Current and future directions in interventional neuro-oncology-are we there yet?

Advancements in technology and technical expertise increasingly enable neurointerventionalists to deliver safer and more effective endovascular treatments to cancers of the brain, spine, head, and neck. In addition to established neuro-oncological interventions such as pre-surgical tumor embolization and percutaneous ablation, newer modalities focused on direct arterial infusion of chemotherapy, radioisotopes, and radiosensitizers continue to gain traction as complementary treatment options, while stem cell-mediated delivery of theranostic nanoparticles and oncolytic virus are being explored for even greater specificity in targeting cancers across the blood-brain barrier. This article aims to provide an overview of the current state of the art and future directions for the field of interventional neuro-oncology, as well as opportunities and challenges presented by this emerging treatment modality.

Laparoscopic adrenalectomy for metastatic disease: Retrospective cohort with long-term, comprehensive follow-up.

BACKGROUND: Several malignancies metastasize to the adrenal gland, especially non-small cell lung cancer, renal cell carcinoma, and melanoma. Adrenalectomy is associated with prolonged survival, but laparoscopic adrenalectomy for this indication is controversial. Our objective was to characterize and quantify outcomes after laparoscopic adrenalectomy for metastases to the adrenal gland. METHODS: A prospectively maintained surgical database and institutional cancer registry were queried for patients who underwent adrenalectomy for metastases. From 1995 to 2016, a total of 62 patients underwent adrenalectomy for metastases, with 59 (95.%) having been performed laparoscopically. Primary end points were cumulative probability of 5-year survival and median survival. Patients in the institutional series were compared with Surveillance, Epidemiology, and End Results patients with metastatic non-small cell lung cancer, renal cell carcinoma, and melanoma. RESULTS: There were no deaths within a 30-day period, 6 complications, and 2 conversions to open adrenalectomy. Non-small cell lung cancer (N = 20), renal cell carcinoma (N = 14), and melanoma (N = 8) were the 3 most common adrenal metastases. Overall, cumulative probability of 5-year survival was 37% and median survival was 34 months (95% CI 26-53 months). Median survival for non-small cell lung cancer was 26 months, for renal cell carcinoma was 67 months, and for melanoma was 30 months (P = NS). There was no demonstrable survival benefit for metachronous versus synchronous presentations, no association with size or disease-free interval, nor the presence/history of other metastases. CONCLUSION: Laparoscopic adrenalectomy for metastases is safe when performed by experienced surgeons. Outcomes are similar or improved compared with series with predominantly open adrenalectomies. Patients selected for laparoscopic adrenalectomy to treat metastatic disease also have prolonged survival compared with Surveillance, Epidemiology, and End Results patients with metastatic non-small cell lung cancer, renal cell carcinoma, or melanoma who do not undergo resection of metastatic disease.

Resection of Pheochromocytoma Improves Diabetes Mellitus in the Majority of Patients.

BACKGROUND: Catecholamine excess in patients with pheochromocytoma often results in impaired glucose tolerance, leading to diabetes mellitus. Little data are available on the long-term effect of surgery on diabetes. OBJECTIVE: The primary aim of this study was to determine the likelihood of diabetes cure after surgery, while secondary objectives were to determine risk factors for development of diabetes preoperatively and persistence of diabetes postoperatively. METHODS: All patients undergoing surgery for pheochromocytoma from 1996 to 2015 were retrospectively reviewed to identify those with a preoperative diagnosis of diabetes. Demographic and diabetes-specific data were collected. Median follow-up was 52.1 months. RESULTS: Overall, 153 patients underwent surgery. Diabetes was seen in 36 (23.4%) patients. Eight patients met the exclusion criteria and were removed from the final analysis, while 22 (78.6%) patients had complete resolution of diabetes. Four patients remained on medication with improved control. Overall, 93.0% of patients had improvement of their diabetes; two patients did not improve. Patients with large, symptomatic tumors were more likely to develop preoperative diabetes, and diabetes was more likely to persist in patients who had an elevated body mass index (BMI). CONCLUSIONS: Diabetes was found concurrently with pheochromocytoma in 23% of patients, more often in those with large, symptomatic tumors. The majority of patients had long-term resolution of diabetes after successful resection; however, some patients may continue to require treatment of diabetes after operation, especially those with a higher BMI.

PRE-ABLATION THYROGLOBULIN AND THYROGLOBULIN TO THYROID-STIMULATING HORMONE RATIO MAY BE ASSOCIATED WITH PULMONARY METASTASES IN CHILDREN WITH DIFFERENTIATED THYROID CANCER.

OBJECTIVE: Pediatric differentiated thyroid cancer (DTC) frequently presents with extensive disease. We studied the value of pre-ablation thyroglobulin (Tg) and Tg normalized to thyroid-stimulating hormone (TSH) levels in predicting distant metastases in pediatric patients with DTC. METHODS: This is a retrospective cohort study of patients <21 years old who underwent thyroidectomy followed by 131I ablation for DTC at 3 university hospitals over 20 years. Tg levels and the Tg/TSH ratio following surgery but prior to 131I ablation were assessed. The presence of distant metastatic disease was determined from the postablation whole-body scan. RESULTS: We studied 44 patients with a mean age of 15.2 years (range 7 to 21 years) and mean tumor size of 2.8 cm. Eight patients had distant metastases and had a higher mean pre-ablation Tg value compared to patients without distant metastases (1,037 µg/L versus 93.5 µg/L, P<.01). The pre-ablation Tg/TSH ratio was also associated with the presence of distant metastases: 12.5 ± 18.8 µg/mU in patients with distant metastases versus 0.7 ± 1.8 µg/mU in patients without (P<.01). A nomogram to predict distant metastases yielded areas under the receiver operating characteristic curve of 0.85 for Tg and 0.83 for Tg/TSH ratio. CONCLUSION: After initial thyroidectomy, elevated preablation Tg and Tg/TSH ratio are associated with distant metastatic disease in pediatric DTC. This may inform the decision to ablate with 131I, as well as the dosage. ABBREVIATIONS: ATA = American Thyroid Association CI = confidence interval DTC = differentiated thyroid cancer OR = odds ratio ROC = receiver operating characteristic Tg = thyroglobulin.

Incidence, Risk Factors, and Clinical Outcomes of Incidental Parathyroidectomy During Thyroid Surgery.

BACKGROUND: The reported rate of incidental parathyroidectomy (IP) during thyroid surgery is between 5.2 and 21.6 %. Current literature reports wide discrepancy in incidence, risk factors, and outcomes. Thus study was designed to address definitively the topic of IP and identify associated risk factors and clinical outcomes with this multi-institutional study. METHODS: This retrospective cohort study included 1767 total thyroidectomies that occurred between 1995 and 2014 at two academic centers. Pathologic reports were reviewed for the presence of unintentionally removed parathyroid glands. Demographics, potential risk factors, and postoperative calcium levels were compared with matched control group. Logistic regression, t tests, and Chi squared tests were used when appropriate. RESULTS: IP occurred in 286 (16.2 %) of thyroidectomies. Risk factors for IP were: malignancy, neck dissection, and lymph node metastases (p = 0.005, <0.001, and <0.001). Fifty-three (19.2 %) of IPs were intrathyroidal. Those with IP were more likely to have postoperative biochemical (65.6 vs. 42.0 %; p < 0.001) and symptomatic (13.4 vs. 8.1 %; p = 0.044) hypocalcemia than controls. The number of parathyroids identified intraoperatively was inversely correlated with the number of parathyroid glands in the specimen (p < 0.001). CONCLUSIONS: Our findings indicate that malignancy, lymph node dissection, and metastatic nodal disease are risk factors for IP. Patients with IP were more likely to have postoperative biochemical and symptomatic hypocalcemia than controls, showing that there is a physiologic consequence to IP. Additionally, intraoperative surgeon identification of parathyroid glands results in a lower incidence of IP, highlighting the importance of awareness of parathyroid anatomy during thyroid surgery.

Testing the semantic differential as a model of task processes with the implicit association test.

In this study, we examined the hypothesis that semantic judgment tasks share overlapping processes if they require processing on common dimensions but not if they require processing on orthogonal dimensions in semantic space (Osgood, Suci, & Tannenbaum, 1957). We tested the hypothesis with the implicit association test (IATl Greenwald, McGhee, & Schwartz, 1998) in three experiments. Consistent with the hypothesis, IAT effects (costs in reaction time because of incompatible response mapping between associated judgment tasks) occurred consistently when judgment tasks tapped into common semantic dimensions, whereas no IAT effect appeared when judgment tasks entailed processing on orthogonal semantic dimensions.

Repetition priming mediated by task similarity in semantic classification.

In the present study, the specificity of repetition priming between semantic classification tasks was examined using Osgood's (Osgood, Suci, & Tannenbaum, 1957) semantic space as a heuristic for determining the similarity between classifications. The classification tasks involved judging the meaning of words on semantic scales, such as pleasant/unpleasant. The amount of priming across classifications was hypothesized to decrease with increasing distance (decreasing similarity) between semantic scales in connotative semantic space. The results showed maximum repetition priming when the study and the test classifications were the same, intermediate degrees of priming when the study and the test classification scales shared loadings on semantic factors, and little priming when the study and the test classification scales loaded primarily on orthogonal semantic factors--that is, when the distance between scales was maximized. Consistent with the transfer-appropriate processing framework, repetition priming in semantic classifications was highly task specific, decreasing with increasing distance between classification scales.