Differences in the ultrastructure of neurons in the spinal ganglion and dorsal rootlet between rats treated with cisplatin only versus co-administration with a sphingosine 1-phosphate receptor 2 agonist in attenuating neuropathy and allodynia.

BACKGROUND AND AIMS: Cisplatin is a chemotherapeutic agent for many types of cancer. The neurotoxicity of cisplatin includes neuropathy and allodynia. We aimed to study structural changes by using CYM54-78, attenuating cisplatin-induced neuropathy and blocking the pathogenesis in neurons, and promoting axonal regeneration. METHODS: TEM (transmission electron microscopy) was used to distinguish ultrastructural changes in dorsal root ganglion (DRG) and dorsal rootlets (DR) between rats treated with cisplatin alone and rats co-treated with cisplatin and sphingosine -1-phosphate receptor2 (S1P2) agonist, CYM-5478. RESULTS: In DRG of rats treated with cisplatin alone, TEM micrographs showed necrosis and apoptotic cells. Neuronal cytoplasm showed numerous vacuole (stage C) and swelling (stage B➔C) mitochondrial degeneration. Neurons in DRG from cisplatin+CYM-5478 group showed a higher percentage of healthy mitochondria (from 5.3% to 75.6%) than those treated with cisplatin alone. DR of cisplatin only group showed abnormal axoplasm, axolemma, and focal detached myelin sheaths, especially in Aδ (fast pain) and Aß (touch) fibers, and revealed collateral branches that sprouted from Aß fibers, which is characteristic of allodynia. Moreover, vasoconstriction was observed in DRG and DR. Rats in cisplatin+CYM-5478 group showed not only fewer abnormal structures than those in cisplatin only group, but also showed Bands of Büngner and onion bulb-like structures, which are characteristic of nerve regeneration. INTERPRETATION: Together with our previous study, showed that CYM-5478 attenuated neuropathy and allodynia in a rat model of cisplatin-induced neuropathy, these results suggest S1P2 agonists as a potential approach the for treatment of cancer due to the reduction of side effects of cisplatin.

Clinical characteristics and treatment outcomes in acromegaly, a retrospective single-center case series from Thailand.

INTRODUCTION: acromegaly, an overproduction of growth hormone (GH), is associated with high rate of morbidity and mortality particularly in case of delayed in diagnosis and treatment. A wide variation of clinical presentations, treatment outcomes and morbidities have been reported. METHODS: a retrospective study was conducted to review clinical characteristics and treatment outcomes of patients with acromegaly treated in King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between 2006 and 2018. RESULTS: eighty-four patients (31 males and 53 females) were reviewed, mean age at diagnosis was 45.7 ± 12.6 years (±SD), mean time of disease onset was 7.6 ± 6.4 years and mean follow-up period was 7.8 ± 5.3 years. The most common presenting symptoms were maxillofacial change (96.8%) and acral enlargement (94.7%). Hypertension (39.3%), diabetes mellitus (28.6%) and dyslipidemia (23.8%) were prevalent co-existing conditions. Four patients were identified having cancer at presentation; however, no additional malignancy was reported during the follow up. Most patients harbored macroadenomas, only 10 were found to have microadenomas. The outcomes of treatment were controlled disease in 70% of microadenoma and 64.9% of macroadenoma. Permanent loss of pituitary function was found in about 21.3% and there was one case reported of mortality. The logistic regression analysis for controlled disease outcome showed the IGF-I index after surgery was associated with controlled disease outcome with statistically significant result (P-value=0.006). CONCLUSION: our study offers descriptive clinical data of case series of acromegalic patients, which had favorable outcomes comparable with previous reports. In addition, IGF-I index after surgery is a predictive parameter for outcome of treatment.

A case of coexistence of TSH/GH-secreting pituitary tumor and papillary thyroid carcinoma: Challenges in pathogenesis and management.

Co-existence of thyrotropin/growth hormone-secreting pituitary adenoma with differentiated thyroid carcinoma is exceedingly rare, with less than 15 cases having been reported. Its clinical presentation and treatment strategy are challenging. We report a case of pituitary macroadenoma, with clinical syndromes of acromegaly and hyperthyroidism, and a thyroid nodule, with cytologically confirmed to be a papillary thyroid carcinoma. Clinical implications, focusing on the strategy for proper management, and possible pathogenesis were discussed.

Duration of symptoms in brain tumors: influencing factors and its value in predicting malignant tumors.

BACKGROUND: Although brain tumor is a common neurosurgical condition, diagnosis is generally made after long duration of symptoms. This may have negative impact on treatment outcome. OBJECTIVE: Study the duration of symptoms of brain tumor, how it is influenced by various factors, and find their value in predicting malignant tumors. MATERIAL AND METHOD: The authors retrospectively reviewed 185 patients with pathologically proven brain tumors. Pertinent data including age, types of tumors, locations of tumors, symptoms, and duration of symptoms were analyzed by univariate and multivariate analysis. RESULTS: There were 70 males and 115 females. The mean age at diagnosis was 47.3 years. The average duration of symptoms was 471 days with median of 120 days. On univariate analysis, hormone symptoms (p = 0.001), age more than 45 years old (p = 0.005), malignant tumor (p < 0.001), auditory symptoms (p = 0.004), and motor symptoms (p < 0.001) had significant influence on duration of symptom. In multivariate analyses, malignant types of tumor, age, and hormonal symptoms were significant. In addition, there was higher risk of malignant brain tumor in patients with duration of symptoms 1 month or less (p < 0.001). CONCLUSION: Certain factors were associated with longer duration of symptoms in brain tumors. This information may lead to early diagnosis of brain tumors. Furthermore, duration ofsymptoms of 1 month or less was suggestive of malignant brain tumors.

One-staged subtotal sacrectomy for primary sacral tumor.

BACKGROUND: Sacrectomy with adequate margins is challenging because of the complexity of the surgical approach and morbidities. Two-staged sequential approach, therefore, has been advocated. This study was designed to demonstrate the modification of this technique. METHODS: This is a case presentation of a 45-year-old man with chordoma involving the lower border of S2, who underwent one-staged subtotal sacrectomy. The technique involved the following: midline incision, mobilization of the rectum, construction of a colostomy and the modified Hartmann stump with intact superior rectal vessels, ligation of internal iliac arteries, ligation of all branches connecting to external iliac veins resulting in "complete isolation" of the external iliac veins, dissection of presacral tissue, anterior osteotomy at the S1-S2 junction and the sacroiliac joints, and abdominal closure. The posterior approach involved a three-limbed incision, dissection of the gluteus muscle and ligaments from the sacrum, subperiosteal dissection, S1 laminectomy, posterior osteotomy corresponding with the anterior osteotomy line with preservation of S1 nerves, division of S2-S4 nerves from sciatic nerves, and specimen removal. Closure of the large sacral defect was undertaken using the Hartmann stump and bilateral gluteus maximus flaps. RESULTS: En bloc resection with free margins without tumor rupture was accomplished. Operative time was 12 hours. Blood transfusion was 6 units. This patient had a good recovery without complications. He was able to ambulate within 1 week and walk normally within 1 month. No recurrence was found at a 24-month-follow-up. CONCLUSIONS: One-staged sacrectomy can be safely performed, obtaining the satisfactory outcomes.

Sacrectomy for primary sacral tumors.

PURPOSE: En bloc resection with adequate margins has provided a chance for cure of primary sacral tumors. However, high sacral lesions are challenging because of the complexity of the surgical approach. The aims of this study were to describe a modification in technique and to evaluate the outcomes. METHODS: This is a study of eight sacrectomies performed at King Chulalongkorn Memorial Hospital between February 2000 and July 2007. Cadaveric dissections were carried out prior to surgery. We have modified the technique by ligation of the branches of the external iliac veins, resulting in "isolation" of the external iliac veins. Spinopelvic reconstruction was performed for total and extended total sacrectomy. Closure of the sacral defect was done with use of the Hartmann stump and the gluteus maximus flaps. RESULTS: Two total sacrectomies, one extended total sacrectomy, and five subtotal S1 sacrectomies were performed. En bloc resection with adequate margins was achieved in all patients. The patient who underwent extended total sacrectomy and one patient who underwent total sacrectomy had nonunion requiring removal of the spinopelvic instrumentation. Five patients who underwent subtotal sacrectomy were ambulating well postoperatively, except for one who had an S1 fracture after falling. No sacral hernias were observed. None of the patients developed recurrence of the primary tumor. Mean follow-up time was four years. CONCLUSIONS: Sacrectomy for primary sacral tumors can be safely conducted, achieving tumor-free margins and acceptable functional and long-term outcomes.

The outcome of surgical treatment for tumors of the craniocervical junction.

OBJECTIVE: The authors report the clinical, radiological, and surgicalfindings ofpatients with craniocervical junction tumors surgically treated in the institution over the last 8 years. MATERIAL AND METHOD: A retrospective study was performed. Clinical, radiological, and operative data were evaluated, and follow-up information was obtained from outpatient examinations, and telephone interviews. RESULTS: There were 25 patients consisting of nine chordomas, eight meningiomas, three cysts, two schwannomas, one each of aneurysmal bone cyst, plasmacytoma, and metastasis. Twenty-nine operative procedures were performed, classified as 12 anterior nine posterior-lateral, and eight posterior approaches. Gross total removal was achieved in 17 cases, subtotal removal in six cases, and partial removal in two cases. Re-operation was performed in six cases. Median follow-up time was 31 months. The authors found significant improvement in Karnofsky Performance Scale scores. CONCLUSION: Appropriate surgical approaches provide successful tumor removal with less surgical morbidities, nevertheless recurrent tumors occasionally occur and so, long-term follow-up is mandatory.

Posterior cranial fossa gangliogliomas.

Ganglioglioma (GG) is an uncommon primary lesion of the central nervous system that is typically located supratentorially. There are only a few reports of GG arising from the cerebellum. To the best of our knowledge this is the first case of a cerebellar GG with supratentorial extension and a longstanding history before its recognition. In fact, this 29-year-old male presented with an 11-year history of intermittent headaches. A cranial computerized tomography (CT) performed at the onset of his complaints failed to reveal the tumor. After a particularly longstanding cephalalgic episode, the patient underwent a new CT scan that was also negative. However, magnetic resonance (MR) imaging of the brain revealed a space-occupying lesion in the right cerebellar hemisphere with extension to the level of the superior colliculi and pineal recess. The tumor was partially removed through a midline suboccipital craniotomy and supracerebellar approach. Pathological examination of the tumor showed composition of atypical ganglion cells and astrocytes, indicating the diagnosis of cerebellar GG. At last follow-up, 24 months after surgery, the patient reported a marked improvement of his clinical condition with significant reduction of intensity and frequency of the headache. The present report illustrates how cerebellar GG may remain undetectable by CT and may therefore present with a longstanding history and nonspecific signs and symptoms. MR investigation can lead to the proper diagnosis. Even after partial removal the prognosis remains good and remission of the symptoms may be achieved. In this article, we review the literature and summarize the current understanding of infratentorial GGs.

Supratentorial lobar anaplastic ependymoma resembling cerebral metastasis: a case report.

A 45-year-old man presented with progressive deterioration of vision. Visual acuity test revealed no light perception in both eyes. The fundoscopic examination demonstrated pale optic discs, consistent with secondary optic atrophy. Preoperative neuroimaging studies revealed a well-defined contrast-enhancing mass, 3 cm in diameter, at the left parietal region. Its radiologic appearances simulated those of cerebral metastases. A totally removed lesion was verified pathologically as an anaplastic clear cell ependymoma, which is rare in this location. A brief review of clinical features and neuroimaging of supratentorial lobar ependymoma is also included.