Performance of adjuvant treatment correlates with survival in reoperated glioblastomas.

OBJECTIVE: To analyze cases of recurrent glioblastoma subjected to reoperation at a Brazilian public healthcare service. METHODS: A total of 39 patients subjected to reoperation for recurrent glioblastoma at the Department of Neurosurgery, São Paulo Hospital, Federal University of São Paulo, from January 2000 to December 2013 were retrospectively analyzed. RESULTS: The median overall survival was 20 months (95% confidence interval - CI = 14.9-25.2), and the median survival after reoperation was 9.1 months (95%CI: 2.8-15.4). The performance of adjuvant treatment after the first operation was the single factor associated with overall survival on multivariate analysis (relative risk - RR = 0.3; 95%CI = 0.2-0.7); p = 0.005). CONCLUSION: The length of survival of patients subjected to reoperation for glioblastoma at a Brazilian public healthcare service was similar to the length reported in the literature. Reoperation should be considered as a therapeutic option for selected patients.

Performance of adjuvant treatment correlates with survival in reoperated glioblastomas / Uso de tratamento adjuvante é relacionado ao aumento da sobrevida em pacientes com glioblastoma submetidos à reoperação

ABSTRACT Objective To analyze cases of recurrent glioblastoma subjected to reoperation at a Brazilian public healthcare service. Methods A total of 39 patients subjected to reoperation for recurrent glioblastoma at the Department of Neurosurgery, São Paulo Hospital, Federal University of São Paulo, from January 2000 to December 2013 were retrospectively analyzed. Results The median overall survival was 20 months (95% confidence interval – CI = 14.9–25.2), and the median survival after reoperation was 9.1 months (95%CI: 2.8–15.4). The performance of adjuvant treatment after the first operation was the single factor associated with overall survival on multivariate analysis (relative risk – RR = 0.3; 95%CI = 0.2–0.7); p = 0.005). Conclusion The length of survival of patients subjected to reoperation for glioblastoma at a Brazilian public healthcare service was similar to the length reported in the literature. Reoperation should be considered as a therapeutic option for selected patients.

RESUMO Objetivo Analisar o papel da reoperação em pacientes com glioblastoma recidivado em um serviço público no Brasil. Métodos Foram analisados retrospectivamente 39 pacientes submetidos à reoperação por recorrência de glioblastoma no Departamento de Neurocirurgia da Universidade Federal de São Paulo, no período de janeiro de 2000 até dezembro de 2013. Resultados A sobrevida global mediana foi de 20 meses (IC 95% = 14.9–25.2), e a sobrevida mediana após a reoperação foi de 9.1 meses (IC 95% = 2.8–15.4). A realização de tratamento adjuvante após a primeira cirurgia foi o único fator associado com a sobrevida global numa análise multivariada (RR = 0.3; IC 95% = 0.2–0.7; p = 0.005). Conclusão A sobrevida dos pacientes submetidos à reoperação em um serviço público no Brasil é semelhante à reportada pela literatura. A reoperação deve ser considerada como uma opção terapêutica em pacientes selecionados.

Stereotactic biopsy guidance in adults with supratentorial nonenhancing gliomas: role of perfusion-weighted magnetic resonance imaging.

OBJECT: The. diagnosis of low-grade glioma (LGG) cannot be based exclusively on conventional magnetic resonance (MR) imaging studies, and target selection for stereotactic biopsy is a crucial issue given the high risk of sampling errors. The authors hypothesized that perfusion-weighted imaging could provide information on the microcirculation in presumed supratentorial LGGs. METHODS: All adult patients with suspected (nonenhancing) supratentorial LGGs on conventional MR imaging between February 2001 and February 2004 were included in this study. Preoperative MR imaging was performed using a dynamic first-pass gadopentate dimeglumine-enhanced spin echo-echo planar perfusion-weighted sequence, and the tumors' relative cerebral blood volume (rCBV) measurements were expressed in relation to the values observed in contralateral white matter. In patients with heterogeneous tumors a stereotactic biopsy was performed in the higher perfusion areas before resection. Among 21 patients (16 men and five women with a mean age of 36 years, range 23-60 years), 10 had diffuse astrocytomas (World Health Organization Grade II) and 11 had other LGGs and anaplastic gliomas. On perfusion-weighted images demonstrating heterogeneous tumors, areas of higher rCBV focus were found to be oligodendrogliomas or anaplastic astrocytomas on stereotactic biopsy; during tumor resection, however, specimens were characterized predominantly as astrocytomas. Diffuse astrocytomas were associated with significantly lower mean rCBV values compared with those in the other two lesion groups (p < 0.01). The rCBV ratio cutoff value that permitted better discrimination between diffuse astrocytomas and the other lesion groups was 1.2 (80% sensitivity and 100% specificity). CONCLUSIONS: Perfusion-weighted imaging is a feasible method of reducing the sampling error in the histopathological diagnosis of a presumed LGG, particularly by improving the selection of targets for stereotactic biopsy.

[Arteriovenous malformation-glioma association: study of four cases]. / Associação de malforma o vascular e gliomas: estudo de quatro casos.

We reviewed the clinical presentation, imaging and histopathologic findings in 4 patients with the diagnosis of arteriovenous malformation associated with glioma that were operated on from 1991 to 2000 in our institution. Four patients (2 males; age between 15 and 52 years) presented with progressive headache with clinical evidence of intracranial hypertension (in 3) and partial seizures (in 1). CT scan showed a brain tumor without any detectable pathologic vessels. Histologic examination revealed astrocytic tumors associated with arteriovenous malformation. No patient presented the vascular component intermixed with the tumor. The arteriovenous-glioma association is rare and must be identified by a clear demarcation between the malformation and the tumor.

Associaçäo de malformaçäo vascular e gliomas: estudo de quatro casos / Arteriovenous malformation-glioma association: study of four cases

Entre os pacientes operados no Hospital São Paulo e acompanhados pelo setor de neuro-oncologia no período de 1991 a 2000, avaliamos a apresentaçäo clínica, aspectos de imagem e características histopatológicas de 4 pacientes (2 homens; idade entre 15 e 52 anos) cujo diagnóstico histológico foi malformaçäo vascular associada a glioma. O quadro inicial foi cefaléia progressiva com características de hipertensäo intracraniana (em 3) e crises parciais motoras (em 1). O diagnóstico tomográfico inicial foi processo expansivo, sem que houvesse suspeita de malformaçäo vascular pelo aspecto da imagem em nenhum caso. O exame histológico mostrou neoplasias de linhagem astrocítica associadas a malformações vasculares. Em nenhum paciente o componente vascular esteve localizado na intimidade da neoplasia. A associaçäo de malformaçäo vascular e gliomas é rara e deve ser caracterizada por nítida separaçäo entre a malformaçäo e a neoplasia, independente da vascularizaçäo própria do tumor

Medulloblastoma in adults: a series from Brazil.

We retrospectively reviewed 15 adult patients (11 males, median age 34 years; range 23-48) who had been treated and followed in our Institution since 1991 from the time of diagnosis until death or last follow-up in December 2001. Headache was the most frequent symptom (93%). The tumor was hemispheric in 11 patients. Complete resection was achieved in eight. CSF in 12 patients and craniospinal MRI in 6 did not show metastatic disease. Two patients refused adjuvant treatment and died with progressive disease. Thirteen patients received adjuvant craniospinal radiotherapy and 11 systemic chemotherapy. After initial treatment only 2 of the 13 patients relapsed in the posterior fossa. Recurrence was probably related to sub-optimal radiotherapy planning: inadequate low dose in the posterior fossa (37.5 Gy) and long delay in initiating treatment. Two of the 13 patients that received adjuvant treatment died: one from meningitis, and one from recurrent disease. Eleven patients remained alive, and disease-free with Karnofsky performance status ranging 80-100. The median overall survival was not reached after a median follow-up of 5.6 years (range 0.7-10.8 years). Estimated 1-, 5- and 10-year overall survival rates were 86.7%, 72.7%, and 72.7%, respectively. Adult medulloblastoma was predominant in males and the majority of patients had hemispheric tumors. Long-term survival was not uncommon. Although chemotherapy may be useful and well tolerated, radiotherapy remains the mainstay adjuvant treatment as suggested by our two recurrences associated with a delay or inadequate dose.