardiovascular safety of psilocybin-assisted therapy for alcohol use disorder. Front Psychiatry 2023; 14:1215972. [PMID: 37795513 PMCID: PMC10545868 DOI: 10.3389/fpsyt.2023.1215972] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/28/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction Psychedelic-assisted therapy with psilocybin has shown promise in Phase 2 trials for alcohol use disorder (AUD). Set and setting, particularly factors facilitating a connection with nature, may positively influence the psychedelic experience and therapeutic outcomes. But to date, randomized controlled trials of interventions to enhance set and setting for psychedelic-assisted therapy are lacking. Methods This was a pilot randomized, controlled trial of Visual Healing, a nature-themed video intervention to optimize set and setting, versus Standard set and setting procedures with two open-label psilocybin 25 mg dosing sessions among 20 participants with AUD. For the first session, participants randomized to Visual Healing viewed nature-themed videos during the preparation session and the "ascent" and "descent" phases of the psilocybin dosing session while participants randomized to the Standard condition completed a meditation during the preparatory session and wore eyeshades and listened to a music playlist throughout the dosing session. For the second session 4 weeks later, participants chose either Visual Healing or Standard procedures. Primary outcomes were feasibility, safety, and tolerability of Visual Healing. Secondary and exploratory outcomes were changes in alcohol use, psychedelic effects, anxiety and stress. Results Nineteen of 20 (95%) randomized participants (mean age 49 ± 11 years, 60% female) completed the 14-week study. During the first psilocybin session, participants viewed an average of 37.9 min of the 42-min video and there were no video-related adverse events. Peak increase in post-psilocybin blood pressure was significantly less for participants randomly assigned to Visual Healing compared to Standard procedures. Alcohol use decreased significantly in both Visual Healing and Standard groups and psychedelic effects, stress, and anxiety were similar between groups. Discussion In this open-label pilot study, viewing Visual Healing videos during preparation and psilocybin dosing sessions was feasible, safe, and well-tolerated among participants with AUD. Preliminary findings suggest that Visual Healing has potential to reduce the cardiovascular risks of psychedelic therapy, without interfering with the psychedelic experience or alcohol-related treatment outcomes. Studies to replicate our findings as well as studies of different set and setting interventions with other psychedelic medications and indications are warranted.
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Affiliation(s)
- Keith G. Heinzerling
- Treatment and Research In Psychedelics (TRIP) Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
- Brain Health Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
| | - Karina Sergi
- Treatment and Research In Psychedelics (TRIP) Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
| | - Micah Linton
- Treatment and Research In Psychedelics (TRIP) Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
| | - Rhianna Rich
- Treatment and Research In Psychedelics (TRIP) Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
| | - Brittany Youssef
- Treatment and Research In Psychedelics (TRIP) Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
| | - Inez Bentancourt
- Treatment and Research In Psychedelics (TRIP) Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
| | - Jennifer Bramen
- Brain Health Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
| | - Prabha Siddarth
- Brain Health Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
| | | | - Daniel F. Kelly
- Treatment and Research In Psychedelics (TRIP) Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
- Brain Health Center, Pacific Neuroscience Institute at Providence Saint John’s Health Center, Santa Monica, CA, United States
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Raison CL, Sanacora G, Woolley J, Heinzerling K, Dunlop BW, Brown RT, Kakar R, Hassman M, Trivedi RP, Robison R, Gukasyan N, Nayak SM, Hu X, O’Donnell KC, Kelmendi B, Sloshower J, Penn AD, Bradley E, Kelly DF, Mletzko T, Nicholas CR, Hutson PR, Tarpley G, Utzinger M, Lenoch K, Warchol K, Gapasin T, Davis MC, Nelson-Douthit C, Wilson S, Brown C, Linton W, Ross S, Griffiths RR. Single-Dose Psilocybin Treatment for Major Depressive Disorder: A Randomized Clinical Trial. JAMA 2023; 330:843-853. [PMID: 37651119 PMCID: PMC10472268 DOI: 10.1001/jama.2023.14530] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/13/2023] [Indexed: 09/01/2023]
Abstract
Importance Psilocybin shows promise as a treatment for major depressive disorder (MDD). Objective To evaluate the magnitude, timing, and durability of antidepressant effects and safety of a single dose of psilocybin in patients with MDD. Design, Setting, and Participants In this phase 2 trial conducted between December 2019 and June 2022 at 11 research sites in the US, participants were randomized in a 1:1 ratio to receive a single dose of psilocybin vs niacin placebo administered with psychological support. Participants were adults aged 21 to 65 years with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of MDD of at least 60 days' duration and moderate or greater symptom severity. Exclusion criteria included history of psychosis or mania, active substance use disorder, and active suicidal ideation with intent. Participants taking psychotropic agents who otherwise met inclusion/exclusion criteria were eligible following medication taper. Primary and secondary outcomes and adverse events (AEs) were assessed at baseline (conducted within 7 days before dosing) and at 2, 8, 15, 29, and 43 days after dosing. Interventions Interventions were a 25-mg dose of synthetic psilocybin or a 100-mg dose of niacin in identical-appearing capsules, each administered with psychological support. Main Outcomes and Measures The primary outcome was change in central rater-assessed Montgomery-Asberg Depression Rating Scale (MADRS) score (range, 0-60; higher scores indicate more severe depression) from baseline to day 43. The key secondary outcome measure was change in MADRS score from baseline to day 8. Other secondary outcomes were change in Sheehan Disability Scale score from baseline to day 43 and MADRS-defined sustained response and remission. Participants, study site personnel, study sponsor, outcome assessors (raters), and statisticians were blinded to treatment assignment. Results A total of 104 participants (mean [SD] age, 41.1 [11.3] years; 52 [50%] women) were randomized (51 to the psilocybin group and 53 to the niacin group). Psilocybin treatment was associated with significantly reduced MADRS scores compared with niacin from baseline to day 43 (mean difference,-12.3 [95% CI, -17.5 to -7.2]; P <.001) and from baseline to day 8 (mean difference, -12.0 [95% CI, -16.6 to -7.4]; P < .001). Psilocybin treatment was also associated with significantly reduced Sheehan Disability Scale scores compared with niacin (mean difference, -2.31 [95% CI, 3.50-1.11]; P < .001) from baseline to day 43. More participants receiving psilocybin had sustained response (but not remission) than those receiving niacin. There were no serious treatment-emergent AEs; however, psilocybin treatment was associated with a higher rate of overall AEs and a higher rate of severe AEs. Conclusions and Relevance Psilocybin treatment was associated with a clinically significant sustained reduction in depressive symptoms and functional disability, without serious adverse events. These findings add to increasing evidence that psilocybin-when administered with psychological support-may hold promise as a novel intervention for MDD. Trial Registration ClinicalTrials.gov Identifier: NCT03866174.
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Affiliation(s)
| | - Gerard Sanacora
- Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut
| | - Joshua Woolley
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | - Boadie W. Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Randall T. Brown
- Department of Family Medicine & Community Health, University of Wisconsin School of Medicine & Public Health, Madison
| | - Rishi Kakar
- Center for Psychedelic Research, Segal Trials, Lauderhill, Florida
| | | | | | - Reid Robison
- Numinus Wellness, Draper, Utah
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City
| | - Natalie Gukasyan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sandeep M. Nayak
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xiaojue Hu
- NYU Langone Center for Psychedelic Medicine, Department of Psychiatry, NYU Grossman School of Medicine, New York, New York
| | - Kelley C. O’Donnell
- NYU Langone Center for Psychedelic Medicine, Department of Psychiatry, NYU Grossman School of Medicine, New York, New York
| | - Benjamin Kelmendi
- Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut
| | - Jordan Sloshower
- Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut
| | - Andrew D. Penn
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco
- School of Nursing, University of California San Francisco
| | - Ellen Bradley
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | - Tanja Mletzko
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Christopher R. Nicholas
- Department of Family Medicine & Community Health, University of Wisconsin School of Medicine & Public Health, Madison
| | - Paul R. Hutson
- Pharmacy Practice & Translational Research Division, School of Pharmacy, University of Wisconsin-Madison
| | | | | | | | | | | | | | | | | | | | | | - Stephen Ross
- NYU Langone Center for Psychedelic Medicine, Department of Psychiatry, NYU Grossman School of Medicine, New York, New York
| | - Roland R. Griffiths
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Kelly DF, Heinzerling K, Sharma A, Gowrinathan S, Sergi K, Mallari RJ. Psychedelic-Assisted Therapy and Psychedelic Science: A Review and Perspective on Opportunities in Neurosurgery and Neuro-Oncology. Neurosurgery 2023; 92:680-694. [PMID: 36512813 PMCID: PMC9988324 DOI: 10.1227/neu.0000000000002275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/23/2022] [Indexed: 12/14/2022] Open
Abstract
After a decades-long pause, psychedelics are again being intensely investigated for treating a wide range of neuropsychiatric ailments including depression, anxiety, addiction, post-traumatic stress disorder, anorexia, and chronic pain syndromes. The classic serotonergic psychedelics psilocybin and lysergic acid diethylamide and nonclassic psychedelics 3,4-methylenedioxymethamphetamine and ketamine are increasingly appreciated as neuroplastogens given their potential to fundamentally alter mood and behavior well beyond the time window of measurable exposure. Imaging studies with psychedelics are also helping advance our understanding of neural networks and connectomics. This resurgence in psychedelic science and psychedelic-assisted therapy has potential significance for the fields of neurosurgery and neuro-oncology and their diverse and challenging patients, many of whom continue to have mental health issues and poor quality of life despite receiving state-of-the-art care. In this study, we review recent and ongoing clinical trials, the set and setting model of psychedelic-assisted therapy, potential risks and adverse events, proposed mechanisms of action, and provide a perspective on how the safe and evidence-based use of psychedelics could potentially benefit many patients, including those with brain tumors, pain syndromes, ruminative disorders, stroke, SAH, TBI, and movement disorders. By leveraging psychedelics' neuroplastic potential to rehabilitate the mind and brain, novel treatments may be possible for many of these patient populations, in some instances working synergistically with current treatments and in some using subpsychedelic doses that do not require mind-altering effects for efficacy. This review aims to encourage broader multidisciplinary collaboration across the neurosciences to explore and help realize the transdiagnostic healing potential of psychedelics.
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Affiliation(s)
- Daniel F. Kelly
- Treatment & Research in Psychedelics Program, Pacific Neuroscience Institute, Santa Monica, California, USA
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Keith Heinzerling
- Treatment & Research in Psychedelics Program, Pacific Neuroscience Institute, Santa Monica, California, USA
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Akanksha Sharma
- Treatment & Research in Psychedelics Program, Pacific Neuroscience Institute, Santa Monica, California, USA
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Shanthi Gowrinathan
- Treatment & Research in Psychedelics Program, Pacific Neuroscience Institute, Santa Monica, California, USA
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Karina Sergi
- Treatment & Research in Psychedelics Program, Pacific Neuroscience Institute, Santa Monica, California, USA
| | - Regin Jay Mallari
- Treatment & Research in Psychedelics Program, Pacific Neuroscience Institute, Santa Monica, California, USA
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Meysami S, Raji CA, Glatt RM, Popa ES, Ganapathi AS, Bookheimer T, Slyapich CB, Pierce KP, Richards CJ, Lampa MG, Gill JM, Rapozo MK, Hodes JF, Tongson YM, Wong CL, Kim M, Porter VR, Kaiser SA, Panos SE, Dye RV, Miller KJ, Bookheimer SY, Martin NA, Kesari S, Kelly DF, Bramen JE, Siddarth P, Merrill DA. Handgrip Strength Is Related to Hippocampal and Lobar Brain Volumes in a Cohort of Cognitively Impaired Older Adults with Confirmed Amyloid Burden. J Alzheimers Dis 2023; 91:999-1006. [PMID: 36530088 PMCID: PMC9912728 DOI: 10.3233/jad-220886] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Strength and mobility are essential for activities of daily living. With aging, weaker handgrip strength, mobility, and asymmetry predict poorer cognition. We therefore sought to quantify the relationship between handgrip metrics and volumes quantified on brain magnetic resonance imaging (MRI). OBJECTIVE To model the relationships between handgrip strength, mobility, and MRI volumetry. METHODS We selected 38 participants with Alzheimer's disease dementia: biomarker evidence of amyloidosis and impaired cognition. Handgrip strength on dominant and non-dominant hands was measured with a hand dynamometer. Handgrip asymmetry was calculated. Two-minute walk test (2MWT) mobility evaluation was combined with handgrip strength to identify non-frail versus frail persons. Brain MRI volumes were quantified with Neuroreader. Multiple regression adjusting for age, sex, education, handedness, body mass index, and head size modeled handgrip strength, asymmetry and 2MWT with brain volumes. We modeled non-frail versus frail status relationships with brain structures by analysis of covariance. RESULTS Higher non-dominant handgrip strength was associated with larger volumes in the hippocampus (p = 0.02). Dominant handgrip strength was related to higher frontal lobe volumes (p = 0.02). Higher 2MWT scores were associated with larger hippocampal (p = 0.04), frontal (p = 0.01), temporal (p = 0.03), parietal (p = 0.009), and occipital lobe (p = 0.005) volumes. Frailty was associated with reduced frontal, temporal, and parietal lobe volumes. CONCLUSION Greater handgrip strength and mobility were related to larger hippocampal and lobar brain volumes. Interventions focused on improving handgrip strength and mobility may seek to include quantified brain volumes on MR imaging as endpoints.
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Affiliation(s)
- Somayeh Meysami
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Saint John’s Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Cyrus A. Raji
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Ryan M. Glatt
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Emily S. Popa
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
| | - Aarthi S. Ganapathi
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
| | - Tess Bookheimer
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
| | - Colby B. Slyapich
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
| | - Kyron P. Pierce
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
| | - Casey J. Richards
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
| | - Melanie G. Lampa
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
| | - Jaya M. Gill
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
| | - Molly K. Rapozo
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
| | - John F. Hodes
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Ynez M. Tongson
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Claudia L. Wong
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Mihae Kim
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Verna R. Porter
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Saint John’s Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Scott A. Kaiser
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Stella E. Panos
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Saint John’s Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Richelin V. Dye
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Behavioral Health Institute, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Karen J. Miller
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Saint John’s Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Susan Y. Bookheimer
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Neil A. Martin
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Saint John’s Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Santosh Kesari
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Saint John’s Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Daniel F. Kelly
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Saint John’s Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Jennifer E. Bramen
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Saint John’s Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
| | - Prabha Siddarth
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - David A. Merrill
- Pacific Brain Health Center, Pacific Neuroscience Institute and Foundation, Santa Monica, CA, USA
- Saint John’s Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
- Providence Saint John’s Health Center, Santa Monica, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
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Meysami S, Raji CA, Chwa WJ, Popa ES, Ganapathi AS, Bookheimer T, Slyapich CB, Pierce KP, Richards CJ, Gill JM, Lampa MG, Rapozo MK, Hodes JF, Glatt RM, Tongson YM, Wong CL, Kim M, Porter VR, Kaiser SA, Panos SE, Dye RV, Miller KJ, Bookheimer SY, Martin NA, Kesari S, Kelly DF, Siddarth P, Roach JC, Bramen JE, Merrill DA. Preliminary Evaluation of Longitudinal Brain MRI Volumetric Quantification in Persons with Cognitive Decline and Confirmed Amyloid Burden Undergoing Multi‐Modal Interventions at an Outpatient Memory Clinic. Alzheimers Dement 2022. [DOI: 10.1002/alz.063695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Somayeh Meysami
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
| | - Cyrus A. Raji
- Mallinckrodt Institute of Radiology, Washington University St. Louis MO USA
| | - Won Jong Chwa
- Mallinckrodt Institute of Radiology, Washington University St. Louis MO USA
| | - Emily S. Popa
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Aarthi S. Ganapathi
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Tess Bookheimer
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Colby B. Slyapich
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Kyron P. Pierce
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Casey J. Richards
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Jaya M. Gill
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Melanie G. Lampa
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Molly K. Rapozo
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - John F. Hodes
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Drexel University College of Medicine Philadelphia PA USA
| | - Ryan M. Glatt
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
| | | | - Claudia L. Wong
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
| | - Mihae Kim
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
| | - Verna R. Porter
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
- Providence Saint John's Health Center Santa Monica CA USA
| | - Scott A. Kaiser
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
| | - Stella E. Panos
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
| | - Richelin V. Dye
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Behavioral Health Institute, Loma Linda University School of Medicine Loma Linda CA USA
| | - Karen J. Miller
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
| | - Susan Y. Bookheimer
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
| | - Neil A. Martin
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
| | - Santosh Kesari
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
| | - Daniel F. Kelly
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
| | - Prabha Siddarth
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
| | | | - Jennifer E. Bramen
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
| | - David A. Merrill
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
- Providence Saint John's Health Center Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
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11
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Meysami S, Raji CA, Popa ES, Ganapathi AS, Bookheimer T, Slyapich CB, Pierce KP, Richards CJ, Gill JM, Lampa MG, Rapozo MK, Hodes JF, Glatt RM, Tongson YM, Wong CL, Kim M, Porter VR, Kaiser SA, Panos SE, Dye RV, Miller KJ, Bookheimer SY, Martin NA, Kesari S, Kelly DF, Siddarth P, Bramen JE, Merrill DA. Handgrip Strength is Related to Regional Brain Volumes in a Cohort of Cognitively Impaired Older Adults with Confirmed Amyloid Burden. Alzheimers Dement 2022. [DOI: 10.1002/alz.068108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Somayeh Meysami
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
| | - Cyrus A. Raji
- Mallinckrodt Institute of Radiology, Washington University St. Louis MO USA
| | - Emily S. Popa
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Aarthi S. Ganapathi
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Tess Bookheimer
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Colby B. Slyapich
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Kyron P. Pierce
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Casey J. Richards
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Jaya M. Gill
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Melanie G. Lampa
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - Molly K. Rapozo
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
| | - John F. Hodes
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Drexel University College of Medicine Philadelphia PA USA
| | - Ryan M. Glatt
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
| | | | - Claudia L. Wong
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
| | - Mihae Kim
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
| | - Verna R. Porter
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
- Providence Saint John's Health Center Santa Monica CA USA
| | - Scott A. Kaiser
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
| | - Stella E. Panos
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
| | - Richelin V. Dye
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Behavioral Health Institute, Loma Linda University School of Medicine Loma Linda CA USA
| | - Karen J. Miller
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
| | - Susan Y. Bookheimer
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
| | - Neil A. Martin
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
| | - Santosh Kesari
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
| | - Daniel F. Kelly
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Providence Saint John's Health Center Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
| | - Prabha Siddarth
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
| | - Jennifer E. Bramen
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
| | - David A. Merrill
- Pacific Brain Health Center, Pacific Neuroscience Institute Foundation Santa Monica CA USA
- David Geffen School of Medicine at University of California Los Angeles Los Angeles CA USA
- Providence Saint John's Health Center Santa Monica CA USA
- Saint John's Cancer Institute at Providence Saint John's Health Center Santa Monica CA USA
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12
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Avery MB, Mallari RJ, Barkhoudarian G, Kelly DF. Supraorbital and mini-pterional keyhole craniotomies for brain tumors: a clinical and anatomical comparison of indications and outcomes in 204 cases. J Neurosurg 2022; 136:1314-1324. [PMID: 34715664 DOI: 10.3171/2021.6.jns21759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' objective was to compare the indications, outcomes, and anatomical limits of supraorbital (SO) and mini-pterional (MP) craniotomies in patients with intra- and extraaxial brain tumors, and to assess approach selection, utility of endoscopy, and surgical field overlap. METHODS A retrospective analysis was conducted of all brain tumor patients who underwent an SO or MP approach. The analyzed characteristics included pathology, endoscopy use, extent of resection, length of stay (LOS), and complications. On the basis of preoperative MRI data, tumor heatmaps were constructed to compare surgical access provided by both routes, including coronal projection heatmaps for parasellar tumors. RESULTS From 2007 to 2020, 158 patients underwent 173 (84.8%) SO craniotomies and 30 patients underwent 31 (15.2%) MP craniotomies; 71 (34.8%) procedures were reoperations. Of these 204 operations, 110 (63.6%) SO and 21 (67.7%) MP approaches were for extraaxial tumors (meningiomas in 65% and 76.2%, respectively). Gliomas and metastases together represented 84.1% and 70% of intraaxial tumors accessed with SO and MP approaches, respectively. Overall, 56.1% of tumors accessed with the SO approach and 41.9% of those accessed with the MP approach were in the parasellar region. Axial projection heatmaps showed that SO access extended along the entire ipsilateral and medial contralateral anterior cranial fossa, parasellar region, ipsilateral sylvian fissure, medial middle cranial fossa, and anterior midbrain, whereas MP access was limited to the ipsilateral middle cranial fossa, sylvian fissure, lateral parasellar region, and posterior aspect of anterior cranial fossa. Coronal projection heatmaps showed that parasellar access extended further superiorly with the SO approach compared with that of the MP approach. Endoscopy was utilized in 98 (56.6%) SO craniotomies and 7 (22.6%) MP craniotomies, with further tumor resection in 48 (49%) and 5 (71.4%) cases, respectively. Endoscope-assisted tumor removal was clustered in areas that were generally at farther distances from the craniotomy or in angled locations such as the cribriform plate region where microscopic visualization is limited. Gross-total or near-total resection was achieved in 120/173 (69%) SO approaches and 21/31 (68%) MP approaches. Major complications occurred in 11 (6.4%) SO approaches and 1 (3.2%) MP approach (p = 0.49). The median LOS decreased to 2 days in the last 2 years of the study. CONCLUSIONS This clinical experience suggests the SO and MP craniotomies are versatile, safe, and complementary approaches for tumors located in the anterior and middle cranial fossae and perisylvian and parasellar regions. The SO route, used in 85% of cases, achieved greater overall reach than the MP route. Both approaches may benefit from expanded visualization with endoscopy.
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Affiliation(s)
- Michael B Avery
- 1Pacific Neuroscience Institute, Santa Monica, California; and
- 2Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | | | - Garni Barkhoudarian
- 1Pacific Neuroscience Institute, Santa Monica, California; and
- 2Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Daniel F Kelly
- 1Pacific Neuroscience Institute, Santa Monica, California; and
- 2Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
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13
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Olson MG, Avery MB, Javaherian S, Sivakumar W, Kelly DF, Griffiths C, Barkhoudarian G. MINIMALLY INVASIVE PERICRANIAL FLAP HARVEST THROUGH A SUPRAORBITAL EYEBROW CRANIOTOMY: TECHNICAL NOTE IN SALVAGE SKULL BASE RECONSTRUCTION. Clin Neurol Neurosurg 2022; 217:107266. [DOI: 10.1016/j.clineuro.2022.107266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/21/2022] [Accepted: 04/23/2022] [Indexed: 11/03/2022]
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Mallari RJ, Thakur JD, Barkhoudarian G, Eisenberg A, Rodriguez A, Rettinger S, Cohan P, Nieman L, Kelly DF. Diagnostic Pitfalls in Cushing Disease: Surgical Remission Rates, Test Thresholds, and Lessons Learned in 105 Patients. J Clin Endocrinol Metab 2022; 107:205-218. [PMID: 34478542 PMCID: PMC8684536 DOI: 10.1210/clinem/dgab659] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Confirming a diagnosis of Cushing disease (CD) remains challenging, yet is critically important before recommending transsphenoidal surgery for adenoma resection. OBJECTIVE To describe predictive performance of preoperative biochemical and imaging data relative to post-operative remission and clinical characteristics in patients with presumed CD. DESIGN, SETTING, PATIENTS, INTERVENTIONS Patients (n = 105; 86% female) who underwent surgery from 2007 through 2020 were classified into 3 groups: group A (n = 84) pathology-proven ACTH adenoma; group B (n = 6) pathology-unproven but with postoperative hypocortisolemia consistent with CD; and group C (n = 15) pathology-unproven, without postoperative hypocortisolemia. Group A + B were combined as confirmed CD and group C as unconfirmed CD. MAIN OUTCOMES Group A + B was compared with group C regarding predictive performance of preoperative 24-hour urinary free cortisol (UFC), late night salivary cortisol (LNSC), 1-mg dexamethasone suppression test (DST), plasma ACTH, and pituitary magnetic resonance imaging (MRI). RESULTS All groups had a similar clinical phenotype. Compared with group C, group A + B had higher mean UFC (P < 0.001), LNSC (P = 0.003), DST (P = 0.06), and ACTH (P = 0.03) and larger MRI-defined lesions (P < 0.001). The highest accuracy thresholds were: UFC 72 µg/24 hours; LNSC 0.122 µg/dL, DST 2.70 µg/dL, and ACTH 39.1 pg/mL. Early (3-month) biochemical remission was achieved in 76/105 (72%) patients: 76/90(84%) and 0/15(0%) of group A + B vs group C, respectively, P < 0.0001. In group A + B, nonremission was strongly associated with adenoma cavernous sinus invasion. CONCLUSIONS Use of strict biochemical thresholds may help avoid offering transsphenoidal surgery to presumed CD patients with equivocal data and improve surgical remission rates. Patients with Cushingoid phenotype but equivocal biochemical data warrant additional rigorous testing.
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Affiliation(s)
- Regin Jay Mallari
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
| | - Jai Deep Thakur
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
- University of South Alabama, Mobile, AL 36604, USA
| | - Garni Barkhoudarian
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
- Saint John’s Cancer Institute at Saint John’s Health Center, Santa Monica, CA 90404, USA
| | - Amy Eisenberg
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
| | - Amanda Rodriguez
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
| | - Sarah Rettinger
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
| | - Pejman Cohan
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
| | - Lynnette Nieman
- Diabetes, Endocrine and Obesity Branch, The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD 20814, USA
| | - Daniel F Kelly
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA 90404, USA
- Saint John’s Cancer Institute at Saint John’s Health Center, Santa Monica, CA 90404, USA
- Correspondence: Daniel F. Kelly, MD, Pacific Neuroscience Institute, Saint John’s Cancer Institute, Providence Saint John’s Health Center, 2125 Arizona Ave., Santa Monica, CA 90404, USA.
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15
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Fleseriu M, Auchus R, Bancos I, Ben-Shlomo A, Bertherat J, Biermasz NR, Boguszewski CL, Bronstein MD, Buchfelder M, Carmichael JD, Casanueva FF, Castinetti F, Chanson P, Findling J, Gadelha M, Geer EB, Giustina A, Grossman A, Gurnell M, Ho K, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Kelly DF, Lacroix A, McCormack A, Melmed S, Molitch M, Mortini P, Newell-Price J, Nieman L, Pereira AM, Petersenn S, Pivonello R, Raff H, Reincke M, Salvatori R, Scaroni C, Shimon I, Stratakis CA, Swearingen B, Tabarin A, Takahashi Y, Theodoropoulou M, Tsagarakis S, Valassi E, Varlamov EV, Vila G, Wass J, Webb SM, Zatelli MC, Biller BMK. Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet Diabetes Endocrinol 2021; 9:847-875. [PMID: 34687601 PMCID: PMC8743006 DOI: 10.1016/s2213-8587(21)00235-7] [Citation(s) in RCA: 265] [Impact Index Per Article: 88.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/22/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
Cushing's disease requires accurate diagnosis, careful treatment selection, and long-term management to optimise patient outcomes. The Pituitary Society convened a consensus workshop comprising more than 50 academic researchers and clinical experts to discuss the application of recent evidence to clinical practice. In advance of the virtual meeting, data from 2015 to present about screening and diagnosis; surgery, medical, and radiation therapy; and disease-related and treatment-related complications of Cushing's disease summarised in recorded lectures were reviewed by all participants. During the meeting, concise summaries of the recorded lectures were presented, followed by small group breakout discussions. Consensus opinions from each group were collated into a draft document, which was reviewed and approved by all participants. Recommendations regarding use of laboratory tests, imaging, and treatment options are presented, along with algorithms for diagnosis of Cushing's syndrome and management of Cushing's disease. Topics considered most important to address in future research are also identified.
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Affiliation(s)
| | | | | | | | - Jerome Bertherat
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares de la Surrénale, Service d'Endocrinologie, Hôpital Cochin, Paris, France
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | | | | | | | - John D Carmichael
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Felipe F Casanueva
- Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM, Marseille, France; Assistance Publique Hopitaux de Marseille, Marseille, France; Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Mônica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliza B Geer
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Ashley Grossman
- University of London, London, UK; University of Oxford, Oxford, UK
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK; NIHR Cambridge Biomedical Research Center, Cambridge, UK; Addenbrooke's Hospital, Cambridge, UK
| | - Ken Ho
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Ursula B Kaiser
- Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - André Lacroix
- Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Ann McCormack
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Alberto M Pereira
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | | | - Hershel Raff
- Medical College of Wisconsin, Milwaukee, WI, USA; Advocate Aurora Research Institute, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Martin Reincke
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | | | - Ilan Shimon
- Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | | | | | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | | | - Marily Theodoropoulou
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital General de Catalunya, Barcelona, Spain; Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- Churchill Hospital, Oxford, United Kingdom
| | - Susan M Webb
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
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16
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Thakur JD, Corlin A, Mallari RJ, Yawitz S, Eisenberg A, Sivakumar W, Griffiths C, Carrau RL, Rettinger S, Cohan P, Krauss H, Araque KA, Barkhoudarian G, Kelly DF. Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients. Pituitary 2021; 24:930-942. [PMID: 34215990 PMCID: PMC8252985 DOI: 10.1007/s11102-021-01167-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE To evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis. METHODS All patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery. RESULTS Of 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p < 0.001. Readmissions occurred in 6%(31/535), mostly for hyponatremia (18/31). Gross total resection was achieved in 214/312(69%) endocrine-inactive adenomas; biochemical remission was achieved in 148/209(71%) endocrine-active adenomas. Visual field or acuity defects improved in 126/138(91.3%) patients. CONCLUSION This study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.
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Affiliation(s)
| | - Alex Corlin
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Regin Jay Mallari
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Samantha Yawitz
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Amalia Eisenberg
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Chester Griffiths
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | | | - Sarah Rettinger
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Howard Krauss
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Katherine A Araque
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA.
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA.
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17
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Thakur JD, Mallari RJ, Corlin A, Yawitz S, Huang W, Eisenberg A, Sivakumar W, Krauss HR, Griffiths C, Barkhoudarian G, Kelly DF. Minimally invasive surgical treatment of intracranial meningiomas in elderly patients (≥ 65 years): outcomes, readmissions, and tumor control. Neurosurg Focus 2021; 49:E17. [PMID: 33002879 DOI: 10.3171/2020.7.focus20515] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Increased lifespan has led to more elderly patients being diagnosed with meningiomas. In this study, the authors sought to analyze and compare patients ≥ 65 years old with those < 65 years old who underwent minimally invasive surgery for meningioma. To address surgical selection criteria, the authors also assessed a cohort of patients managed without surgery. METHODS In a retrospective analysis, consecutive patients with meningiomas who underwent minimally invasive (endonasal, supraorbital, minipterional, transfalcine, or retromastoid) and conventional surgical treatment approaches during the period from 2008 to 2019 were dichotomized into those ≥ 65 and those < 65 years old to compare resection rates, endoscopy use, complications, and length of hospital stay (LOS). A comparator meningioma cohort of patients ≥ 65 years old who were observed without surgery during the period from 2015 to 2019 was also analyzed. RESULTS Of 291 patients (median age 60 years, 71.5% females, mean follow-up 36 months) undergoing meningioma resection, 118 (40.5%) were aged ≥ 65 years and underwent 126 surgeries, including 20% redo operations, as follows: age 65-69 years, 46 operations; 70-74 years, 40 operations; 75-79 years, 17 operations; and ≥ 80 years, 23 operations. During 2015-2019, of 98 patients referred for meningioma, 67 (68%) had surgery, 1 (1%) had radiosurgery, and 31 (32%) were observed. In the 11-year surgical cohort, comparing 173 patients < 65 years versus 118 patients ≥ 65 years old, there were no significant differences in tumor location, size, or outcomes. Of 126 cases of surgery in 118 elderly patients, the approach was a minimally invasive approach to skull base meningioma (SBM) in 64 cases (51%) as follows: endonasal 18, supraorbital 28, minipterional 6, and retrosigmoid 12. Endoscope-assisted surgery was performed in 59.5% of patients. A conventional approach to SBM was performed in 15 cases (12%) (endoscope-assisted 13.3%), and convexity craniotomy for non-skull base meningioma (NSBM) in 47 cases (37%) (endoscope-assisted 17%). In these three cohorts (minimally invasive SBM, conventional SBM, and NSBM), the gross-total/near-total resection rates were 59.5%, 60%, and 91.5%, respectively, and an improved or stable Karnofsky Performance Status score occurred in 88.6%, 86.7%, and 87.2% of cases, respectively. For these 118 elderly patients, the median LOS was 3 days, and major complications occurred in 10 patients (8%) as follows: stroke 4%, vision decline 3%, systemic complications 0.7%, and wound infection or death 0. Eighty-three percent of patients were discharged home, and readmissions occurred in 5 patients (4%). Meningioma recurrence occurred in 4 patients (3%) and progression in 11 (9%). Multivariate regression analysis showed no significance of American Society of Anesthesiologists physical status score, comorbidities, or age subgroups on outcomes; patients aged ≥ 80 years showed a trend of longer hospitalization. CONCLUSIONS This analysis suggests that elderly patients with meningiomas, when carefully selected, generally have excellent surgical outcomes and tumor control. When applied appropriately, use of minimally invasive approaches and endoscopy may be helpful in achieving maximal safe resection, reducing complications, and promoting short hospitalizations. Notably, one-third of our elderly meningioma patients referred for possible surgery from 2015 to 2019 were managed nonoperatively.
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Affiliation(s)
- Jai Deep Thakur
- 1Pacific Neuroscience Institute, and.,2John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California; and.,3University of South Alabama, Mobile, Alabama
| | | | | | | | | | | | - Walavan Sivakumar
- 1Pacific Neuroscience Institute, and.,2John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California; and
| | - Howard R Krauss
- 1Pacific Neuroscience Institute, and.,2John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California; and
| | - Chester Griffiths
- 1Pacific Neuroscience Institute, and.,2John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California; and
| | - Garni Barkhoudarian
- 1Pacific Neuroscience Institute, and.,2John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California; and
| | - Daniel F Kelly
- 1Pacific Neuroscience Institute, and.,2John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California; and
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18
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Nordberg B, Lopez-Hernandez DW, Bueno A, Victor TL, Saravia S, Baez AJ, Sidhu J, Munoz I, Cantu RC, Guskiewicz KM, Kelly DF, Swerdloff R, Hardy DJ, Woo E, Litvin PY, Wright MJ. A-122 Verbal Fluency Switching and Clustering Performance in Retired Professional Football Players. Arch Clin Neuropsychol 2021. [DOI: 10.1093/arclin/acab062.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Repeated sports-related concussion has been associated with cognitive deficits, like other forms of traumatic brain injury. Football speed players (FSP; e.g., quarterbacks) are at greater risk of cognitive impairment compared to football non-speed players (FNP). Verbal fluency is typically comprised of two tasks: letter fluency (LF) and semantic fluency (SF). Verbal clustering (production of continuous words belonging to the same category or subcategory) and switching (abandoning an exhausted semantic cluster to a new one in order to produce more words) reflect executive control and strategy use. We examined LF, SF, as well as LF and SF switching and clustering performance in retired FSP, FNP, and healthy comparison (HC) participants.
Methods
The sample consisted of 28 HC, 17 retired FSP, and 53 retired FNP. ANOVAs were conducted to determine group differences on LF, SF, switching, and clustering. FSP and FNP did not differ in concussion frequency.
Results
We found the HC group outperformed the FSP group in LF, p = 0.042, ηp2 = 0.07. For SF, the HC and FNP groups outperformed the FSP group, p = 0.013, ηp2 = 0.09. Furthermore, we found the HC group outperformed both football groups in SF switching, p = 0.000, ηp2 = 0.17.
Conclusion
As expected, the HC group outperformed the FSP group on LF and SF. Also, the FNP group outperformed the FSP group on SF. Interestingly, FSP displayed generally worse performances, supporting the notion that their experience of sub-concussive blows puts them at greater risk for cognitive impairment. Further investigation is needed with larger sample sizes to evaluate SF and other cognitive deficits in the FSP participants.
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19
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Lopez-Hernandez DW, Nordberg BA, Bueno A, Litvin PY, Bichlmeier A, Smith KE, Olmos W, Sidhu J, Saravia S, Mangassarian S, Fatoorechi S, Hardy D, Woo E, Schmitter-Edgecombe M, Cantu RC, Guskiewicz KM, Kelly DF, Swerdloff R, Wright MJ. A-104 Examining Methods of Executive Ability from Trail Making Test Part B in Retired Football Players. Arch Clin Neuropsychol 2021. [DOI: 10.1093/arclin/acab062.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Repeated sports-related concussions have been associated with cognitive deficits, similar to other forms of traumatic brain injury. We investigated three different measures of executive ability derived from the Trail Making Test part B (TMT-B) in healthy comparison (HC) adults and retired football players.
Methods
The sample consisted of 32 HC, 15 retired football speed players (FSP; e.g., quarterbacks), and 53 retired football non-speed players (FNP) participants. Participants were administered both TMT part A (TMT-A) and TMT-B, and total time for completion was recorded. A series of ANCOVAs, controlling for age and education were conducted to evaluate group differences in executive abilities. Executive measures included the TMT-B raw score (i.e., seconds to complete TMT-B), the raw score difference (in seconds) between TMT-A and TMT-B (TMT-BA), and the difference between a predicted TMT-B score (TMT-BP) and the obtained TMT-B score (TMT-BBP). Correlations between TMT-B, TMT-BA, and TMT-BBP and other executive functioning tests (i.e., letter fluency and animal naming) were evaluated.
Results
Results revealed that the HC group outperformed both retired football player groups on all measures of executive ability derived from TMT-B, p’s < 0.05, ηps2 = 0.18–0.45. Furthermore, the retired FNP TMT-B and TMT-BA were significantly correlated with both letter fluency and animal naming, r’s = −0.40 to −0.36, p’s < 0.05.
Discussion
We found that the HC group outperformed both retired football player groups on all three TMT variables. In our retired FNP sample, more TMT variables correlated with executive functioning measures which suggests that TMT-B and TMT-BA are likely better measures of executive ability than TMT-BBP.
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20
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Mallari RJ, Thakur JD, Rhee JH, Eisenberg A, Krauss H, Griffiths C, Sivakumar W, Barkhoudarian G, Kelly DF. Endoscopic Endonasal and Supraorbital Removal of Tuberculum Sellae Meningiomas: Anatomic Guides and Operative Nuances for Keyhole Approach Selection. Oper Neurosurg (Hagerstown) 2021; 21:E71-E81. [PMID: 34114024 DOI: 10.1093/ons/opab138] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 02/14/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND With growing worldwide endoscopy experience, endonasal and supraorbital removal of tuberculum sellae meningiomas (TSM) has increased. OBJECTIVE To describe anatomic factors for guiding approach selection and outcomes. METHODS Retrospective analysis of patients undergoing endonasal or supraorbital TSM resection: approach criteria, clinical outcomes, acute magnetic resonance imaging (MRI) fluid-attenuated inversion-recovery (FLAIR)/T2 changes. RESULTS From 2008 to 2020, 33 patients (mean age 55 ± 11 yr) were identified: 20 (61%) had endonasal and 13 (39%) supraorbital removal. Comparing endonasal and supraorbital approaches, mean tumor volume (3.7 ± 3.5 cm3 vs 7.7 ± 8.5 cm3, P = .07); percent tumor above planum (42% vs 65%, P = .02), and lateral tumor beyond supraclinoid internal carotid arteries (1.4 ± 2.0 mm vs 4.0 ± 3.2 mm, P = .006) were greater for supraorbital route. Sellar depth was greater for endonasal route tumors (12.2 ± 2.6 mm vs 9.3 ± 2.4 mm, P = .003). Endoscopy, used in 10/13(77%) supraorbital cases, was helpful in additional tumor removal in 4/10(40%). Gross total removal and mean volumetric tumor resection were 16/20(80%) and 97.5% by endonasal, and 5/13(39%) and 96% by supraorbital route. Vision improved in 12/17 (71%) endonasal, 6/8 (75%) supraorbital operations, and worsened in 1 (3%) supraorbital case. Endonasal approach with optic canal decompression increased over study period: 15/20 (75%) endonasal patients vs 1/13(8%) supraorbital (P < .001). Postoperative FLAIR/T2 MRI changes occurred in 2/12 supraorbital and 0/20 endonasal cases. CONCLUSION In our experience, both endonasal and supraorbital routes are safe and effective for TSM removal. Greater tumor extension below planum and medial optic canal invasion favor endonasal route, while larger size and lateral extension favor supraorbital route. Given high frequency of TSM growth into optic canals and better access for medial optic canal tumor removal, endonasal route may be preferred for most TSMs.
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Affiliation(s)
| | - Jai Deep Thakur
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA.,University of South Alabama, Mobile, Alabama, USA
| | - John H Rhee
- Pacific Neuroscience Institute, Santa Monica, California, USA
| | | | - Howard Krauss
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Chester Griffiths
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
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21
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Shoji Y, Furuhashi S, Kelly DF, Bilchik AJ, Hoon DSB, Bustos MA. Current status of gastrointestinal tract cancer brain metastasis and the use of blood-based cancer biomarker biopsy. Clin Exp Metastasis 2021; 39:61-69. [PMID: 33950411 DOI: 10.1007/s10585-021-10094-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/25/2021] [Indexed: 12/24/2022]
Abstract
Brain metastasis (BM) frequently occurs in patients with cutaneous melanoma, lung, and breast cancer; although, BM rarely arises from cancers of the gastrointestinal tract (GIT). The reported incidence of GIT cancer BM is less than 4%. In the last few years, effective systemic therapy has prolonged the survival of GIT patients and consequently, the incidence of developing BM is rising. Therefore, the epidemiology and biology of BM arising from GIT cancer requires a more comprehensive understanding. In spite of the development of new therapeutic agents for patients with metastatic GIT cancers, survival for patients with BM still remains poor, with a median survival after diagnosis of less than 4 months. Limited evidence suggests that early detection of isolated intra-cranial lesions will enable surgical resection plus systemic and/or radiation therapy, which may lead to an increase in overall survival. Novel diagnostic methods such as blood-based biomarker biopsies may play a crucial role in the early detection of BM. Circulating tumor cells and circulating cell-free nucleic acids are known to serve as blood biomarkers for early detection and treatment response monitoring of multiple cancers. Blood biopsy may improve early diagnosis and treatment monitoring of GIT cancers BM, thus prolonging patients' survivals.
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Affiliation(s)
- Yoshiaki Shoji
- Division of Molecular Oncology, Department of Translational Molecular Medicine, Saint John's Cancer Institute at Providence Saint John's Health Center, 2200 Santa Monica Blvd, Santa Monica, CA, 90404, USA
| | - Satoru Furuhashi
- Division of Molecular Oncology, Department of Translational Molecular Medicine, Saint John's Cancer Institute at Providence Saint John's Health Center, 2200 Santa Monica Blvd, Santa Monica, CA, 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Anton J Bilchik
- Department of Surgical Oncology, Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Dave S B Hoon
- Division of Molecular Oncology, Department of Translational Molecular Medicine, Saint John's Cancer Institute at Providence Saint John's Health Center, 2200 Santa Monica Blvd, Santa Monica, CA, 90404, USA
| | - Matias A Bustos
- Division of Molecular Oncology, Department of Translational Molecular Medicine, Saint John's Cancer Institute at Providence Saint John's Health Center, 2200 Santa Monica Blvd, Santa Monica, CA, 90404, USA.
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22
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Wright MJ, Monti MM, Lutkenhoff ES, Hardy DJ, Litvin PY, Kelly DF, Guskiewicz K, Cantu RC, Vespa PM, Hovda DA, Lopez WD, Wang C, Swerdloff R, Fuster JM. Memory in repeat sports-related concussive injury and single-impact traumatic brain injury. Brain Inj 2020; 34:1666-1673. [PMID: 32990043 DOI: 10.1080/02699052.2020.1825806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Repeat sports-related concussive/subconcussive injury (RC/SCI) is related to memory impairment. Objective & Methods: We sought to determine memory differences between persons with RC/SCI, moderate-to-severe single-impact traumatic brain injury (SI-TBI), and healthy controls. MRI scans from a subsample of participants with SI-TBI were used to identify the neuroanatomical correlates of observed memory process differences between the brain injury groups. Results: Both brain injury groups evidenced worse learning and recall in contrast to controls, although SI-TBI group had poorer memory than the RC/SCI group. Regarding memory process differences, in contrast to controls, the SI-TBI group evidenced difficulties with encoding, consolidation, and retrieval, while the RC/SCI group showed deficits in consolidation and retrieval. Delayed recall was predicted by encoding, with consolidation as a secondary predictor in the SI-TBI group. In the RC/SCI group, delayed recall was only predicted by consolidation. MRI data showed that the consolidation index we used mapped onto hippocampal atrophy. Conclusions: RC/SCI is primarily associated with consolidation deficits, which differs from SI-TBI. Given the role of the hippocampus in memory consolidation and the fact that hyperphosphorylated tau tends to accumulate in the medial temporal lobe in RC/SCI, consolidation deficits may be a cognitive marker of chronic traumatic encephalopathy in athletes.
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Affiliation(s)
- Matthew J Wright
- Lundquist Institute at Harbor-UCLA Medical Center , Torrance, California, USA.,Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine , Los Angeles, California, USA
| | - Martin M Monti
- Department of Psychology, UCLA , Los Angeles, California, USA.,Department of Neurosurgery, UCLA School of Medicine , Los Angeles, California, USA
| | - Evan S Lutkenhoff
- Department of Psychology, UCLA , Los Angeles, California, USA.,Department of Neurosurgery, UCLA School of Medicine , Los Angeles, California, USA
| | - David J Hardy
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine , Los Angeles, California, USA.,Department of Psychology, Loyola Marymount University , Los Angeles, California, USA
| | - Pavel Y Litvin
- Lundquist Institute at Harbor-UCLA Medical Center , Torrance, California, USA
| | - Daniel F Kelly
- Department of Neurosurgery, Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center , Santa Monica, California, USA
| | - Kevin Guskiewicz
- Department of Exercise & Sports Science, Center for the Study of Retired Athletes at the University of North Carolina , Chapel Hill, North Carolina, USA
| | - Robert C Cantu
- Department of Neurosurgery, Boston University School of Medicine , Boston, Massachusetts, USA
| | - Paul M Vespa
- Department of Neurosurgery, UCLA School of Medicine , Los Angeles, California, USA.,Department of Neurology, UCLA School of Medicine , Los Angeles, California, USA
| | - David A Hovda
- Department of Neurosurgery, UCLA School of Medicine , Los Angeles, California, USA
| | - Walter D Lopez
- Lundquist Institute at Harbor-UCLA Medical Center , Torrance, California, USA
| | - Christina Wang
- Lundquist Institute at Harbor-UCLA Medical Center , Torrance, California, USA
| | - Ronald Swerdloff
- Lundquist Institute at Harbor-UCLA Medical Center , Torrance, California, USA
| | - Joaquín M Fuster
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine , Los Angeles, California, USA
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23
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Mooney MA, Sarris CE, Zhou JJ, Barkhoudarian G, Chicoine MR, Fernandez-Miranda JC, Gardner PA, Hardesty DA, Jahnke H, Kelly DF, Liebelt BD, Mayberg MR, Prevedello DM, Sfondouris J, Sheehy JP, Chandler JP, Yuen KCJ, White WL, Little AS. Proposal and Validation of a Simple Grading Scale (TRANSSPHER Grade) for Predicting Gross Total Resection of Nonfunctioning Pituitary Macroadenomas After Transsphenoidal Surgery. Oper Neurosurg (Hagerstown) 2020; 17:460-469. [PMID: 30649445 DOI: 10.1093/ons/opy401] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 12/31/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND A simple, reliable grading scale to better characterize nonfunctioning pituitary adenomas (NFPAs) preoperatively has potential for research and clinical applications. OBJECTIVE To develop a grading scale from a prospective multicenter cohort of patients that accurately and reliably predicts the likelihood of gross total resection (GTR) after transsphenoidal NFPA surgery. METHODS Extent-of-resection (EOR) data from a prospective multicenter study in transsphenoidal NFPA surgery were analyzed (TRANSSPHER study; ClinicalTrials.gov NCT02357498). Sixteen preoperative radiographic magnetic resonance imaging (MRI) tumor characteristics (eg, tumor size, invasion measures, tumor signal characteristics, and parameters impacting surgical access) were evaluated to determine EOR predictors, to calculate receiver-operating characteristic curves, and to develop a grading scale. A separate validation cohort (n = 165) was examined to assess the scale's performance and inter-rater reliability. RESULTS Data for 222 patients from 7 centers treated by 15 surgeons were analyzed. Approximately one-fifth of patients (18.5%; 41 of 222) underwent subtotal resection (STR). Maximum tumor diameter > 40 mm; nodular tumor extension through the diaphragma into the frontal lobe, temporal lobe, posterior fossa, or ventricle; and Knosp grades 3 to 4 were identified as independent STR predictors. A grading scale (TRANSSPHER grade) based on a combination of these 3 features outperformed individual variables in predicting GTR (AUC, 0.732). In a validation cohort, the scale exhibited high sensitivity and specificity (AUC, 0.779) and strong inter-rater reliability (kappa coefficient, 0.617). CONCLUSION This simple, reliable grading scale based on preoperative MRI characteristics can be used to better characterize NFPAs for clinical and research purposes and to predict the likelihood of achieving GTR.
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Affiliation(s)
- Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - James J Zhou
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute and Pituitary Disorders Center, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Douglas A Hardesty
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Heidi Jahnke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Daniel F Kelly
- Pacific Neuroscience Institute and Pituitary Disorders Center, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Brandon D Liebelt
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Marc R Mayberg
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John Sfondouris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - John P Sheehy
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - James P Chandler
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kevin C J Yuen
- Department of Neurology and Barrow Neuroendocrinology Clinic, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - William L White
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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24
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Ansari SF, Eisenberg A, Rodriguez A, Barkhoudarian G, Kelly DF. The Supraorbital Eyebrow Craniotomy for Intra- and Extra-Axial Brain Tumors: A Single-Center Series and Technique Modification. Oper Neurosurg (Hagerstown) 2020; 19:667-677. [PMID: 32745195 DOI: 10.1093/ons/opaa217] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 05/03/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The supraorbital (SO) eyebrow craniotomy provides minimally invasive access to the anterior and middle fossae and parasellar region. OBJECTIVE To present a series of patients treated with the SO approach to assess outcomes, the impact of endoscopy, and describe a modified pericranial flap aimed at reducing postoperative frontalis paresis and hypesthesia. METHODS A retrospective analysis was undertaken of our prospective database of patients who underwent SO craniotomy for tumor/cyst removal. Patients were evaluated based on pathology, utility of endoscopy, extent of resection, complications, and functional/esthetic recovery. RESULTS From 2007 to 2018, 129 operations were performed in 117 patients (54% women; mean age 60 ± 16.5 yr). The most common lesions were meningiomas (43%), gliomas (15%), and metastases (15%). Prior surgery and/or radiation had been performed in 37% and 26% of patients, respectively. Endoscopy was used in 76 (61%) operations and allowed more complete tumor removal in 38 (50%). For first-time operations, gross-total removal was achieved in 78%. Major complications included stroke (3%), cranial nerve deficit (3%), acute hematoma (1%), and cerebrospinal fluid leak (1%). The modified pericranial flap technique used in 18 recent patients resulted in a shorter duration of transient frontalis paresis and forehead hypesthesia with complete functional recovery in all 18. CONCLUSION The SO craniotomy is an effective keyhole approach for intra- and extra-axial tumors. Endoscopic assistance may allow additional tumor removal in almost 30% of the cases. The modified pericranial flap appears to accelerate functional recovery, although additional patients and follow-up are required to better assess this technique.
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Affiliation(s)
- Shaheryar F Ansari
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, California.,John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Amy Eisenberg
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, California.,John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Amanda Rodriguez
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, California.,John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, California.,John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, California.,John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
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25
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Bustos MA, Tran KD, Rahimzadeh N, Gross R, Lin SY, Shoji Y, Murakami T, Boley CL, Tran LT, Cole H, Kelly DF, O’Day S, Hoon DSB. Integrated Assessment of Circulating Cell-Free MicroRNA Signatures in Plasma of Patients with Melanoma Brain Metastasis. Cancers (Basel) 2020; 12:E1692. [PMID: 32630542 PMCID: PMC7352246 DOI: 10.3390/cancers12061692] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022] Open
Abstract
Primary cutaneous melanoma frequently metastasizes to distant organs including the brain. Identification of cell-free microRNAs (cfmiRs) found in the blood can be used as potential body fluid biomarkers for detecting and monitoring patients with melanoma brain metastasis (MBM). In this pilot study, we initially aimed to identify cfmiRs in the blood of MBM patients. Normal donors plasma (healthy, n = 48) and pre-operative MBM patients' plasma samples (n = 36) were compared for differences in >2000 microRNAs (miRs) using a next generation sequencing (NGS) probe-based assay. A 74 cfmiR signature was identified in an initial cohort of MBM plasma samples and then verified in a second cohort of MBM plasma samples (n = 24). Of these, only 58 cfmiRs were also detected in MBM tissues (n = 24). CfmiR signatures were also found in patients who have lung and breast cancer brain metastasis (n = 13) and glioblastomas (n = 36) compared to MBM plasma samples. The 74 cfmiR signature and the latter cfmiR signatures were then compared. We found a 6 cfmiR signature that was commonly upregulated in MBM plasma samples in all of the comparisons, and a 29 cfmiR signature that distinguishes MBM patients from normal donors' samples. In addition, we assessed for cfmiRs in plasma (n = 20) and urine (n = 14) samples collected from metastatic melanoma patients receiving checkpoint inhibitor immunotherapy (CII). Pre- and post-treatment samples showed consistent changes in cfmiRs. Analysis of pre- and post-treatment plasma samples showed 8 differentially expressed (DE) cfmiRs that overlapped with the 35 cfmiR signature found in MBM patients. In paired pre-treatment plasma and urine samples receiving CII 8 cfmiRs overlapped. This study identified specific cfmiRs in MBM plasma samples that may potentially allow for assessment of melanoma patients developing MBM. The cfmiR signatures identified in both blood and urine may have potential utility to assess CII responses after further validation.
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Affiliation(s)
- Matias A. Bustos
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (M.A.B.); (N.R.); (R.G.); (S.Y.L.); (Y.S.); (T.M.)
| | - Kevin D. Tran
- Department of Genomic Sequencing Center, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (K.D.T.); (L.T.T.)
| | - Negin Rahimzadeh
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (M.A.B.); (N.R.); (R.G.); (S.Y.L.); (Y.S.); (T.M.)
| | - Rebecca Gross
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (M.A.B.); (N.R.); (R.G.); (S.Y.L.); (Y.S.); (T.M.)
| | - Selena Y. Lin
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (M.A.B.); (N.R.); (R.G.); (S.Y.L.); (Y.S.); (T.M.)
| | - Yoshiaki Shoji
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (M.A.B.); (N.R.); (R.G.); (S.Y.L.); (Y.S.); (T.M.)
| | - Tomohiro Murakami
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (M.A.B.); (N.R.); (R.G.); (S.Y.L.); (Y.S.); (T.M.)
| | - Christine L. Boley
- Department of Immuno-Oncology and Clinical Research, John Wayne Cancer Institute, Santa Monica, CA 90404, USA; (C.L.B.); (H.C.); O’
| | - Linh T. Tran
- Department of Genomic Sequencing Center, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (K.D.T.); (L.T.T.)
| | - Hunter Cole
- Department of Immuno-Oncology and Clinical Research, John Wayne Cancer Institute, Santa Monica, CA 90404, USA; (C.L.B.); (H.C.); O’
| | - Daniel F. Kelly
- Pacific Neuroscience Institute, John Wayne Cancer Institute, Saint John’s Health Center, Santa Monica, CA 90404, USA;
| | - Steven O’Day
- Department of Immuno-Oncology and Clinical Research, John Wayne Cancer Institute, Santa Monica, CA 90404, USA; (C.L.B.); (H.C.); O’
| | - Dave S. B. Hoon
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (M.A.B.); (N.R.); (R.G.); (S.Y.L.); (Y.S.); (T.M.)
- Department of Genomic Sequencing Center, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (K.D.T.); (L.T.T.)
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26
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Ramos RI, Bustos MA, Wu J, Jones P, Chang SC, Kiyohara E, Tran K, Zhang X, Stern SL, Izraely S, Sagi-Assif O, Witz IP, Davies MA, Mills GB, Kelly DF, Irie RF, Hoon DSB. Upregulation of cell surface GD3 ganglioside phenotype is associated with human melanoma brain metastasis. Mol Oncol 2020; 14:1760-1778. [PMID: 32358995 PMCID: PMC7400791 DOI: 10.1002/1878-0261.12702] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/24/2020] [Accepted: 04/27/2020] [Indexed: 12/23/2022] Open
Abstract
Melanoma metastasis to the brain is one of the most frequent extracranial brain tumors. Cell surface gangliosides are elevated in melanoma metastasis; however, the metabolic regulatory mechanisms that govern these specific changes are poorly understood in melanoma particularly brain metastases (MBM) development. We found ganglioside GD3 levels significantly upregulated in MBM compared to lymph node metastasis (LNM) but not for other melanoma gangliosides. Moreover, we demonstrated an upregulation of ST8SIA1 (GD3 synthase) as melanoma progresses from melanocytes to MBM cells. Using RNA‐ISH on FFPE specimens, we evaluated ST8SIA1 expression in primary melanomas (PRM) (n = 23), LNM and visceral metastasis (n = 45), and MBM (n = 39). ST8SIA1 was significantly enhanced in MBM compared to all other specimens. ST8SIA1 expression was assessed in clinically well‐annotated melanoma patients from multicenters with AJCC stage III B‐D LNM (n = 58) with 14‐year follow‐up. High ST8SIA1 expression was significantly associated with poor overall survival (HR = 3.24; 95% CI, 1.19–8.86, P = 0.02). In a nude mouse human xenograft melanoma brain metastasis model, MBM variants had higher ST8SIA1 expression than their respective cutaneous melanoma variants. Elevated ST8SIA1 expression enhances levels of cell surface GD3, a phenotype that favors MBM development, hence associated with very poor prognosis. Functional assays demonstrated that ST8SIA1 overexpression enhanced cell proliferation and colony formation, whereby ST8SIA1 knockdown had opposite effects. Icaritin a plant‐derived phytoestrogen treatment significantly inhibited cell growth in high GD3‐positive MBM cells through targeting the canonical NFκB pathway. The study demonstrates GD3 phenotype associates with melanoma progression and poor outcome.
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Affiliation(s)
- Romela Irene Ramos
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI), Santa Monica, CA, USA
| | - Matias A Bustos
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI), Santa Monica, CA, USA
| | - Jinfeng Wu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Peter Jones
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI), Santa Monica, CA, USA
| | - Shu Ching Chang
- Medical Data Research Center, Providence St. Joseph Health Center, Portland, OR, USA
| | - Eiji Kiyohara
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI), Santa Monica, CA, USA
| | - Kevin Tran
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI), Santa Monica, CA, USA
| | - Xiaoqing Zhang
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI), Santa Monica, CA, USA
| | - Stacey L Stern
- Department of Biostatistics, JWCI, Santa Monica, CA, USA
| | - Sivan Izraely
- Department of Cell Research and Immunology, George S. Wise Faculty of Life Sciences, Tel-Aviv University, Tel Aviv, Israel
| | - Orit Sagi-Assif
- Department of Cell Research and Immunology, George S. Wise Faculty of Life Sciences, Tel-Aviv University, Tel Aviv, Israel
| | - Isaac P Witz
- Department of Cell Research and Immunology, George S. Wise Faculty of Life Sciences, Tel-Aviv University, Tel Aviv, Israel
| | - Michael A Davies
- Department of Melanoma Medical Oncology, Systems Biology and Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gordon B Mills
- Department of Cell Development and Cancer Biology, Oregon Health and Science University (OHSU) Knight Cancer Institute Portland, OR, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, JWCI, Santa Monica, CA, USA
| | - Reiko F Irie
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI), Santa Monica, CA, USA
| | - Dave S B Hoon
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI), Santa Monica, CA, USA
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27
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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28
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Wang X, Bustos MA, Zhang X, Ramos RI, Tan C, Iida Y, Chang SC, Salomon MP, Tran K, Gentry R, Kravtsova-Ivantsiv Y, Kelly DF, Mills GB, Ciechanover A, Mao Y, Hoon DS. Downregulation of the Ubiquitin-E3 Ligase RNF123 Promotes Upregulation of the NF-κB1 Target SerpinE1 in Aggressive Glioblastoma Tumors. Cancers (Basel) 2020; 12:E1081. [PMID: 32349217 PMCID: PMC7281601 DOI: 10.3390/cancers12051081] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 12/28/2022] Open
Abstract
This study examined the role of the ubiquitin E3-ligase RNF123 in modulating downstream NF-κB1 targets in glioblastoma (GB) tumor progression. Our findings revealed an oncogenic pathway (miR-155-5p-RNF123-NF-κB1-p50-SerpinE1) that may represent a new therapeutic target pathway for GB patients with isocitrate dehydrogenase 1 and 2 (IDH) WT (wild type). Mechanistically, we demonstrated that RNF123 is downregulated in IDH WT GB patients and leads to the reduction of p50 levels. RNA-sequencing, reverse-phase protein arrays, and in vitro functional assays on IDH WT GB cell lines with RNF123 overexpression showed that SerpinE1 was a downstream target that is negatively regulated by RNF123. SERPINE1 knockdown reduced the proliferation and invasion of IDH WT GB cell lines. Both SerpinE1 and miR-155-5p overexpression negatively modulated RNF123 expression. In clinical translational analysis, RNF123, SerpinE1, and miR-155-5p were all associated with poor outcomes in GB patients. Multivariable analysis in IDH WT GB patients showed that concurrent low RNF123 and high SerpinE1 was an independent prognostic factor in predicting poor overall survival (p < 0.001, hazard ratio (HR) = 2.93, 95% confidence interval (CI) 1.7-5.05), and an increased risk of recurrence (p < 0.001, relative risk (RR) = 3.56, 95% CI 1.61-7.83).
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Affiliation(s)
- Xiaowen Wang
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI) at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (X.W.); (M.A.B.); (X.Z.); (R.I.R.); (Y.I.); (M.P.S.); (K.T.); (R.G.); (Y.M.)
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Matias A. Bustos
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI) at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (X.W.); (M.A.B.); (X.Z.); (R.I.R.); (Y.I.); (M.P.S.); (K.T.); (R.G.); (Y.M.)
| | - Xiaoqing Zhang
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI) at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (X.W.); (M.A.B.); (X.Z.); (R.I.R.); (Y.I.); (M.P.S.); (K.T.); (R.G.); (Y.M.)
| | - Romela Irene Ramos
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI) at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (X.W.); (M.A.B.); (X.Z.); (R.I.R.); (Y.I.); (M.P.S.); (K.T.); (R.G.); (Y.M.)
| | - Cong Tan
- Department of Pathology, Cancer Hospital, Fudan University, Shanghai 200032, China;
| | - Yuuki Iida
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI) at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (X.W.); (M.A.B.); (X.Z.); (R.I.R.); (Y.I.); (M.P.S.); (K.T.); (R.G.); (Y.M.)
| | - Shu-Ching Chang
- Medical Data Research Center, Providence Saint Joseph’s Health, Portland, OR 97225, USA;
| | - Matthew P. Salomon
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI) at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (X.W.); (M.A.B.); (X.Z.); (R.I.R.); (Y.I.); (M.P.S.); (K.T.); (R.G.); (Y.M.)
| | - Kevin Tran
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI) at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (X.W.); (M.A.B.); (X.Z.); (R.I.R.); (Y.I.); (M.P.S.); (K.T.); (R.G.); (Y.M.)
| | - Rebecca Gentry
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI) at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (X.W.); (M.A.B.); (X.Z.); (R.I.R.); (Y.I.); (M.P.S.); (K.T.); (R.G.); (Y.M.)
| | - Yelena Kravtsova-Ivantsiv
- The David and Janet Polak Cancer and Vascular Biology Research Center, The Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology, Efron Street, Bat-Galim, Haifa 31096, Israel; (Y.K.-I.); (A.C.)
| | - Daniel F. Kelly
- Pacific Neuroscience Institute, JWCI, Santa Monica, CA 90404, USA;
| | - Gordon B. Mills
- Department of Cell Development and Cancer Biology, Knight Cancer Institute, Portland, OR 97239, USA;
| | - Aaron Ciechanover
- The David and Janet Polak Cancer and Vascular Biology Research Center, The Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology, Efron Street, Bat-Galim, Haifa 31096, Israel; (Y.K.-I.); (A.C.)
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China
- The Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200032, China
| | - Dave S.B. Hoon
- Department of Translational Molecular Medicine, John Wayne Cancer Institute (JWCI) at Providence Saint John’s Health Center, Santa Monica, CA 90404, USA; (X.W.); (M.A.B.); (X.Z.); (R.I.R.); (Y.I.); (M.P.S.); (K.T.); (R.G.); (Y.M.)
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Little AS, Gardner PA, Fernandez-Miranda JC, Chicoine MR, Barkhoudarian G, Prevedello DM, Yuen KCJ, Kelly DF. Pituitary gland recovery following fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenoma: results of a prospective multicenter study. J Neurosurg 2019; 133:1732-1738. [PMID: 31731279 DOI: 10.3171/2019.8.jns191012] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/05/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recovery from preexisting hypopituitarism after transsphenoidal surgery for pituitary adenoma is an important outcome to investigate. Furthermore, pituitary function has not been thoroughly evaluated after fully endoscopic surgery, and benchmark outcomes have not been clearly established. Here, the authors characterize pituitary gland outcomes with a focus on gland recovery following endoscopic transsphenoidal removal of clinically nonfunctioning adenomas. METHODS This multicenter prospective study was conducted at 6 US pituitary centers among adult patients with nonfunctioning pituitary macroadenomas who had undergone endoscopic endonasal pituitary surgery. Pituitary gland function was evaluated 6 months after surgery. RESULTS The 177 enrolled patients underwent fully endoscopic transsphenoidal surgery; 169 (95.5%) of them were available for follow-up. Ninety-five (56.2%) of the 169 patients had had a preoperative deficiency in at least one hormone axis, and 20/95 (21.1%) experienced recovery in at least one axis at the 6-month follow-up. Patients with adrenal insufficiency were more likely to recover (10/34 [29.4%]) than were those with hypothyroidism (8/72 [11.1%]) or male hypogonadism (5/50 [10.0%]). At the 6-month follow-up, 14/145 (9.7%) patients had developed at least one new deficiency. The study did not identify any predictors of gland recovery (p ≥ 0.20). Permanent diabetes insipidus was observed in 4/166 (2.4%) patients. Predictors of new gland dysfunction included a larger tumor size (p = 0.009) and Knosp grade 3 and 4 (p = 0.051). CONCLUSIONS Fully endoscopic pituitary surgery resulted in improvement of pituitary gland function in a substantial minority of patients. The deficiency from which patients were most likely to recover was adrenal insufficiency. Overall rates of postoperative permanent diabetes insipidus were low. This study provides multicenter benchmark neuroendocrine clinical outcome data for the endoscopic technique.
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Affiliation(s)
- Andrew S Little
- 1Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Paul A Gardner
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | | | - Michael R Chicoine
- 4Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Garni Barkhoudarian
- 5Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Daniel M Prevedello
- 6Department of Neurological Surgery, The Ohio State University, Columbus, Ohio; and
| | - Kevin C J Yuen
- 7Department of Neuroendocrinology, Barrow Neurological Institute, Phoenix, Arizona
| | - Daniel F Kelly
- 5Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
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Gravbrot N, Kelly DF, Milligan J, Griffiths CF, Barkhoudarian G, Jahnke H, White WL, Little AS. The Minimal Clinically Important Difference of the Anterior Skull Base Nasal Inventory-12. Neurosurgery 2019; 83:277-280. [PMID: 28973679 DOI: 10.1093/neuros/nyx401] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/19/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The minimal clinically important difference (MCID) is defined as the smallest change in health-related quality of life (QOL) that patients consider meaningful. The MCID is essential for determining clinically significant changes, rather than simply statistically significant changes, in QOL scores. The Anterior Skull Base Nasal Inventory-12 (ASK Nasal-12), a site-specific sinonasal QOL instrument, has emerged as a standard instrument for assessing QOL in patients who have undergone endonasal transsphenoidal surgery. OBJECTIVE To determine the MCID for the ASK Nasal-12. METHODS Distribution- and anchor-based methods were used to determine the MCID for the ASK Nasal-12 based on raw data from a multicenter prospective QOL study of 218 patients. RESULTS Two distribution-based statistical methods, the one-half standard deviation method and the effect-size method, both yielded MCIDs of 0.37 (medium effect). The first anchor-based method, using the 2-wk postoperative overall nasal functioning item as the anchor, yielded an MCID of 0.31. The second anchor-based method, using the 2-wk postoperative Short Form Health Survey 8 bodily pain item as the anchor, yielded an MCID of 0.29. CONCLUSION The largest MCID obtained for the ASK Nasal-12 using 4 statistical methods 2 wk postoperatively was 0.37. This information provides clinicians with an essential context for determining the clinical significance of changes in QOL scores after interventions. Our results will help clinicians better interpret QOL scores and design future studies that are powered to detect meaningful QOL changes.
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Affiliation(s)
- Nicholas Gravbrot
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Ari-zona
| | - Daniel F Kelly
- Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, California
| | - John Milligan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Ari-zona
| | - Chester F Griffiths
- Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, California
| | - Garni Barkhoudarian
- Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, California
| | - Heidi Jahnke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Ari-zona
| | - William L White
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Ari-zona
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Ari-zona
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Abstract
Pituitary apoplexy is a clinical condition with acute-onset headaches, vision loss, and/or pituitary dysfunction associated with a hemorrhagic or infarcted pituitary tumor or cyst. Treatment varies based on clinical presentation, although often urgent or emergent surgical resection is indicated. Conservative treatment strategies tend to be applied for more mild conditions of apoplexy. Overall outcomes may be similar in this less severe cohort. Acute-onset vision loss with apoplexy should be treated with urgent or emergent surgical evacuation of hematoma and resection of tumor when possible.
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Affiliation(s)
- Garni Barkhoudarian
- John Wayne Cancer Institute, Santa Monica, CA, USA; Pacific Neuroscience Institute, 2125 Arizona Avenue, Santa Monica, CA 90404, USA.
| | - Daniel F Kelly
- John Wayne Cancer Institute, Santa Monica, CA, USA; Pacific Neuroscience Institute, 2125 Arizona Avenue, Santa Monica, CA 90404, USA
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Barkhoudarian G, Palejwala SK, Ansari S, Eisenberg AA, Huang X, Griffiths CF, Cohan P, Rettinger S, Lavin N, Kelly DF. Rathke's cleft cysts: a 6-year experience of surgery vs. observation with comparative volumetric analysis. Pituitary 2019; 22:362-371. [PMID: 31016554 DOI: 10.1007/s11102-019-00962-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rathke's cleft cysts (RCCs) are common sellar lesions. Their management remains controversial, particularly when small or asymptomatic. Herein we review a consecutive series of RCC patients managed with surgery or observation. METHODS All patients with a new diagnosis of presumed RCC, based on MRI, from February 2012-March 2018 were retrospectively divided into observational and surgical cohorts based on an intent-to-treat model. The cohorts were compared for clinical presentation, and cyst volume. The observational cohort was followed for change in cyst size. The surgical cohort was followed for changes in endocrinopathy, visual symptoms, headache and recurrence. RESULTS Of 90 patients (mean age 36.7 ± 19.4 years; 68% female), 60% (n = 54) were in the observational cohort and 40% (n = 36) in the surgical cohort. Average follow-up was 13 ± 23 months in the observational cohort and 24 ± 19 months in the surgical group. In comparing the cohorts, mean ages were similar with more women in the surgical group (81% vs. 56%, p = 0.04). Most patients in the observational cohort had incidentally-discovered RCCs (n = 50, 88%) as opposed to the surgical cohort (n = 6, 17%). The surgical cohort had higher rates of headache (89% vs 26%, p < 0.001), endocrinopathy (36% vs 0%, p < 0.001), and visual dysfunction (19% vs 0%, p = 0.001). Mean cyst volume and maximal cyst dimensions were greater in the surgical cohort (0.94 ± 0.77 cm3 and 14.2 ± 4.1 mm), compared to the observational cohort (0.1 ± 0.14 cm3 and 6.4 ± 3 mm), (p < 0.001). Among the 53% (n = 30/54) of patients in the observational group with follow-up, 3 (10%) had spontaneous RCC shrinkage, 1 (3%) had modest asymptomatic growth (at 10 months from initial MRI), and 87% had stable cyst size. Of the 36 patients recommended to have surgery, 89% (n = 32) did so. Post-operatively, complete or partial resolution of headache, endocrinopathy and visual dysfunction were documented in 90% (n = 28/30), 75% (n = 10/12), and 100% (n = 7/7), respectively. On follow-up MRI, 8 (22%) patients had some cyst reaccumulation, of whom 3 (8%) were symptomatic and underwent uneventful reoperation. No major complications such as hematoma, CSF leak, new endocrinopathy or visual deficits occurred. CONCLUSION From this consecutive series, a majority (60%) of RCCs do not appear to warrant surgical intervention and have a low risk of cyst progression. However, surgical cyst removal appears to be indicated and safe for patients with larger, symptomatic RCCs. Simple cyst drainage has a high rate of improvement in pituitary gland function, visual function and headache resolution with low complication rates and symptomatic recurrence risk. These findings stress the importance of careful case selection and potential utility of volumetric assessment for patients with RCCs.
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Affiliation(s)
- Garni Barkhoudarian
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA.
| | - Sheri K Palejwala
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Shaheryar Ansari
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Amalia A Eisenberg
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Xiang Huang
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Chester F Griffiths
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Sarah Rettinger
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Norman Lavin
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
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Barkhoudarian G, Palejwala SK, Ansari S, Eisenberg AA, Huang X, Griffiths CF, Cohan P, Rettinger S, Lavin N, Kelly DF. Correction to: Rathke's cleft cysts: a 6-year experience of surgery vs. observation with comparative volumetric analysis. Pituitary 2019; 22:372. [PMID: 31292917 DOI: 10.1007/s11102-019-00975-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The original version of this article unfortunately contained errors in legend numbers of Figure 2 caption.
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Affiliation(s)
- Garni Barkhoudarian
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA.
| | - Sheri K Palejwala
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Shaheryar Ansari
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Amalia A Eisenberg
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Xiang Huang
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Chester F Griffiths
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Sarah Rettinger
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Norman Lavin
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
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Griffiths CF, Barkhoudarian G, Cutler A, Duong HT, Karimi K, Doyle O, Carrau R, Kelly DF. Analysis of Olfaction after Bilateral Nasoseptal Rescue Flap Transsphenoidal Approach with Olfactory Mucosal Preservation. Otolaryngol Head Neck Surg 2019; 161:881-889. [PMID: 31331243 DOI: 10.1177/0194599819861340] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To ascertain the impact of septal olfactory strip preservation and bilateral rescue flap elevation on the incidence of olfactory dysfunction. STUDY DESIGN Case series with chart review of patients undergoing endoscopic endonasal skull base surgery (2012-2014). SETTING Providence Saint John's Health Center and John Wayne Cancer Institute. SUBJECTS AND METHODS The incidences of postoperative epistaxis, hyposmia, and anosmia were analyzed using the Brief Smell Identification Test (B-SIT), which was completed in 110 of the 165 patients. RESULTS Seventy-eight patients required extended approaches. Bilateral nasoseptal rescue flaps were elevated in 144 patients (87.3%) and pedicled nasoseptal or middle turbinate flaps in 21 patients (12.7%). The neurovascular pedicles were preserved in all patients, and there were no episodes of postoperative arterial epistaxis. Normal olfaction was noted in 95 patients (86%), with new hyposmia noted in 5 patients (5.5%). Within the rescue flap cohort, new hyposmia occurred in 6.3% (P < .01) of patients, balanced by improvement of olfaction in 43% of patients with preoperative dysfunction (overall pre- and postoperative olfactory function: 85% vs 86%). Patients with pedicled nasoseptal flaps did not have new hyposmia, with a net improvement of olfaction (71% vs 86%, P = .07). No patients experienced new anosmia. There was no difference between flap type within either subgroup. CONCLUSIONS Superior olfactory strip preservation during elevation of reconstructive flaps preserves olfactory function and maintains adequate surgical exposure. In addition, rescue flaps have significantly diminished the rate of arterial postoperative epistaxis while maintaining the ability to harvest nasoseptal flaps for future reconstruction.
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Affiliation(s)
- Chester F Griffiths
- Pacific Neuroscience Institute & Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute & Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
| | - Aaron Cutler
- Inland Neurosurgery Institute, Pomona, California, USA
| | - Huy T Duong
- University of California, Davis Medical School, Davis, California and The Kaiser Permanente Medical Group, Sacramento, California, USA
| | - Kian Karimi
- Pacific Eye and Ear Specialists, Los Angeles, California, USA
| | - Olivia Doyle
- Pacific Eye and Ear Specialists, Los Angeles, California, USA
| | - Ricardo Carrau
- Comprehensive Skull Base Surgery Program, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute & Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
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Zhang D, Kim SSR, Kelly DF, Asa SL, Movassaghi M, Mareninov S, Yong WH, Cloughesy TF, Rodriguez FJ, McKeever P, Qian J, Li JY, Mao Q, Newell KL, Green RM, Welsh CT, Xiong Z, Heaney AP. Somatostatin Receptor Ligand Therapy-A Potential Therapy for Neurocytoma. J Clin Endocrinol Metab 2019; 104:2395-2402. [PMID: 30722009 DOI: 10.1210/jc.2018-02419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/29/2019] [Indexed: 02/13/2023]
Abstract
CONTEXT Neurocytoma (NC) is a rare, low-grade tumor of the central nervous system, with a 10-year survival rate of 90% and local control rate of 74%. However, 25% of NCs will be atypical, with an elevated Ki-67 labeling index >2%, and will exhibit a more aggressive course, with a high propensity for local recurrence and/or craniospinal dissemination. Although no standard treatment regimen exists for these atypical cases, adjuvant stereotactic or conventional radiotherapy and/or chemotherapy have been typically offered but have yielded inconsistent results. CASE DESCRIPTION We have described the case of a patient with a vasopressin-secreting atypical NC of the sellar and cavernous sinus region. After subtotal resection via endoscopic transsphenoidal surgery, the residual tumor showed increased fluorodeoxyglucose uptake and high somatostatin receptor (SSTR) expression on a 68Ga-DOTA-TATE positron emission tomography/CT scan. Somatostatin receptor ligand (SRL) therapy with lanreotide (120 mg every 28 days) was initiated. Four years later, the residual tumor was stable with decreased fluorodeoxyglucose tumor uptake. Immunocytochemical SSTR2 and SSTR5 expression >80% was further confirmed in a series of NC tissues. CONCLUSIONS To the best of our knowledge, we have described the first use of SRL therapy for an atypical NC. Our results support consideration of adjuvant SRL therapy for NC refractory to surgical removal. Our findings further raise the possibility of SSTR-directed peptide receptor radionuclide therapy as NC therapy.
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Affiliation(s)
- Dongyun Zhang
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Sarah S R Kim
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Santa Monica, California
- Providence John Wayne Cancer Institute, Santa Monica, California
| | - Sylvia L Asa
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Masoud Movassaghi
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Sergey Mareninov
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - William H Yong
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Timothy F Cloughesy
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Fausto J Rodriguez
- Division of Neuropathology, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Paul McKeever
- Department of Pathology and Clinical Laboratories, University of Michigan, Ann Arbor, Michigan
| | - Jiang Qian
- Department of Pathology, Albany Medical Center, Albany, New York
| | - Jian Yi Li
- Department of Pathology and Laboratory Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Lake Success, New York
| | - Qinwen Mao
- Department of Pathology, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Kathy L Newell
- Department of Pathology and Laboratory Medicine, University of Kansas, Kansas City, Kansas
| | - Richard M Green
- Neuro-Oncology Program, Kaiser Los Angeles Medical Center, Los Angeles, California
| | - Cynthia T Welsh
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Zhenggang Xiong
- Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School and Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Anthony P Heaney
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California
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Little AS, Chicoine MR, Kelly DF, Sarris CE, Mooney MA, White WL, Gardner PA, Fernandez-Miranda JC, Barkhoudarian G, Chandler JP, Prevedello DM, Liebelt BD, Sfondouris J, Mayberg MR. Evaluation of Surgical Resection Goal and Its Relationship to Extent of Resection and Patient Outcomes in a Multicenter Prospective Study of Patients With Surgically Treated, Nonfunctioning Pituitary Adenomas: A Case Series. Oper Neurosurg (Hagerstown) 2019; 18:26-33. [DOI: 10.1093/ons/opz085] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/25/2018] [Indexed: 02/02/2023] Open
Abstract
Abstract
BACKGROUND
The influence of the surgeon's preoperative goal regarding the extent of tumor resection on patient outcomes has not been carefully studied among patients with nonfunctioning pituitary adenomas.
OBJECTIVE
To analyze the relationship between surgical tumor removal goal and patient outcomes in a prospective multicenter study.
METHODS
Centrally adjudicated extent of tumor resection (gross total resection [GTR] and subtotal resection [STR]) data were analyzed using standard univariate and multivariable analyses.
RESULTS
GTR was accomplished in 148 of 171 (86.5%) patients with planned GTR and 32 of 50 (64.0%) patients with planned STR (P = .001). Sensitivity, specificity, positive predictive value, and negative predictive value of GTR goal were 82.2, 43.9, 86.5, and 36.0%, respectively. Knosp grade 0-2, first surgery, and being an experienced surgeon were associated with surgeons choosing GTR as the goal (P < .01). There was no association between surgical goal and presence of pituitary deficiency at 6 mo (P = .31). Tumor Knosp grade (P = .004) and size (P = .001) were stronger predictors of GTR than was surgical goal (P = .014). The most common site of residual tumor was the cavernous sinus (29 of 41 patients; 70.1%).
CONCLUSION
This is the first pituitary surgery study to examine surgical goal regarding extent of tumor resection and associated patient outcomes. Surgical goal is a poor predictor of actual tumor resection. A more aggressive surgical goal does not correlate with pituitary gland dysfunction. A better understanding of the ability of surgeons to meet their expectations and of the factors associated with surgical result should improve prognostication and preoperative counseling.
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Affiliation(s)
- Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel F Kelly
- Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - William L White
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Garni Barkhoudarian
- Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - James P Chandler
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio
| | - Brandon D Liebelt
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - John Sfondouris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Marc R Mayberg
- Department of Neurological Surgery, University of Washington, Seattle, Washington
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Little AS, Kelly DF, White WL, Gardner PA, Fernandez-Miranda JC, Chicoine MR, Barkhoudarian G, Chandler JP, Prevedello DM, Liebelt BD, Sfondouris J, Mayberg MR. Results of a prospective multicenter controlled study comparing surgical outcomes of microscopic versus fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenomas: the Transsphenoidal Extent of Resection (TRANSSPHER) Study. J Neurosurg 2019; 132:1043-1053. [PMID: 30901746 DOI: 10.3171/2018.11.jns181238] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 11/27/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Many surgeons have adopted fully endoscopic over microscopic transsphenoidal surgery for nonfunctioning pituitary tumors, although no high-quality evidence demonstrates superior patient outcomes with endoscopic surgery. The goal of this analysis was to compare these techniques in a prospective multicenter controlled study. METHODS Extent of tumor resection was compared after endoscopic or microscopic transsphenoidal surgery in adults with nonfunctioning adenomas. The primary end point was gross-total tumor resection determined by postoperative MRI. Secondary end points included volumetric extent of tumor resection, pituitary hormone outcomes, and standard quality measures. RESULTS Seven pituitary centers and 15 surgeons participated in the study. Of the 530 patients screened, 260 were enrolled (82 who underwent microscopic procedures, 177 who underwent endoscopic procedures, and 1 who cancelled surgery) between February 2015 and June 2017. Surgeons who used the microscopic technique were more experienced than the surgeons who used the endoscopic technique in terms of years in practice and number of transsphenoidal surgeries performed (p < 0.001). Gross-total resection was achieved in 80.0% (60/75) of microscopic surgery patients and 83.7% (139/166) of endoscopic surgery patients (p = 0.47, OR 0.8, 95% CI 0.4-1.6). Volumetric extent of resection, length of stay, surgery-related deaths, and unplanned readmission rates were similar between groups (p > 0.2). New hormone deficiency was present at 6 months in 28.4% (19/67) of the microscopic surgery patients and 9.7% (14/145) of the endoscopic surgery patients (p < 0.001, OR 3.7, 95% CI 1.7-7.7). Microscopic surgery cases were significantly shorter in duration than endoscopic surgery cases (p < 0.001). CONCLUSIONS Experienced surgeons who performed microscopic surgery and less experienced surgeons who performed endoscopic surgery achieved similar extents of tumor resection and quality outcomes in patients with nonfunctioning pituitary adenomas. The endoscopic technique may be associated with lower rates of postoperative pituitary gland dysfunction. This study generally supports the transition to endoscopic pituitary surgery when the procedure is performed by proficient surgeons, although both techniques yield overall acceptable surgical outcomes.■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: prospective cohort trial; evidence: class III.Clinical trial registration no.: NCT02357498 (clinicaltrials.gov).
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Affiliation(s)
- Andrew S Little
- 1Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Daniel F Kelly
- 2Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - William L White
- 1Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | | | - Michael R Chicoine
- 4Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Garni Barkhoudarian
- 2Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - James P Chandler
- 5Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel M Prevedello
- 6Department of Neurological Surgery, The Ohio State University, Columbus, Ohio; and
| | - Brandon D Liebelt
- 1Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - John Sfondouris
- 1Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Marc R Mayberg
- 7Department of Neurological Surgery, University of Washington, Seattle, Washington
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Piccioni DE, Achrol AS, Kiedrowski LA, Banks KC, Boucher N, Barkhoudarian G, Kelly DF, Juarez T, Lanman RB, Raymond VM, Nguyen M, Truong JD, Heng A, Gill J, Saria M, Pingle SC, Kesari S. Analysis of cell-free circulating tumor DNA in 419 patients with glioblastoma and other primary brain tumors. CNS Oncol 2019; 8:CNS34. [PMID: 30855176 PMCID: PMC6713031 DOI: 10.2217/cns-2018-0015] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Aim: Genomically matched trials in primary brain tumors (PBTs) require recent tumor sequencing. We evaluated whether circulating tumor DNA (ctDNA) could facilitate genomic interrogation in these patients. Methods: Data from 419 PBT patients tested clinically with a ctDNA NGS panel at a CLIA-certified laboratory were analyzed. Results: A total of 211 patients (50%) had ≥1 somatic alteration detected. Detection was highest in meningioma (59%) and gliobastoma (55%). Single nucleotide variants were detected in 61 genes, with amplifications detected in ERBB2, MET, EGFR and others. Conclusion: Contrary to previous studies with very low yields, we found half of PBT patients had detectable ctDNA with genomically targetable off-label or clinical trial options for almost 50%. For those PBT patients with detectable ctDNA, plasma cfDNA genomic analysis is a clinically viable option for identifying genomically driven therapy options.
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Affiliation(s)
- David E Piccioni
- Department of Neurosciences, University of California San Diego Moores Cancer Center, San Diego, CA, USA
| | - Achal Singh Achrol
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | | | - Kimberly C Banks
- Department of Medical Affairs, Guardant Health, Redwood City, CA, USA
| | - Najee Boucher
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Garni Barkhoudarian
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Daniel F Kelly
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Tiffany Juarez
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Richard B Lanman
- Department of Medical Affairs, Guardant Health, Redwood City, CA, USA
| | | | - Minhdan Nguyen
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Judy D Truong
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Annie Heng
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Jaya Gill
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Marlon Saria
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Sandeep C Pingle
- Department of Neurosciences, University of California San Diego Moores Cancer Center, San Diego, CA, USA
| | - Santosh Kesari
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
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Asa SL, Ezzat S, Kelly DF, Cohan P, Takasumi Y, Barkhoudarian G, Heaney AP, Ridout R, Chik CL, Thompson LD, Gentili F, Mete O. Hypothalamic Vasopressin-Producing Tumors. Am J Surg Pathol 2019; 43:251-260. [DOI: 10.1097/pas.0000000000001185] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
PURPOSE In most clinical series of Cushing's disease (CD), over 80% of patients are women, many of whom are of reproductive age. The year following pregnancy may be a common time to develop CD. We sought to establish the incidence of CD onset associated with pregnancy. METHODS A retrospective review was conducted for patients with biochemically-proven CD. Demographics, clinical history, biochemistry, imaging, pathology, and outcomes were reviewed. Pregnancy-associated CD was defined as symptom onset within 1 year of childbirth. RESULTS Over 10 years, 77 patients including 64 women (84%), with CD underwent endonasal surgery. Of the 64 women, 64% were of reproductive age (15-45 years) at the time of diagnosis, and 11 (27%) met criteria for pregnancy-associated CD. Of these 11 women, median number of pregnancies prior to onset of CD was 2 (range 1-4) compared to zero (range 0-7) for 30 other women with CD onset during reproductive age (p = 0.0024). With an average follow-up of 47 ± 34 months, sustained surgical remission rates for woman with pregnancy-associated CD, other women of reproductive age, and women not of reproductive age were 91%, 80% and 83%, respectively. The average lag-time from symptom onset to diagnosis for women with pregnancy-associated CD was 4 ± 2 years. CONCLUSIONS In this exploratory study, over one quarter of women of reproductive age with CD appeared to have symptomatic disease onset within 1 year of childbirth. This relatively high rate of pregnancy-associated CD suggests a possible causal relationship related to the stress of pregnancy and pituitary corticotroph hyperactivity in the peripartum period. This possible association suggests a heightened degree of clinical suspicion and biochemical testing for CD may be warranted after childbirth. Further study of this possible link between pregnancy and CD is warranted.
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Affiliation(s)
- Sheri K Palejwala
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Andrew R Conger
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Amy A Eisenberg
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Chester F Griffiths
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA.
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Orozco JIJ, Knijnenburg TA, Manughian-Peter AO, Salomon MP, Barkhoudarian G, Jalas JR, Wilmott JS, Hothi P, Wang X, Takasumi Y, Buckland ME, Thompson JF, Long GV, Cobbs CS, Shmulevich I, Kelly DF, Scolyer RA, Hoon DSB, Marzese DM. Epigenetic profiling for the molecular classification of metastatic brain tumors. Nat Commun 2018; 9:4627. [PMID: 30401823 PMCID: PMC6219520 DOI: 10.1038/s41467-018-06715-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 09/19/2018] [Indexed: 01/29/2023] Open
Abstract
Optimal treatment of brain metastases is often hindered by limitations in diagnostic capabilities. To meet this challenge, here we profile DNA methylomes of the three most frequent types of brain metastases: melanoma, breast, and lung cancers (n = 96). Using supervised machine learning and integration of DNA methylomes from normal, primary, and metastatic tumor specimens (n = 1860), we unravel epigenetic signatures specific to each type of metastatic brain tumor and constructed a three-step DNA methylation-based classifier (BrainMETH) that categorizes brain metastases according to the tissue of origin and therapeutically relevant subtypes. BrainMETH predictions are supported by routine histopathologic evaluation. We further characterize and validate the most predictive genomic regions in a large cohort of brain tumors (n = 165) using quantitative-methylation-specific PCR. Our study highlights the importance of brain tumor-defining epigenetic alterations, which can be utilized to further develop DNA methylation profiling as a critical tool in the histomolecular stratification of patients with brain metastases.
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Affiliation(s)
- Javier I J Orozco
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | | | - Ayla O Manughian-Peter
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | - Matthew P Salomon
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | - John R Jalas
- Department of Pathology, Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | - James S Wilmott
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, 2065, Australia
| | - Parvinder Hothi
- Ben & Catherine Ivy Center for Advanced Brain Tumor Treatment, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | - Xiaowen Wang
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | - Yuki Takasumi
- Department of Pathology, Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | - Michael E Buckland
- Department of Neuropathology, Royal Prince Alfred Hospital, the Brain and Mind Centre, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, 2065, Australia
- Sydney Medical School, The University of Sydney, Camperdown, NSW, 2006, Australia
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, 2065, Australia
- Royal North Shore Hospital, Sydney, NSW, 2065, Australia
| | - Charles S Cobbs
- Ben & Catherine Ivy Center for Advanced Brain Tumor Treatment, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | | | - Daniel F Kelly
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, 2065, Australia
- Sydney Medical School, The University of Sydney, Camperdown, NSW, 2006, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
| | - Dave S B Hoon
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
- Sequencing Center, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | - Diego M Marzese
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA.
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Barkhoudarian G, Palejwala SK, Ogunbameru R, Wei H, Eisenberg A, Kelly DF. Early Recognition and Initiation of Temozolomide Chemotherapy for Refractory, Invasive Pituitary Macroprolactinoma with Long-Term Sustained Remission. World Neurosurg 2018; 118:118-124. [DOI: 10.1016/j.wneu.2018.07.082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
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Mooney MA, Herro AM, Fintelmann RE, Mayberg MR, Barkhoudarian G, Gardner PA, Prevedello DM, Chicoine MR, Kelly DF, Chandler JP, Jahnke H, White WL, Little AS. Visual Field Outcome Reporting in Neurosurgery: Lessons Learned from a Prospective, Multicenter Study of Transsphenoidal Pituitary Surgery. World Neurosurg 2018; 120:e326-e332. [PMID: 30144606 DOI: 10.1016/j.wneu.2018.08.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/09/2018] [Accepted: 08/11/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Visual field (VF) outcomes are commonly reported in neurosurgical case series; however, substantial variability can exist in VF testing and outcome reporting. We aimed to evaluate the challenges of VF testing and to develop detailed recommendations for VF outcome reporting by analyzing results from an ongoing, multicenter study of transsphenoidal pituitary surgery. METHODS VF testing results were collected during a prospective, multicenter clinical trial evaluating patient outcomes after transsphenoidal surgery for nonfunctioning pituitary adenomas (TRANSSPHER). Two independent ophthalmologists reviewed reliability and outcomes of all VF studies. Preoperative and postoperative VF studies were evaluated individually and as preoperative/postoperative pairs. RESULTS Suboptimal perimetry field settings were reported in 37% of VF studies. Automated reliability criteria flagged 25%-29% of VF studies as unreliable, whereas evaluation by 2 independent ophthalmologists flagged 16%-28%. Agreement between automated criteria and raters for VF reliability was inconsistent (κ coefficients = 0.55-0.83), whereas agreement between the 2 raters was substantial to almost perfect (κ coefficients = 0.78-0.83). Most patients demonstrated improvement after surgery (rater 1, 67%; rater 2, 60%), with substantial rater agreement on outcomes for paired examinations (κ coefficient = 0.62). CONCLUSIONS VF outcome studies demonstrated significant variability of test parameters and patient performance. Perimetry field settings varied among patients and for some patients varied preoperatively versus postoperatively. Reliance on automated criteria alone could not substitute for independent ophthalmologist review of test reliability. Standardized guidelines for VF data collection and reporting could increase reliability of results and allow better comparisons of outcomes in future studies.
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Affiliation(s)
- Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Angela M Herro
- Horizon Eye Specialists and Lasik Center, Phoenix, Arizona, USA
| | | | - Marc R Mayberg
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Garni Barkhoudarian
- Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, California, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel F Kelly
- Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, California, USA
| | - James P Chandler
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Heidi Jahnke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - William L White
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Little AS, Kelly DF, White WL, Gardner PA, Fernandez-Miranda JC, Chicoine MR, Barkhoudarian G, Chandler JP, Prevedello DM, Liebelt BD, Sfondouris J, Mayberg MR. 142 Comparison of Volumetric Extent of Tumor Resection From a Prospective Multicenter Controlled Study of Fully Endoscopic versus Microscopic Transsphenoidal Surgery for Nonfunctioning Pituitary Adenomas: The TRANSSPHER Study. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Deutsch GB, Tyrell R, Yost S, Deutsch MB, Barkhoudarian G, Kelly DF, Faries MB. Predicting the incidence and timing of central nervous system disease in metastatic melanoma: Implications for surveillance and preventative therapy. J Am Acad Dermatol 2018; 78:419-421. [PMID: 29332716 DOI: 10.1016/j.jaad.2017.07.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/06/2017] [Accepted: 07/23/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Gary B Deutsch
- Hofstra-Northwell School of Medicine Uniondale, New York, New York.
| | - Richard Tyrell
- Hofstra-Northwell School of Medicine Uniondale, New York, New York
| | | | - Mariel B Deutsch
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Mark B Faries
- Donald L. Morton, MD, Melanoma Research Program, New York, New York
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Salomon MP, Wang X, Marzese DM, Hsu SC, Nelson N, Zhang X, Matsuba C, Takasumi Y, Ballesteros-Merino C, Fox BA, Barkhoudarian G, Kelly DF, Hoon DSB. The Epigenomic Landscape of Pituitary Adenomas Reveals Specific Alterations and Differentiates Among Acromegaly, Cushing's Disease and Endocrine-Inactive Subtypes. Clin Cancer Res 2018; 24:4126-4136. [PMID: 30084836 DOI: 10.1158/1078-0432.ccr-17-2206] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 12/19/2017] [Accepted: 05/15/2018] [Indexed: 11/16/2022]
Abstract
Purpose: Pituitary adenomas are one of the most common benign neoplasms of the central nervous system. Although emerging evidence suggests roles for both genetic and epigenetic factors in tumorigenesis, the degree to which these factors contribute to disease remains poorly understood.Experimental Design: A multiplatform analysis was performed to identify the genomic and epigenomic underpinnings of disease among the three major subtypes of surgically resected pituitary adenomas in 48 patients: growth hormone (GH)-secreting (n = 17), adrenocorticotropic hormone (ACTH)-secreting (n = 13, including 3 silent-ACTH adenomas), and endocrine-inactive (n = 18). Whole-exome sequencing was used to profile the somatic mutational landscape, whole-transcriptome sequencing was used to identify disease-specific patterns of gene expression, and array-based DNA methylation profiling was used to examine genome-wide patterns of DNA methylation.Results: Recurrent single-nucleotide and small indel somatic mutations were infrequent among the three adenoma subtypes. However, somatic copy-number alterations (SCNA) were identified in all three pituitary adenoma subtypes. Methylation analysis revealed adenoma subtype-specific DNA methylation profiles, with GH-secreting adenomas being dominated by hypomethylated sites. Likewise, gene-expression patterns revealed adenoma subtype-specific profiles. Integrating DNA methylation and gene-expression data revealed that hypomethylation of promoter regions are related with increased expression of GH1 and SSTR5 genes in GH-secreting adenomas and POMC gene in ACTH-secreting adenomas. Finally, multispectral IHC staining of immune-related proteins showed abundant expression of PD-L1 among all three adenoma subtypes.Conclusions: Taken together, these data stress the contribution of epigenomic alterations to disease-specific etiology among adenoma subtypes and highlight potential targets for future immunotherapy-based treatments. This article reveals novel insights into the epigenomics underlying pituitary adenomas and highlights how differences in epigenomic states are related to important transcriptome alterations that define adenoma subtypes. Clin Cancer Res; 24(17); 4126-36. ©2018 AACR.
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Affiliation(s)
- Matthew P Salomon
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Xiaowen Wang
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Diego M Marzese
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Sandy C Hsu
- Sequencing Center, John Wayne Cancer Institute at Saint John's Health Center, Providence Health and Service (PHS), Santa Monica, California
| | - Nellie Nelson
- Sequencing Center, John Wayne Cancer Institute at Saint John's Health Center, Providence Health and Service (PHS), Santa Monica, California
| | - Xin Zhang
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Chikako Matsuba
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Yuki Takasumi
- Department of Pathology, Saint John's Health Center, PHS, Santa Monica, California
| | | | - Bernard A Fox
- Earle A. Chiles Research Institute, Providence Cancer Center, PHS, Portland, Oregon
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, PHS, Santa Monica, California.,John Wayne Cancer Institute Brain Tumor Center, Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Daniel F Kelly
- Pacific Neuroscience Institute, PHS, Santa Monica, California.,John Wayne Cancer Institute Brain Tumor Center, Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Dave S B Hoon
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California. .,Sequencing Center, John Wayne Cancer Institute at Saint John's Health Center, Providence Health and Service (PHS), Santa Monica, California.,Pacific Neuroscience Institute, PHS, Santa Monica, California
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Palejwala SK, Zhao F, Lanker KC, Sivakumar W, Takasumi Y, Griffiths CF, Barkhoudarian G, Kelly DF. Imaging-Ambiguous Lesions of Meckel's Cave-Utility of Endoscopic Endonasal Transpterygoid Biopsy. World Neurosurg 2018; 118:e346-e355. [PMID: 29969735 DOI: 10.1016/j.wneu.2018.06.190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/21/2018] [Accepted: 06/22/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Meckel's cave is a dural-lined cavity in the middle fossa skull base in which lies the Gasserian ganglion, a potential site for tumors and inflammatory lesions. A variety of lesions can be predominantly isolated to Meckel's cave, including extension from head and neck cancers, other malignant tumors, as well as benign lesions. Clinical presentation and imaging findings are often insufficient to establish a diagnosis. Hence, histologic confirmation is required to determine the appropriate treatment strategy. Several surgical approaches have been used to reach this deep-seated area, often with significant morbidity and prolonged recovery. Given advancements in endoscopy and greater facility with the technique, the endoscopic endonasal approach has been used increasingly to reach lesions in the region. METHODS A single-institution, retrospective chart review over a 10-year period was performed to identify and describe patients with pathologically differing but imaging-similar lesions with their epicenter in Meckel's cave. RESULTS Of a total of 21 cases of lesions in Meckel's cave approached by an endoscopic endonasal transpterygoid approach, we present 6 patients with imaging-ambiguous lesions involving Meckel's cave that were biopsied via the extended endoscopic endonasal approach. Among this diverse group, pathology included B-cell lymphoma, squamous cell carcinoma, adenocarcinoma, malignant schwannoma, benign schwannoma, and neurosarcoidosis. CONCLUSIONS We explore not only the relevance of this approach in the armamentarium of the modern skull-base surgeon but also its limitations and conclude that the endoscopic endonasal approach provides a safe and relatively direct, minimally invasive corridor to many lesions of Meckel's cave.
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Affiliation(s)
- Sheri K Palejwala
- Pacific Neuroscience Institute, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Fan Zhao
- Pacific Neuroscience Institute, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA; Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Kayla C Lanker
- Pacific Neuroscience Institute, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Yuki Takasumi
- Department of Pathology, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Chester F Griffiths
- Pacific Neuroscience Institute, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA.
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Grubman ME, Saria MG, Nguyen M, Trong J, Boucher N, Gill J, Heng A, Moses AA, Juarez T, Achrol A, O'Day S, Barkhoudarian G, Kelly DF, Kesari S. A comprehensive initiative to optimize accrual to neuro oncology clinical trials. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e18546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mathew England Grubman
- Pacific Neuroscience Institute and John Wayne Cancer Institute at Providence, St. John's Health Center, Santa Monica, CA
| | | | - Minhdan Nguyen
- Pacific Neuroscience Institute and John Wayne Cancer Institute at Providence, Saint John’s Health Center, Santa Monica, CA
| | - Judy Trong
- Pacific Neuroscience Institute and John Wayne Cancer Institute at Providence, Saint John’s Health Center, Santa Monica, CA
| | | | - Jaya Gill
- Pacific Neuroscience Institute and John Wayne Cancer Institute at Providence, Saint John’s Health Center, Santa Monica, CA
| | - Anne Heng
- Pacific Neuroscience Institute and John Wayne Cancer Institute at Providence, Saint John’s Health Center, Santa Monica, CA
| | | | | | - Achal Achrol
- Pacific Neuroscience Institute and John Wayne Cancer Institute at Providence, Saint John’s Health Center, Santa Monica, CA
| | | | - Garni Barkhoudarian
- Pacific Neuroscience Institute and John Wayne Cancer Institute at Providence, Saint John’s Health Center, Santa Monica, CA
| | - Daniel F. Kelly
- Pacific Neuroscience Institute and John Wayne Cancer Institute at Providence, Saint John’s Health Center, Santa Monica, CA
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Phillips M, Saria M, Eisenberg A, Kelly DF, Barkhoudarian G. Safety of commercial airflight in patients with brain tumors: a case series. J Neurooncol 2018; 139:617-623. [PMID: 29774497 DOI: 10.1007/s11060-018-2905-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/14/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Patients with intracranial masses are often advised to avoid airflight due to concerns of worsening neurological symptoms or deterioration. However, many patients often travel cross-country or internationally to tertiary care centers for definitive care. This study assesses the safety of commercial airflight for brain and skull base tumor patients without severe or progressive neurological deficits. METHODS Patients that had traveled to our institution for surgery via commercial airflight from 2014 to 2017 were identified. An electronic survey was administered (RedCap) and flight duration, aircraft type, presenting symptoms and new or worsened peri-flight symptoms were queried. Severity was assessed using visual analogue scale (VAS). Significant change of symptoms was determined to be greater than 25%. Demographics and clinical history were obtained from electronic medical records. Providence Health System IRB: 16-168. RESULTS Of 665 patients operated on for brain tumor, 63 (9.5%) traveled by airflight to our center for surgery and of these, 41 (65%) completed the study (mean age 48.5 ± 16.8 years, 63% female). Pathology included pituitary and other parasellar tumors (58%), meningiomas (22%), metastatic tumors (5%), gliomas (5%), pineal tumor (5%), cerebello-pontine tumor (5%). Average tumor volume was 11.4 cc and average maximal dimension was 2.7 cm. Ten (24.4%) patients developed worsened symptoms during airflight including: headaches 3/19 (15.8%), fatigue 3/14 (21.4%), dizziness 3/5 (60%) and ear pain 3/3 (100%), as well as one patient who had new onset seizures inflight. Seven patients (70%) sustained worsened symptoms after airflight. There were no permanent neurological deficits related to airflight. There was no correlation with tumor size, volume, location or flight duration with development of neurological symptoms. There was an inverse correlation between peri-flight corticosteroid usage and symptom exacerbation (p = 0.048). No patient with completely asymptomatic tumors developed new symptoms during flight. CONCLUSIONS Most patients with brain and skull base tumors can travel safely via commercial airflight with acceptable symptom exacerbation. However, consideration should be given to administering corticosteroids and possibly anticonvulsants to patients who are symptomatic and/or have relatively large tumors with mass effect and peritumoral edema.
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Affiliation(s)
- Michelle Phillips
- Pacific Neuroscience Institute, Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, 2200 Santa Monica Blvd., Santa Monica, CA, 90404, USA
| | - Marlon Saria
- Department of Translational Neurosciences and Neurotherapeutics, Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | - Amy Eisenberg
- Pacific Neuroscience Institute, Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, 2200 Santa Monica Blvd., Santa Monica, CA, 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, 2200 Santa Monica Blvd., Santa Monica, CA, 90404, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, 2200 Santa Monica Blvd., Santa Monica, CA, 90404, USA.
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Conger A, Zhao F, Wang X, Eisenberg A, Griffiths C, Esposito F, Carrau RL, Barkhoudarian G, Kelly DF. Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients. J Neurosurg 2018; 130:861-875. [PMID: 29749920 DOI: 10.3171/2017.11.jns172141] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 11/28/2017] [Indexed: 11/06/2022]
Abstract
Objective The authors previously described a graded approach to skull base repair following endonasal microscopic or endoscope-assisted tumor surgery. In this paper they review their experience with skull base reconstruction in the endoscopic era. Methods A retrospective review of a single-institution endonasal endoscopic patient database (April 2010–April 2017) was undertaken. Intraoperative CSF leaks were graded based on size (grade 0 [no leak], 1, 2, or 3), and repair technique was documented across grades. The series was divided into 2 epochs based on implementation of a strict perioperative antibiotic protocol and more liberal use of permanent and/or temporary buttresses; repair failure rates and postoperative meningitis rates were assessed for the 2 epochs and compared. Results In total, 551 operations were performed in 509 patients for parasellar pathology, including pituitary adenoma (66%), Rathke’s cleft cyst (7%), meningioma (6%), craniopharyngioma (4%), and other (17%). Extended approaches were used in 41% of cases. There were 9 postoperative CSF leaks (1.6%) and 6 cases of meningitis (1.1%). Postoperative leak rates for all 551 operations by grade 0, 1, 2, and 3 were 0%, 1.9%, 3.1%, and 4.8%, respectively. Fat grafts were used in 33%, 84%, 97%, and 100% of grade 0, 1, 2, and 3 leaks, respectively. Pedicled mucosal flaps (78 total) were used in 2.6% of grade 0–2 leaks (combined) and 79.5% of grade 3 leaks (60 nasoseptal and 6 middle turbinate flaps). Nasoseptal flap usage was highest for craniopharyngioma operations (80%) and lowest for pituitary adenoma operations (2%). Two (3%) nasoseptal flaps failed. Contributing factors for the 9 repair failures were BMI ≥ 30 (7/9), lack of buttress (4/9), grade 3 leak (4/9), and postoperative vomiting (4/9). Comparison of the epochs showed that grade 1–3 repair failures decreased from 6/143 (4.1%) to 3/141 (2.1%) and grade 1–3 meningitis rates decreased from 5 (3.5%) to 1 (0.7%) (p = 0.08). Prophylactic lumbar CSF drainage was used in only 4 cases (< 1%), was associated with a higher meningitis rate in grades 1–3 (25% vs 2%), and was discontinued in 2012. Comparison of the 2 epochs showed increase buttress use in the second, with use of a permanent buttress in grade 1 and 3 leaks increasing from 13% to 55% and 32% to 76%, respectively (p < 0.001), and use of autologous septal/keel bone as a permanent buttress in grade 1, 2, and 3 leaks increasing from 15% to 51% (p < 0.001). Conclusions A graded approach to skull base repair after endonasal surgery remains valid in the endoscopic era. However, the technique has evolved significantly, with further reduction of postoperative CSF leak rates. These data suggest that buttresses are beneficial for repair of most grade 1 and 2 leaks and all grade 3 leaks. Similarly, pedicled flaps appear advantageous for grade 3 leaks, while CSF diversion may be unnecessary and a risk factor for meningitis. High BMI should prompt an aggressive multilayered repair strategy. Achieving repair failure and meningitis rates lower than 1% is a reasonable goal in endoscopic skull base tumor surgery.
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Affiliation(s)
- Andrew Conger
- 1Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania
| | - Fan Zhao
- 2Department of Neurosurgery, Fudan University, Shanghai, China
| | - Xiaowen Wang
- 2Department of Neurosurgery, Fudan University, Shanghai, China
| | - Amalia Eisenberg
- 3Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Chester Griffiths
- 3Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Felice Esposito
- 4Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, Division of NeuroSurgery, Università degli Studi di Messina, Messina, Italy; and
| | - Ricardo L Carrau
- 5Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Medical Center, Columbus, Ohio
| | - Garni Barkhoudarian
- 3Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Daniel F Kelly
- 3Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
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