Influence of glioblastoma contact with the subventricular zone on survival and recurrence patterns.

BACKGROUND: There is growing evidence that the subventricular zone (SVZ) may be involved in both the initiation and progression of glioblastoma (GB). We aimed to assess tumor proximity to the SVZ as a potential prognostic factor in GB. METHOD: Retrospective study of 133 patients diagnosed with primary GB who underwent surgery followed by temozolomide-based chemoradiation between 2010 and 2016. All lesions were classified according to their anatomic relation with the SVZ. We determined the effect of tumor contact with the SVZ on progression-free survival (PFS), overall survival (OS), type, and patterns of recurrence. RESULTS: At a median follow-up of 18.6 months (95% CI 15.9-21.2), PFS and OS were 7.5 (95% CI 6.7-8.3) and 13.9 (95% CI 10.9-16.9) months, respectively. On the univariate analyses, initial contact with the SVZ was a factor for poor prognosis for both PFS (6.1 vs. 8.7 months; p = 0.006) and OS (10.6 vs. 17.9 months; p = 0.037). On the multivariate analysis, tumor contact with the SVZ remained statistically significant for PFS, but not OS. Patients with SVZ-contacting tumors presented a higher rate of aggressive clinical progression (30.9% vs. 11.3%; p = 0.007) and contralateral relapse patterns (23.4% vs. 9.1%; p = 0.048). CONCLUSIONS: Our results suggest that glioblastoma contact with the SVZ appears to be an independent prognostic factor for poor PFS. The presence of an SVZ-contacting tumor was associated with more aggressive recurrences and a higher rate of contralateral relapses. These findings suggest that this variable may be a new prognostic factor in glioblastoma.

Results of a multicenter survey showing interindividual variability among neurosurgeons when deciding on the radicality of surgical resection in glioblastoma highlight the need for more objective guidelines.

PURPOSE: We assessed agreement among neurosurgeons on surgical approaches to individual glioblastoma patients and between their approach and those recommended by the topographical staging system described by Shinoda. METHODS: Five neurosurgeons were provided with pre-surgical MRIs of 76 patients. They selected the surgical approach [biopsy, partial resection, or gross total resection (GTR)] that they would recommend for each patient. They were blinded to each other's response and they were told that patients were younger than 50 years old and without symptoms. Three neuroradiologists classified each case according to the Shinoda staging system. RESULTS: Biopsy was recommended in 35.5-82.9%, partial resection in 6.6-32.9%, and GTR in 3.9-31.6% of cases. Agreement among their responses was fair (global kappa = 0.28). Nineteen patients were classified as stage I, 14 as stage II, and 43 as stage III. Agreement between the neurosurgeons and the recommendations of the staging system was poor for stage I (kappa = 0.14) and stage II (kappa = 0.02) and fair for stage III patients (kappa = 0.29). An individual analysis revealed that in contrast to the Shinoda system, neurosurgeons took into account T2/FLAIR sequences and gave greater weight to the involvement of eloquent areas. CONCLUSIONS: The surgical approach to glioblastoma is highly variable. A staging system could be used to examine the impact of extent of resection, monitor post-operative complications, and stratify patients in clinical trials. Our findings suggest that the Shinoda staging system could be improved by including T2/FLAIR sequences and a more adequate weighting of eloquent areas.

[Comparison [corrected] of Chiari I malformation treatment using suboccipital craniectomy and posterior arch of C1 resection with or without dural graft]. / Comparación del tratamiento de la malformación de Chiari tipo I mediante craniectomía suboccipital y resección del arco posterior de C1 con o sin duroplastia.

UNLABELLED: There are various surgical approaches to treat Chiari I malformation. In spite of the good clinical results that are reported with most of them, there is still controversy about the optimal treatment of this pathology. OBJECTIVE: To compare the clinical and radiological results of surgical treatment of the Chiari I malformation with suboccipital craniectomy, posterior arch of C1 resection with or without dural graft, analyzing clinical and radiological findings and describing the complications. MATERIAL AND METHODS: Retrospectively clinical cases series of patients who underwent Chiari I malformation surgery between 1998 and 2006 in the Hospital Germans Trias i Pujol in Badalona. The inclusion criteria consisted in: patients older than 18 years, who have had surgery in our hospital, detailed neurological examination before and after surgery (calculating the EDSS scale punctuation), craniospinal magnetic resonance imaging before and after surgery and minimal follow up period of 6 months. The election of the surgical approach was left to the discretion of the main surgeon. Patients were divided in two groups depending of the surgical technique: Group A (with dural graft) and Group B (without dural graft). To evaluate the morphological results in both groups, measurements of the position of the fastigium above a basal line in the midsagittal T1 weighted magnetic resonance images were obtained. In patients with syringomyelia, siringo-to-cord ratio was measured before and after surgery. To evaluate the clinical results, neurological examination was recorded in both groups before and after surgery. RESULTS: The mean age of Group A patients was 47 (-/+12.89) years, and of Group B was 38.3 (-/+7.77) years. Mean follow up period was 2.48 (-/+2.44) years in Group A and 4.2 (-/+4.46) in Group B. Creation of an artificial cisterna magna was observed en 35.7% of Group A patients and only in 3.5% of Group B patients (p=0.022). In 8 patients front Group A, 8 patients (28.6%) an upward migration of the cerebellum was seen, whereas any of the Group B patients presented it (p=0.022) Siringo-to-cord ratios were decreased in both groups without significant differences. All of the Group A patients improved their clinical exploration. In Group B, 60% of the patients improved and the 40% left maintained clinical stability. Any patient worsened. All patients that maintained clinical stability belonged to Group B, the differences between the two groups were statistically significant (p=0.04). Five patients presented immediate surgical complications (2 pseudomeningoceles, 2 meningitis and 1 hydrocephalus). All this patients where operated with dural graft (p=0.049). CONCLUSIONS: According to our study, suboccipital craniectomy with resection of the posterior arch of C1 and dural graft shows better clinical and radiological results than without dural graft. Nevertheless this technique can increase the incidence of surgical complications.

Medulloblastoma in young adults. Must we give adjuvant chemotherapy?

Medulloblastoma is a rare entity in adult patients. All data about treatment are from children, where this disease is the most common cerebral tumour. Reports of medulloblastoma in adults are scarce but in all of them the prognosis seems similar to the prognosis of children. We present our experience in five cases of medulloblastoma in young adults, treated at the University Hospital "Germans Trias i Pujol" from June 1994 to October 2003. This has not been a good experience as more than 50% of the patients had a recurrence in spite of the standard treatment. We have reviewed the literature, concluding that we have to adapt the findings in children to our adult patients, offering them adjuvant chemotherapy after surgery.

[Tentorial meningiomas. Report of our series]. / Meningiomas de la tienda del cerebelo. Revisíon de nuestra casuística.

PURPOSE: The main objectives of this report are to describe the clinical and radiological features, surgical management, complications, and final outcome of patients with a tentorial meningioma. METHODS: This is a retrospective study of 25 patients operated on for tentorial meningiomas at our department since december 1975 to may 2002. All the patients, except the first, were diagnosed by computed tomography; in 13 of them a magnetic resonance imaging was performed too; in 14 patients, diagnosis was completed with cerebral arteriography. The preoperative clinical condition, the interval between the first symptoms and the date of the operation, the postoperative morbidity and the recurrence are analysed. RESULTS: There were 20 women and 5 men of ages ranging from 35 to 79 years (average of 54.6). Surgical removal was considered radical (Simpson I-II) in 22 patients. Of them one had a recurrence 25 years after the operation, another had three recurrences, in two years, that were reoperated, and a third one had recurrence at five years who did not require surgery. The postoperative mortality was 8%. The mean follow-up period was of 5.3 years. The final outcome was good recovery in 19 patients, moderate disability in 1 and death in 4. CONCLUSIONS: Despite the advances in Neuroradiology and Microsurgery, these tumors represent a challenge for the neurosurgeon, due in some cases to a large tumor size and extension to critical areas. A removal as complete as possible allows minimizing the recurrence risk.

[Lumbar root compression secondary to juxtafacet cysts: review of 10 cases]. / Compresión radicular lumbar secundaria a quistes yuxtafacetarios: revisión de 10 casos.

OBJECT: We report a series of 10 patients with 11 juxtafacet cysts of the lumbar spine treated in our center from 1994 to 2000. METHODS: The clinical histories, radiographic images, surgical protocols and pathological records of the 10 patients diagnosed of lumbar juxtafacet cyst have been analyzed. RESULTS: Six patients were women and four were men. The average age of presentation was 54 years. The most frequent clinical presentation was radicular pain, and motor or sensitive deficits were not very common. Computed tomography and magnetic resonance are essential in establishing the diagnosis. The cysts were located at L4-L5 in eight patients, at L2-L3 in one patient, and at L3-L4 in other patient. Eight patients were treated by means of decompressive laminectomy and excision of the cyst, and the remaining two underwent conservative treatment. Degenerative phenomena adjacent to the juxtafacet cysts are easy to evidence. All the patients were improved of their radicular pain. CONCLUSIONS: Analysing our series, we conclude that the juxtafacet cysts appear more frequently at L4-L5 level in people of advanced age, and produce commonly low back pain and radiculopathy. Although they can be treated initially in a conservative way, in the presence of a progressive sciatic syndrome, surgical management is preferable.