Surgical treatment of cerebellar metastases in elderly patients: A threshold that moves forward?

The impact of surgery for cerebellar brain metastases in elderly population has been the object of limited studies in literature. Given the increasing burden of their chronic illnesses, the decision to recommend surgery remains difficult. All patients aged ≥65 years, who underwent surgical resection of a cerebellar brain metastasis from May 2000 and May 2021 at IRCCS National Cancer Institute "Regina Elena", were analyzed. The study cohort includes 48 patients with a mean age of 70.8 years. 7 patients belonged to the II Class according to the RPA classification, 41 to the III Class; the median GPA classification was 1.5. Median pre-operative and post-operative KPS was 60. Median Charlson Comorbidity Index (CCI) was 11; median 5-variable modified Frailty Index was 2. Overall, 14 patients (29%) presented perioperative neurologic and systemic complications. 34 patients (71%) were able to perform adjuvant therapies as RT and/or CHT after surgery. A higher CCI predicted complications occurrence (p = 0.044), while significant factors for a post-operative KPS ≥70, were i) hemispheric location of the metastasis, ii) higher pre-operative KPS, iii) RPA II classification. Median Overall Survival was 7 months. A post-operative KPS <70 (p = 0.004) and a short time interval between diagnosis of the primary tumor and cerebellar metastasis appearance, were predictive for a worse outcome (p = 0.012). Our study suggests that selected elderly patients with cerebellar metastases may benefit from microsurgery to continue their adjuvant therapies, although a high complications rate should be taken in account.

Hemorrhagic Attitude in Frameless and Frame-Based Stereotactic Biopsy for Deep-Seated Primary Central Nervous System Lymphomas in Immunocompetent Patients: A Multicentric Analysis of the Last Twenty Years.

BACKGROUND: Primary central nervous system lymphoma (PCNSL) is a rare manifestation of aggressive extranodal non-Hodgkin lymphoma. In patients with deep-seated lesions, stereotactic brain biopsy (SBB) is an accepted diagnostic procedure to obtain histopathologic confirmation. OBJECTIVE: The aim of this study was to assess the feasibility, diagnostic yield, safety, and complications of stereotactic procedures in midline and deep-seated PCNSLs. METHODS: Patients selected had received a histopathologic diagnosis of PCNSL localized in deep-seated midline structures, obtained by SBB. The intraoperative frozen section was executed as an integral part of the procedure. Computed tomography scan was performed after surgery. RESULTS: A total of 476 SBBs were performed between January 2000 and December 2019 . Of these SBBs, 91 deep-seated lesions had a histologic diagnosis of PCNSL. A significant increase of the incidence of PCNSL compared with all other diseases was observed (P < 0.0001). Eight patients (8.7%) showed a symptomatic hemorrhage, 4 of whom required craniotomy. There were 4 deaths and 2 cases of permanent morbidity. The hemorrhage risk in the PCNSL group was statistically significant (P = 0.0003) compared with other histotypes. CONCLUSIONS: In suspected cases of PCNSL, a histopathologic diagnosis is necessary to distinguish it from glioblastoma or other, nonmalignant conditions. Deep-seated PCNSLs present a higher risk of biopsy-related morbidity and mortality. Intraoperative frozen section increases the diagnostic yield and reduces the number of sampling procedures. Postoperative computed tomography seems to be warranted in patients with suspected PCNSL.

Oblique Lateral Retroperitoneal Lumbar Pre-Psoas Approach for Vertebrectomy in Cancer Patients: Surgical Technique.

Due to the longer survival of cancer patients secondary to improved systemic treatments, there has been a recent increase in the incidence of spinal metastases. Metastatic disease involves the anterior vertebral body in 80% of cases. Progressive osseous invasion may result in pathologic vertebral fractures and neural structure compression. Surgical indications are spinal cord and cauda equina compression or spinal instability in patients with an expected survival of at least 6 months. Tumor resection and spine reconstruction in the lumbar region are technically demanding. Several approaches have recently been developed to access the lumbar spine: anterior lumbar approach (ALIF), lateral and extreme lateral transpsoas lumbar approach (LLIF, XLIF, DLIF), and oblique retroperitoneal lumbar pre-psoas approach (OLIF). Each technique has its advantages and drawbacks. OLIF is an emerging procedure that has progressively been used by spine surgeons. The retroperitoneal space allows direct access to the vertebra, thus avoiding injury to the paraspinal muscles, psoas muscle, and lumbar plexus. Between 2005 and 2017, 14 patients underwent somatectomy and spinal reconstruction using an oblique retroperitoneal lumbar pre-psoas approach at our institution. All were affected by lumbar vertebral metastases from solid and hematological tumors, and all presented a Tokuhashi score ≥ 12. L3 vertebral body was involved in 7 cases, L1 was involved in 3, L2 was involved in 2, and L4 was involved in 2. All patients underwent a lateral retroperitoneal approach to achieve vertebrectomy and spinal reconstruction with a cage. Spinal fixation was completed with pedicle screws and rods in 4 cases. No neurological worsening was noted except in one patient who presented a transitory deficit of the left ileopsoas muscle. The oblique retroperitoneal lumbar pre-psoas approach may be a valuable and feasible technique that is potentially able to significantly reduce tissue trauma in patients while still making it possible to achieve corpectomy and solid reconstruction of lumbar vertebral bodies. To our knowledge, this is the first reported series of patients with lumbar spinal metastases treated with the oblique retroperitoneal lumbar pre-psoas approach.

Schwannomas of the sciatic nerve: A rare and neglected diagnosis. A review of the literature with two illustrative cases.

OBJECTIVE: Schwannomas of the sciatic nerve, which is the largest nerve of the human body, are very rare accounting for ≤ 1% of all schwannomas. They often may raise confusion with other more common causes of sciatica, such as lumbar degenerative and inflammatory diseases or spinal tumors, which may often lead to a late correct diagnosis. PATIENTS AND METHODS: We present two cases of sciatic nerve schwannomas that were recently treated at our Institution, and we review the pertinent English literature on this topic over the last 15 years, yielding twenty three cases to analyze. RESULTS: Even if sciatic nerve schwannomas are a rare occurrence, a thorough clinical and radiological evaluation of the sciatic nerve should be considered whenever a sciatic pain is not otherwise explained. A positive Tinel sign and a palpable mass along the course of the sciatic nerve may be strong clues to achieve the diagnosis. Combined morphological and advanced functional MRI imaging may help to differentiate benign from malignant peripheral nerve sheath tumors, avoiding unnecessary preoperative biopsy. CONCLUSIONS: A standard microsurgical technique guided by ultrasound and neurophysiologic monitoring, allows in most of the cases a safe removal of the tumor and very satisfactory post-operative results for the patients.

Open Kyphoplasty for Metastatic Spine Disease: A Retrospective Clinical Series.

OBJECTIVE: Symptomatic metastatic spine disease (MSD), is a challenging disease involving 3%-20% of patients with bone metastases. Different surgical options are available and must be tailored to the general and neurologic conditions of the patients. Open kyphoplasty (OKP) refers to decompressive hemilaminectomy, associated with a contralateral percutaneous kyphoplasty, and in some cases, to a posterior stabilization. The aim of the study was to critically review our experience during the last decade with OKP in patients with cancer. METHODS: Fifty-three patients with cancer underwent OKP for symptomatic MSD. The Tokuhashi score and Spinal Instability Neoplastic Score were calculated for each patient. Length of hospital stay, perioperative complications, incidence of adjacent-level fractures, and median survival after surgery were evaluated. Karnofsky Performance Status, visual analog scale, and Dennis Pain Score were calculated preoperatively, postoperatively, and at last follow-up. RESULTS: Median Tokuhashi score and Spinal Instability Neoplastic Score were 10 and 10, respectively. The mean volume of filling material inserted was 3.6 mL. Median operative time was 180 minutes. Complications included 8 leakages (15%), 2 permanent motor deficits (3.8%), and 2 asymptomatic pulmonary embolisms (3.8%). Mean length of hospital stay was 7 days. A significant improvement was observed in Karnofsky Performance Status, visual analog scale score, and Dennis Pain Score (P < 0.0001). Median follow-up was 16 months and overall survival 22 months. CONCLUSIONS: OKP was an effective treatment of symptomatic MSDs in selected oncologic patients with low Tokuhashi scores. It relieved lateral epidural compressions, expanded indications of palliative surgery in patients who were not otherwise surgical candidates, and rapidly dealt with cement leakages.

Kyphoplasty with purified silicone VK100 (Elastoplasty) to treat spinal lytic lesions in cancer patients: A retrospective evaluation of 41 cases.

OBJECTIVES: Balloon Kyphoplasty (BKP) for vertebral compression fractures (VCFs) in cancer patients is more challenging than for osteoporotic ones. Cord compressions are frequent and the incidence of complications ten-fold greater. Polymethylmetacrylate (PMMA) is the gold standard material for BKP but has disadvantages: exothermic reaction, short working time, rapid solidification, absence of osteoconduction. VK100 is a mixture of Dimethyl Methylvinyl siloxane and Barium Sulphate. It is elastic, adhesive to bone, leaves 30 min before solidification without exothermic reaction, and shows a stiffness close to the intact vertebrae. The surgical procedure, called elastoplasty, is similar to a BKP. Clinical results obtained with this new silicone in pathological VCFs have been investigated. PATIENTS AND METHODS: 41 cancer patients with symptomatic VCFs (70 vertebral bodies), underwent percutaneous and open elastoplasties. Post-operative leakages, pulmonary embolism (PE) and adjacent fractures were carefully evaluated with neuroimaging. KPS, VAS and Dennis Pain Score were calculated pre- post-operatively and at the last follow-up. RESULTS: The mean volume of silicone inserted in each vertebra was 3.8 cc. Complications included seven leakages (17%), two asymptomatic PE (4.3%) and 3 post-operative adjacent fractures (7.3%). Median follow-up was 29 months. A significant improvement was observed in KPS, VAS and Dennis Pain Score (p < .0001). The 1-yr survival rate was 76.9%. CONCLUSIONS: Elastoplasty appears a safe and effective palliative treatment of VCFs in oncologic patients. Useful qualities of VK100 are the lack of exothermic reaction and the wider working window. The influence of biomechanical properties of silicone on reduction of adjacent level fractures requires further investigations.

Spine Surgery in Patients with Metastatic Breast Cancer: A Retrospective Analysis.

BACKGROUND: Pathologic or iatrogenic symptomatic spinal lesions are common in metastatic breast cancer. Given the longer duration of overall survival provided by modern oncologic therapies, a prompt and effective treatment of such lesions may have a significant impact on patient's quality of life, improving pain and preventing deterioration of neurologic functions. METHODS: A retrospective review was conducted on patients with breast cancer operated to the spine between 2005 and 2013. The series includes 41 patients and 57 vertebral levels treated (4 cervical, 35 dorsal, and 18 lumbar). There were 28 patients who received palliative surgery and 13 who received excisional surgery, according to their clinical conditions, Spinal Instability Neoplastic Score, and Tokuhashi scores. RESULTS: Of the 41 patients, 38 presented with a median survival of 50 months (95% confidence interval [CI], 39-61), still preserving a Karnofsky Performance Status Scale score ≥60 and a retained ability to ambulate independently. The median overall survival after the first spine surgery was also 50 months (95% CI, 35-65), suggesting that in this cohort of patients, a reasonable quality of life was preserved almost to the end of their clinical history. In patients treated with palliative surgery, the median survival was 37 months (95% CI, 26-48). In those treated with complex surgery, it was 57 months (95% CI, 41-73; P = 0.03). CONCLUSIONS: Major excisional surgery, albeit associated with an increased length of hospital stay, allowed in our series a prolonged survival compared with less aggressive types of surgery. However, percutaneous or open balloon kyphoplasty techniques have expanded indications for palliative surgery and even patients with lower Tokuhashi scores may benefit from rapid and sustained pain relief, preservation of neurologic function, and early mobilization.

Unilateral Laminectomy Approach for the Removal of Spinal Meningiomas and Schwannomas: Impact on Pain, Spinal Stability, and Neurologic Results.

BACKGROUND: Spinal intradural tumors are usually removed with laminectomy/laminotomy with a midline dural incision. Pain, discomfort, postoperative kyphosis, and instability may be minimized with unilateral microsurgery. METHODS: Seventy patients with schwannoma (73 tumors) and 27 patients with meningioma (29 tumors) were operated on with unilateral hemilaminectomy (June 2000 to March 2014). Surgery was generally kept to 1 or 2 levels, removing all the craniocaudal ligamentum flavum. Careful radioscopic identification is mandatory; in thoracolumbar schwannomas, the tumor may be mobile; in the prone position, it may move cranially than appears on magnetic resonance imaging. The dura was opened paramedially, and the tumor was dissected and removed either en bloc or piecemeal after ultrasonic debulking. Neurophysiologic monitoring was performed. The tumor was approached tangentially with no cord rotation or minimal manipulation. Average duration of surgery was 160 minutes (100-320 minutes). Removal was total in 72 of 73 schwannomas; Simpson grade was 1 in 10 meningiomas and 2 in 19. RESULTS: Patients with no complications were discharged on day 5-7. Ten patients had orthostatic headaches; 2 had pseudomeningocele that required reoperation. Pain improvement (Dennis Scale) was significant either at discharge or at follow-up (P < 0.0001 schwannomas, P < 0.001 meningiomas). Neurologic results (McCormick Scale, Karnofsky Performance Score) were excellent/good: of 39 patients with preoperative neurologic impairment, 19 recovered completely, 17 had minor spasticity, and 3 had moderate spasticity but autonomous ambulation. Sphincters recovered in 5 of 10 patients At follow-up, average Karnofsky Performance Score improved from 60 to 90 (P < 0.0001) and the McCormick score decreased from 121 to 55 (P < 0.0001). No spinal instability was observed. CONCLUSIONS: Neurologic and oncologic results were good and postoperative pain and discomfort were reduced. Stability was preserved with a unilateral technique. No bracing was necessary, permitting early rehabilitation.

Supraorbital keyhole approach for removal of midline anterior cranial fossa meningiomas: a series of 20 consecutive cases.

The paper describes a retrospective study of a consecutive series of 20 midline anterior cranial fossa meningiomas (five of the olfactory groove, 14 of the tuberculum sellae, and one clinoidal), which were operated on via a supraorbital keyhole approach between 2002 and 2008. The series includes three males and 17 females (mean age 57 years, mean size of the tumors 3.5 × 3 cm, and mean follow-up 48 months). Gross total excision was achieved in 18 cases and subtotal resection in two. Out of 14 patients with visual deficits, nine patients improved, one remained stable, and three deteriorated. Two patients presented a recurrence 3 years after surgery. One peri-operative death was recorded. The subgroup of patients with tuberculum sellae meningiomas was analyzed in details. A meta-analysis of the major series of such meningiomas in the last 20 years has been performed in order to compare results of different surgical techniques. With regard to primary outcomes of these tumors, gross total removal, restoration of visual function, morbidity, mortality, and recurrence rates, the supraorbital approach, for selected cases, seems to offer valuable results, comparable with those reported in conventional and endoscopic approaches and with very low surgical aggressiveness. However, statistical data available from the literature, particularly on visual function, are still too limited to draw definitive conclusions. The best surgical option for the individual patient cannot yet be standardized and should be chosen on the basis of tumor anatomy, pre-operative clinical symptoms, and surgeon's experience.

Gemcitabine treatment of experimental C6 glioma: the effects on cell cycle and apoptotic rate.

Gemcitabine (dFdCyd) is a deoxycytidine analogue showing a broad spectrum of cytotoxic activity; additionally, at non-cytotoxic concentrations, it is a potent radiosensitiser. Its in vitro and in vivo effects were studied on C6 rat glioma. In vitro, dFdCyd induced an increase in S-phase cells at the end of treatment, with a reduction in G1 and G2 cell cycle-phase cells and relevant effects on the apoptotic rate. The in vivo effects of dFdCyd were studied on rats bearing intracranial C6 glioma. The drug was administered at a dose of 120 mg/Kg every 3 days x 4 doses. A significant effect on tumour growth was detected by longitudinal MRI analyses. Furthermore, the drug induced an inhibitory effect on tumour growth, 72 h after a 300 mg/Kg single dose. Analyses performed on tumour specimens showed relevant G1-phase accumulation and about 45% apoptotic cells. The present results justify further studies to determine the potential efficacy of dFdCyd in the treatment of malignant gliomas.

Unilateral limited laminectomy as the approach of choice for the removal of thoracolumbar neurofibromas.

STUDY DESIGN: The paper reports a minimally invasive approach to the dorsolumbar spine for the removal of neurofibromas. OBJECTIVES: Demonstrating that a limited unilateral approach is the one of choice for this kind of tumors. SUMMARY OF BACKGROUND DATA: Spinal intradural extramedullary tumors are generally removed by single-level or multilevel laminectomy with midline dural incision. Cases of delayed postoperative kyphosis and spinal instability (6%) may be reduced by unilateral microsurgery, causing minimum damage to ligaments and joints. METHODS: Ten patients with dorsolumbar neurofibroma were operated on between June 2000 and June 2002. There were 5 males (all with lumbar) and 5 females (2 with lumbar and 3 with inferior dorsal neurofibromas). One female had 3 lumbar tumors and required two operations. Surgery was performed in the prone position with a unilateral approach, sparing the joint and the ligamentum interspinosum. The dura was opened paramedially and the tumor dissected from the root and removed in one piece when possible. Water-tight dural closure was done with 5-0 or 6-0 stitches. RESULTS: All the patients were mobilized on day 2 and discharged on day 4 or day 5. No complications resulting from the technique were observed. Static and dynamic plain radiograph films showed that none of them had kyphosis and/or instability 6 months postoperatively. Neurologic results were good. CONCLUSIONS: Hospital stay may be reduced and stability may be preserved with an appropriate microsurgical technique. The technique reported in the paper should thus become the one of choice and extended to other spinal intradural extramedullary tumors.

Asymptomatic esophageal perforation caused by late screw migration after anterior cervical plating: report of a case and review of relevant literature.

STUDY DESIGN: This report documents a case of asymptomatic esophageal perforation, secondary to a dislocated and then migrated cervical screw after anterior plating, and reviews the relevant Western literature. OBJECTIVES: To report a rare and potentially dangerous complication and suggest mechanisms of asymptomatic esophageal perforation and healing. SUMMARY OF BACKGROUND DATA: Anterior surgical approaches to the cervical spine have become popular and safer during the past decade. Materials and devices for anterior stabilization have improved in quality and safety. Nevertheless, failure of the devices may occur either because of technical mistakes or rupture. Reoperation is not always necessary, as spontaneous recovery is possible. METHODS: Our patient was operated on for severe cervical spondylotic myelopathy. One year after surgery, one of the screws migrated and was found anteriorly to the spine. Six months later, the screw could no longer be identified, and we concluded that an esophageal perforation had occurred and that the screw had been eliminated through the intestinal tract. The results of esophagoscopy were normal. RESULTS: The neurologic conditions of our patient improved constantly, and his spine alignment was maintained despite the missing screw. CONCLUSIONS: This case demonstrates that a serious complication may not need any treatment. Each case of screw displacement in anterior cervical spine surgery should be evaluated separately in conjunction with the clinical symptoms of the patient, as spontaneous resolution is possible.

Quality-of-life assessment in patients who had been surgically treated for cerebellar pilocytic astrocytoma in childhood.

OBJECT: After radical surgery for childhood cerebellar astrocytomas, patients are considered to be cured. Long-term follow up demonstrates that these patients survive, with most of them leading a normal life. The study reported here was aimed at assessing the quality of life (QOL) of these adults, which is defined as a person's sense of well-being, as derived from his or her current experience of life as a whole. METHODS: Twenty patients who had undergone surgery between 1970 and 1985 were enrolled in the study. In four patients ventriculoperitoneal shunts were in place; two of these patients had required more than six shunt revisions. At present, all patients have clear neuroimaging studies and their Karnofsky Performance Scale (KPS) scores are as follows: 70 in three, 80 in seven, 90 in six, and 100 in four. A QOL questionnaire was administered to the patients and to a control group consisting of 20 healthy volunteers of matching age and sex. The chi-square test was applied to compare patients and controls. Traditional questions on the level of education, work, whether the patients have their own families, and whether they possessed a driver's license were asked at the end of the questionnaire. In all the dimensions assessed except one (sex life), the difference between patients and control volunteers was significant, socializing and adolescence being the most striking ones. This was also true when the three patients with the lowest KPS scores and the worst QOL results were excluded. CONCLUSIONS: By traditional standards, these patients appear to fare quite well. Nevertheless, their self-reported life experience is unsatisfying when compared with the control group. The authors conclude that psychosocial factors are critical to complete recovery and the QOL of children who undergo successful operations for benign cerebellar astrocytoma.