Immunohistochemistry or Molecular Analysis: Which Method Is Better for Subtyping Craniopharyngioma?

Craniopharyngioma (CP) is mainly classified into two pathological subtypes: adamantinomatous (ACP) and papillary (PCP). CTNNB1 (ß-catenin) mutations are detected in ACPs, and the BRAF V600E mutation is detected in PCPs. However, genetic analysis is not always possible in general medical practice. In this study, we investigated whether immunohistochemistry could replace genetic analysis as an aid in subtype diagnosis. Here, 38 CP patients who had undergone their first tumor resection were included. Among the 38 cases, 22 were morphologically diagnosed as ACP, 10 cases were diagnosed as PCP, and six cases were diagnosed as undetermined CP that were morphologically difficult to classify as either ACP or PCP. Results of immunohistochemistry and genetic analysis and clinical features were compared. Based on the immunohistochemistry, 26 (22 ACPs and four undetermined CPs) showed nuclear ß-catenin expression, 11 (nine PCPs and two undetermined CPs) exhibited positive BRAF V600E immunostaining, and one PCP showed membranous ß-catenin expression and negative BRAF V600E immunostaining. Among the 26 nuclear ß-catenin expression cases, 11 had CTNNB1 mutations; however, 15 cases had mutations of neither CTNNB1 nor BRAF V600E. All 11 BRAF V600E immunopositive cases had BRAF V600E mutations. When comparing clinical features, pediatric patients and those with tumor calcification and less solid components on MRI more commonly had nuclear ß-catenin expression tumors than BRAF V600E immunopositive tumors, reflecting the differences in clinical features between ACP and PCP. Accordingly, immunohistochemistry can replace genetic analysis as an aid to determine the subtype diagnosis of CP in general medical practice.

Microvascular Decompression for Oculomotor Nerve Palsy Due to Compression by Infundibular Dilatation of Posterior Communicating Artery.

BACKGROUND: Oculomotor nerve palsy is occasionally a key indicator of an internal carotid posterior communicating (ICPC) artery bifurcation aneurysm. The interval between the onset of palsy and the time of surgery is considered to be the most important factor affecting recovery from oculomotor nerve palsy. We encountered a rare case of oculomotor nerve palsy due to compression by the infundibular dilatation of the posterior communicating artery (PcomA) rather than by an ICPC aneurysm. CASE DESCRIPTION: We report the case of a 70-year-old woman who presented with pain in the left forehead and left oculomotor nerve palsy with a prominence at the bifurcation of the left internal carotid artery and PcomA on neuroradiologic imaging, indicating a small aneurysm. However, the positional relationship between the bulging lesion and PcomA was not apparent. The intraoperative microscopic view showed that the lesion was an infundibular dilatation of the PcomA rather than an aneurysm, compressing the oculomotor nerve. Microvascular decompression of the lesion resulted in the disappearance of her symptoms after 3 months. CONCLUSIONS: For the treatment of a symptomatic ICPC unruptured aneurysm, direct observation by open surgery is important when the relationship between the PcomA and aneurysm is not clear by neuroradiologic imaging.

Pathologic Findings and Clinical Course of Midline Paraventricular Gliomas Diagnosed Using a Neuroendoscope.

INTRODUCTION: Removal of midline paraventricular gliomas is difficult because of their deep localization and invasive character, requiring biopsy for pathologic diagnosis. This study aimed to assess the pathologic findings and clinical course of midline paraventricular gliomas diagnosed using a neuroendoscope. METHODS: This study was performed as a retrospective investigation using a neuroendoscope of 26 patients whose tumors were diagnosed as midline paraventricular gliomas. The main loci of the lesions were the thalamus (11 patients), tectum (6 patients), and other areas (9 patients). Of these 26 patients, 21 (81%) had accompanying obstructive hydrocephalus. Surgery was performed via the lateral ventricle using a flexible scope. For patients with obstructive hydrocephalus, we added endoscopic third ventriculostomy, septostomy, and/or plasty of the foramen of Monro. Pathologic diagnosis was determined according to hematoxylin-eosin staining and immunohistochemistry using anti-GFAP, anti-Ki-67, anti-H3-K27M, and anti-IDH1-R132H antibodies. RESULTS: The pathologic diagnoses were grade I (5 patients), grade II (3 patients), grade III (6 patients), and grade IV (4 patients) gliomas. Six patients were diagnosed as having high-grade glioma, which was difficult to distinguish between grade III and grade IV. Two patients were undiagnosable. H3-K27M was strongly positive in 8 of 15 patients with high-grade glioma. All patients with high-grade gliomas died or received best supportive care within 2 years after surgery. CONCLUSIONS: Neuroendoscopic surgery is useful for midline paraventricular gliomas in terms of the treatment of obstructive hydrocephalus, as well as pathologic diagnosis and genetic analysis, which are required under the World Health Organization 2016 classification.

Perifascial Areolar Tissue Graft for Spinal Dural Repair with Cerebrospinal Fluid Leakage: Case Report of Novel Graft Material, Radiological Assessment Technique, and Rare Postoperative Hydrocephalus.

BACKGROUND: Incidental durotomy is a relatively common complication in spinal surgeries, and treatment of persistent cerebrospinal fluid (CSF) leakage is still challenging, especially in cases for which "watertight" suturing is inapplicable. The usefulness of a nonvascularized perifascial areolar tissue (PAT) graft recently was emphasized for plastic and skull base surgeries. Its hypervascularity allows for early engraftment and long-term survival, and its flexibility is advantageous in fixing defects of complex shapes in limited surgical spaces. CASE DESCRIPTION: The authors report a case of persistent CSF leakage after cervical spine surgery in which a PAT graft was used successfully for direct closure of the dural defect. The noninvasive, spin-labeled magnetic resonance imaging technique was used for postoperative assessment of CSF dynamics, not for CSF accumulation but for CSF leakage itself. In addition, some potential causes for the rare development of communicating hydrocephalus after cervical laminoplasty, as seen in this case, are discussed. CONCLUSIONS: PAT was used successfully as an alternative free graft material for direct spinal dural closure, and its hypervascularity seemed to assist with rapid resolution of CSF leakage in our case. Spin-labeled magnetic resonance imaging may enable assessment of spinal CSF dynamics without invasion.

Clinicopathological analysis in patients with neuroendocrine tumors that metastasized to the brain.

BACKGROUND: A neuroendocrine tumor (NET) can develop anywhere in the body, but is mainly found in the pancreas, gastrointestinal tract, and lungs. This report is a retrospective study of the clinicopathological features of NET patients with brain metastasis whose tissue diagnosis was made at our hospital. METHODS: Patients with brain metastasis evidenced by clinical records and images were accumulated among 302 patients in whom tissue diagnosis of NETs was made at our hospital between 2008 and 2013. In the patients, the primary lesion, pathological classification, pattern of metastasis, details of treatment, and outcomes were analyzed. RESULTS: Brain metastasis was observed in 31 patients (10.3%). The primary lesion was in the lungs in 26 patients (83.9%), and the mammary glands, esophagus, and uterus in 1 patient each. Primary lesions were unknown in 2 patients, including 1 patient in whom NETs were detected in the lymph nodes alone. Pathological classification of the primary lesion was NET Grade 2 (Ki-67: 3 to 20%) in 3 patients and neuroendocrine carcinoma (NEC, Ki-67: ≥ 21%) in 26 patients. The median period from onset of the primary lesion up to diagnosis of brain metastasis was 12.8 months, and the brain lesion preceded brain metastasis in 6 patients. Ten patients had a single metastasis whereas 21 patients had multiple metastases, but no characteristics were observed in their images. Brain metastasis was extirpated in 10 patients. Stereotactic radiotherapy alone was administered in 6 patients, and brain metastasis was favorably controlled in most of the patients with coadministration of cranial irradiation as appropriate. The median survival period from diagnosis of brain metastasis was 8.1 months, and the major cause of death was aggravation of the primary lesion or metastatic lesions in other organs. CONCLUSION: Most of NET patients with brain metastasis showed the primary lesion of NEC in the lungs, and they had multiple metastases to the liver, lymph nodes, bones, and so forth at the time of diagnosis of brain metastasis. The guidelines for accurate diagnosis and treatment of NETs should be immediately established based on further analyses of NET patients with brain metastasis.

Disseminated cerebellar hemangioblastoma in two patients without von Hippel-Lindau disease.

BACKGROUND: Two patients who had received a total resection of cerebellar hemangioblastoma developed cerebrospinal fluid dissemination during a long-term follow-up period. We present this rare disease with discussion based on the literature. CASE DESCRIPTION: The patients were two women aged 45 and 57 years. In the cerebellar hemisphere, one patient had cystic hemangioblastoma of mural nodule type and the other had solid type. Both the patients successfully underwent total resection by craniotomy. They presented no mutations in the von Hippel-Lindau disease (VHL) gene or lesions in the other organs. One patient developed local recurrence 38 months after the initial surgery, and received stereotactic radiosurgery. Three spinal cord tumors developed 91 months later, and the tumors were disseminated to the entire cerebrospinal cavity 107 months later. The other patient developed hydrocephalus 53 months after the initial surgery with tumor tissues disseminated in the intracranial subarachnoid space. The conditions of the two patients gradually aggravated despite treatment with ventriculo-peritoneal shunt and irradiation to the whole brain and whole spinal cord. CONCLUSION: Cerebrospinal fluid dissemination of cerebellar hemangioblastoma was found dominantly in non-VHL patients. The diagnosis was made 10 years after the initial surgery. Irradiation therapy was performed, but the patients died about 2 years after the diagnosis was given. Molecular targeted therapies including vascular proliferation suppression have been attempted lately, but no effective therapy has been established. Early diagnosis of dissemination as well as combination of aggressive excision and stereotactic radiosurgery are considered to be appropriate for current interventions.

Suicide gene therapy using adenovirus vector for human oral squamous carcinoma cell line in vitro.

Recently, suicide gene therapy using the herpes simplex virus thymidine kinase (HSVtk) gene followed by ganciclovir (GCV) administration was evaluated for the treatment of cancer. The purpose of this study was to investigate the effectiveness of suicide gene therapy using the replication-deficient recombinant adenovirus vector for human oral squamous carcinoma cell lines. To evaluate transduction efficiency, each cell line was transduced in vitro with an adenovirus vector containing the beta-galactosidase gene. By 24 hours after transduction, nearly 100% of the cells were transduced at a multiplicity of infection (MOI) of 10, and from 30 to 10% at an MOI of 1. Next, each cell line was transduced with an adenovirus vector containing the HSVtk gene, and a subsequent administration of GCV for the assessment of suicide gene therapy. A subsequent administration of GCV resulted in complete tumor cell death. In addition, we conducted a morphological analysis of that cell death using video-enhanced contrast differential interference contrast microscopy, and we observed that it included both apoptosis and necrosis after HSVtk gene and GCV treatment. These results suggest that adenovirus-mediated suicide gene therapy induced remarkable cytotoxicity with a bystander effect in human oral squamous cell carcinoma thus suggesting an effective treatment strategy for that tumor.

Improvement of transduction efficiency of recombinant adenovirus vector conjugated with cationic liposome for human oral squamous cell carcinoma cell lines.

Adenovirus (Ad) vectors are commonly used in gene therapy trials because of their efficiency in gene transfer. However, their use is limited by immune responses that reduce transgene expression and decrease the efficiency of repeated vector administration. In this study, the efficacy of gene transduction and the tumor-cell killing effect on four human oral (SAS, HSC-2, HSC-3, HSC-4) and one murine squamous cell carcinoma cell (SCC-7, a kind gift of Dr. M. Hiraoka, Kyoto University) lines in vitro with Ad vector conjugated with catioic liposome (Ad/SUV) was evaluated. Ad/SUV resulted in two to five-fold over higher transduction efficiency in four human and one murine cell lines in vitro than Ad vector alone. The optimal Ad-SUV ratio was determined as 10(6) pfu of Ad vector with 1 micromol SUV. Ad/SUV showed more tumor-cell killing effect than Ad vector alone. Furthermore, the shielding effects of Ad vector with Ad/SUV from neutralizing antibody were evaluated. We also found that Ad/SUV is less susceptible to inactivation by neutralizing antibodies in vitro. The efficacy of gene transduction with Ad vector was blocked more than 70% with neutralizing serum, while Ad/SUV retained approximately 50% of the control activity in vitro. On the basis of these results, the anti-tumor effect with suicide gene therapy using Ad/SUV in vivo was evaluated. Three injections of Ad/SUV showed the inhibition of tumor growth compared with control in vivo. Our results suggested that an enhanced anti-tumor effect on human oral squamous cell carcinoma would be obtained with repeated administrations of Ad/SUV.

Cell death of human oral squamous cell carcinoma cell line induced by herpes simplex virus thymidine kinase gene and ganciclovir.

Suicide gene therapy combining herpes simplex virus thymidine kinase gene (HSVtk) and ganciclovir (GCV) is one strategy for the treatment of head and neck squamous cell carcinoma (HNSCC). The purpose of this study is to determine the mechanism of cell death that occurs in suicide gene therapy using HSVtk and GCV and to assess the safety of that therapy. The human oral squamous cell carcinoma cell line SAS was treated with adenovirus vector containing HSVtk gene (AdHSVtk) and GCV in vitro. Morphological changes including chromatin condensation, cell shrinkage, blebbing of cell membrane, and ballooning formations were observed. Changes in the localization of phospholipids in the cell membrane were also observed. The results of flow cytometry showed a maximum of about 65% of cells in the early phase of apoptosis. In addition, DNA fragmentation was investigated using the TUNEL method in vivo. Nude mice (BALB/c AJD(-nu-), aged 4 weeks) were implanted with SAS and treated with AdHSVtk and GCV. Tumor sections were then observed. The treatment group was confirmed to have DNA fragmentation-positive cells. These results suggest that suicide gene therapy using AdHSVtk and GCV led to apoptosis of the oral squamous cell carcinoma cell line.