The Role of Liquid Biopsies in Detecting Molecular Tumor Biomarkers in Brain Cancer Patients.

Glioblastoma multiforme (GBM) is one of the most lethal primary central nervous system cancers with a median overall survival of only 12-15 months. The best documented treatment is surgical tumor debulking followed by chemoradiation and adjuvant chemotherapy with temozolomide, but treatment resistance and therefore tumor recurrence, is the usual outcome. Although advances in molecular subtyping suggests GBM can be classified into four subtypes, one concern about using the original histology for subsequent treatment decisions is that it only provides a static snapshot of heterogeneous tumors that may undergo longitudinal changes over time, especially under selective pressure of ongoing therapy. Liquid biopsies obtained from bodily fluids like blood and cerebro-spinal fluid (CSF) are less invasive, and more easily repeated than surgery. However, their deployment for patients with brain cancer is only emerging, and possibly suppressed clinically due to the ongoing belief that the blood brain barrier prevents the egress of circulating tumor cells, exosomes, and circulating tumor nucleic acids into the bloodstream. Although brain cancer liquid biopsy analyses appear indeed challenging, advances have been made and here we evaluate the current literature on the use of liquid biopsies for detection of clinically relevant biomarkers in GBM to aid diagnosis and prognostication.

Lymphoplasmacytic hypophysitis associated with immunoglobulin G4.

We present the unusual case of a 33-year-old woman who presented with a 2 year history of amenorrhoea and an expanding sellar lesion. Initial MRI revealed a lesion in the pituitary fossa, thought to be a pituitary adenoma. One year later, the lesion had enlarged by 5mm, with associated enhancement of the dura of the planum sphenoidale and pituitary stalk. Histopathology revealed a lymphocytic and plasma cell inflammatory infiltrate suggestive of lymphoplasmacytic hypophysitis associated with immunoglobulin G4.

Spinal intradural myxoid chondrosarcoma.

The authors present a rare case of intradural extramedullary spinal chondrosarcoma. This 38-year-old man presented with urinary retention and lower-limb weakness. Magnetic resonance imaging demonstrated a thoracic intradural extramedullary spinal tumor, which was resected. Histopathology revealed a meningeal myxoid chondrosarcoma. Despite adjuvant radiotherapy, the patient had multiple recurrences and metastases and died 18 months following his first surgery. The management of the rare entity of spinal canal chondrosarcoma is discussed.

Giant PICA aneurysm presenting as intractable hiccups.

We report a 23-year-old female with rare intractable hiccups caused by a giant posterior inferior cerebellar artery (PICA) aneurysm compressing the medulla oblongata, which resolved after surgical resection of the aneurysm and decompression of the medulla oblongata. We review the literature on lesions in the posterior fossa presenting as intractable hiccups.

Traumatic spinal epidural hematoma-unusual cause of torticollis in a child.

Traumatic spinal epidural hematoma is rare in children. The presentation could be nonspecific, leading to a delay in diagnosis. We present an infant who sustained an epidural hematoma after a "trivial" injury. The delay in diagnosis led to minor neurological deficit at 6-week follow-up. Irritability and torticollis after a neck trauma in an afebrile child should alert to the possibility of spinal cord compression. Early imaging and early decompression will minimize morbidity.

Facial nerve function and hearing preservation after retrosigmoid excision of vestibular schwannoma: Christchurch Hospital experience with 97 patients.

BACKGROUND: Between January 1988 and December 2002, 97 patients underwent surgery for excision of vestibular schwannoma via the retrosigmoid approach at Christchurch Hospital. METHODS: A retrospective review was undertaken of the clinical notes with emphasis on facial nerve function and hearing preservation postoperatively. RESULTS: Of patients with small and medium-sized tumours, 81% had good facial nerve function at 1 year (House-Brackmann grade 1 and grade 2), 16% had moderate function (grade 3 and grade 4) and 3% had poor function (grade 5). Of patients with large tumours, 22% had good facial function (grade 1 and grade 2), 37% had moderate function (grade 3 and grade 4) and 41% had poor function (grade 5 and grade 6). Useful postoperative hearing was preserved in 21% of the 47 patients with tumours <3 cm and useful preoperative hearing. In the last 5 years the authors have been operating in conjunction with an ear, nose and throat surgeon (PAB) trained in base-of-skull surgery. Over this period, useful hearing was preserved in 32% of patients with small and medium-sized tumours and useful preoperative hearing. CONCLUSIONS: Tumour size was an important predictor of the postoperative facial and cochlear nerve function. The multidisciplinary approach to these tumours offers better results. These results compare well with other published series.

Presacral neuroenteric fistula in a newborn presenting with an epidural abscess: case report and review of the literature.

We describe a newborn infant (<24 hours of age) who presented with mild swelling on the back and buttocks attributable to a neuroenteric fistula complicated by an epidural parasacral abscess infected with mixed coliforms. Epidural abscesses in infancy are extremely rare, and one has not been observed previously in the newborn period. The infant was surprisingly mildly affected. Prompt intervention led to an excellent outcome. Coliforms may colonize the infant gut in <24 hours, even in the developed world. Unexplained swellings on the backs of infants should lead to a search for underlying malformations and an early surgical review, which is best conducted with a combined pediatric surgical and neurosurgical approach.

Head injury and associated maxillofacial injuries.

AIMS: To review patients admitted with head injuries under a regional neurosurgical service, to document the incidence and features of associated maxillofacial trauma, and to assess any delay in referral to a maxillofacial surgeon for definitive management of facial injuries. METHODS: The details of all patients admitted under the neurosurgical service at Christchurch Hospital over the preceding 7 years (1995-2002) were reviewed via that department's database. The records of those patients noted to have a maxillofacial injury were requested, and the following data obtained: demographics, diagnosis, and mode of injury (including specific variables such as alcohol consumption and seatbelt usage in motor vehicle accidents). RESULTS: 2307 patients were admitted under the neurosurgical service at Christchurch Hospital over a 7-year period. Five percent of those patients had an associated maxillofacial injury. Three-quarters were men, with an average age of 27 years. Motor vehicle accidents and assaults were the most common cause of injury. Nearly one-third of those persons in motor vehicle accidents were not wearing seatbelts. Alcohol was more frequently involved in mild and moderate head injuries and these patients were more likely to have been assaulted than those admitted with severe head injuries. There were no significant delays in referring patients admitted who had an associated maxillofacial injury to a maxillofacial surgeon. CONCLUSIONS: A small but significant number of patients admitted with head injuries will have an associated maxillofacial injury.

Clinical and angiographic outcome after Guglielmi detachable coil embolization of intracranial aneurysms.

BACKGROUND: Between July 1997 and April 2001, forty patients underwent Guglielmi detachable coil (GDC) embolization of intracranial aneurysms at Wellington Hospital. METHODS: The clinical notes and imaging were reviewed retrospectively. RESULTS: Complete initial occlusion was achieved in 28 patients (70%). Eleven patients (27.5%) had small residual neck (>90% occlusion) and one patient (2.5%) had substantial filling of the aneurysm. Follow up angiographic assessment was obtained in 28 patients (70%) of whom 24 patients (85.7%) had no recurrence or stable residual neck and four patients (14.3%) had recurrence or enlargement of the residual neck. Stable occlusion was achieved in 100% of small and medium sized aneurysms and 50% of large and giant aneurysms. Technical complications occurred in 10% including aneurysms perforated in two patients (5%) and presumed parent artery occlusion in another two (5%). CONCLUSIONS: The findings of the present study demonstrate the safety of GDC embolization. The initial clinical grade at presentation strongly predicted the clinical outcome. Although the number of patients in this study is small, there is evidence that the angiographic outcome is better for small and medium sized aneurysms. Our results are comparable to other published series.