Decision-making tree for surgical treatment in meningioma: a geriatric cohort study.

Controversies persist regarding the benefits of surgery in elderly patients with meningiomas. The objective of this study was to develop decision-making scale to clarify the necessity for surgical intervention and provide clinical consultation for this special population. This retrospective cohort study was conducted at a single center and included 478 elderly patients (≥ 65 years) who underwent meningioma resection. Follow-up was recorded to determine recurrence and mortality rates. Univariate and multivariate analyses were performed to identify significantly preoperative factors, and prognostic prediction models were developed with determined cutoff values for the prognostic index (PI). Model discrimination was evaluated using Kaplan-Meier curves based on the PI stratification, which categorized patients into low- and high-risk groups. A decision-making tree was then established based on the risk stratification from both models. Among all patients analyzed (n = 478), 62 (13.0%) experience recurrence and 47 (10.0%) died during the follow-up period. Significantly preoperative parameters from both models included advanced age, aCCI, recurrent tumor, motor cortex involvement, male sex, peritumoral edema, and tumor located in skull base (all P < 0.05). According to the classification of PI from the two models, the decision-making tree provided four recommendations that can be used for clinical consultation. Surgery is not recommended for patients assigned to the high-risk group in both models. Patients who meet the low-risk criteria in any model may undergo surgical intervention, but the final decision should depend on the surgeon's expertise.

A new prognostic scoring scale for patients with primary WHO grade III gliomas based on molecular predictors.

This study was designed to select molecular markers associated with prognosis, and to propose a prognostic scoring scale for patients with primary WHO grade III gliomas based on these molecular predictors. A series of 83 grade III glioma patients surgically treated and pathologically confirmed in Beijing Tiantan Hospital between May 2009 and December 2010 were retrospectively reviewed in the study. Log-rank analysis was used to identify molecular markers associated with progression-free survival (PFS) and overall survival (OS), which were further assessed using Cox regression analysis. Based on the prognostic molecular markers, a scoring scale was proposed and Kaplan-Meier plots were compared between different scoring levels by Log-rank method. Age <50, 1p/19q co-deletion, IDH1/2 mutation, negative MGMT and EGFR expression were correlated with longer PFS and OS. Cox regression confirmed age <50 and 1p/19q co-deletion as independent prognostic markers. This scoring scale mainly based on prognostic molecular markers stratified patients into four levels with different prognoses. Longer PFS and OS were correlated with higher scores (P < 0.05). This scoring scale based on prognostic molecular markers identified four levels with significantly different prognoses, and could be used to predict the prognosis of patients with primary WHO grade III gliomas.

Differential molecular genetic analysis in glioblastoma multiforme of long- and short-term survivors: a clinical study in Chinese patients.

This study was designed to find whether long-term survivors (LTSs) exhibit molecular genetic differences compared with short-term survivors (STSs) in patients with GBM. Tumors from 12 patients initially diagnosed with GBM and survived longer than 36 months (LTSs) were compared with 30 patients with GBM and STSs (survival <18 months) for detecting of MGMT promoter methylation, 1p/19q LOH and IDH1 mutation. IDH1 mutation and MGMT promoter methylation were significantly more frequent in the LTSs group (P = 0.039 and 0.017, respectively). The incidence of 1p/19q co-deletion was not significantly different (P = 1.0). IDH1 mutation and MGMT promoter methylation might be independent, significant, and favorable factors for LTSs with GBM.

[Iconographic analysis for pituitary adenoma, craniopharyngioma and Rathke cleft cyst involving both intrasellar and suprasellar regions].

OBJECTIVE: To explore the iconographic differences for pituitary adenoma, craniopharyngioma and Rathke cleft cyst involving both intrasellar and suprasellar regions. METHODS: A total of 99 eligible pathologically confirmed patients (pituitary adenoma, n = 49; craniopharyngioma, n = 35; Rathke cleft cyst, n = 24) were selected during January 2008 and January 2012. The following characteristics were evaluated: (1) calcification or not and density of tumor on computed tomography (CT); (2) shape, size, extent and component characteristics, signal intensities of solid portions on T2-weighted images, signal intensities of cystic portions on T1-weighted images and enhancement patterns of solid portions and cyst walls and complicated hydrocephaly or not. A flowchart for differential diagnosis for three tumors was constructed based on statistical analysis of the results. RESULTS: A snowman shape, solid characteristics and homogeneous enhancement of solid portion were more common in pituitary adenomas; a lobulated shape, third ventricle compression by superior tumor extension, mixed solid and cystic characteristics, reticular enhancement of solid portion, calcification on CT scan and complicated hydrocephalus were more common in craniopharyngioma; an ovoid shape, small tumor size, cystic characteristics and none or thin cyst wall enhancement were more common in Rathke cleft cysts. CONCLUSION: The above iconography characteristics are helpful in the differential diagnosis of three tumors involving both intrasellar and suprasellar regions.

Postoperative Long-Term Independence Among the Elderly With Meningiomas: Function Evolution, Determinant Identification, and Prediction Model Development.

BACKGROUND: Maintenance of postoperative long-term independence has value for older adults who undergo surgical procedures. However, independence has barely caught attention for the elderly with meningiomas. Preventing postoperative long-term independence decline in this population necessitates the identification of the factors related to this outcome and minimizing their implications. Therefore, we assessed the independence evolution and identified potential determinants and population. MATERIALS AND METHODS: From 2010 to 2016, elderly meningioma patients (≥65 years old) undergoing operation at Beijing Tiantan Hospital were included in our study. The primary outcome was 3-year (i.e., long-term) postoperative independence measured by Karnofsky performance scale (KPS) score. We used univariate and multivariate analyses to determine the risk factors for postoperative long-term independence, and nomogram was established. RESULTS: A total of 470 patients were included eligibly. The distribution in each KPS was significantly different before and 3 years after resection (P < 0.001). Especially in patients with preoperative KPS 80 and 70, only 17.5 and 17.3% of the patients kept the same KPS after 3 years, and the remaining patients experienced significant polarization. The most common remaining symptom cluster correlated with postoperative long-term independence included fatigue (R = -0.795), memory impairment (R = -0.512), motor dysfunction (R = -0.636) and communication deficits (R = -0.501). Independent risk factors for postoperative long-term non-independence included: advanced age (70-74 vs. 65-69 OR: 2.631; 95% CI: 1.545-4.481 and ≥75 vs. 65-69 OR: 3.833; 95% CI: 1.667-8.812), recurrent meningioma (OR: 7.791; 95% CI: 3.202-18.954), location in the skull base (OR: 2.683; 95% CI: 1.383-5.205), tumor maximal diameter >6 cm (OR: 3.089; 95% CI: 1.471-6.488), nerves involved (OR: 3.144; 95% CI: 1.585-6.235), high risk of WHO grade and biological behavior (OR: 2.294; 95% CI: 1.193-4.408), recurrence during follow-up (OR: 10.296; 95% CI: 3.253-32.585), lower preoperative KPS (OR: 0.964; 95% CI: 0.938-0.991) and decreased KPS on discharge (OR: 0.967; 95% CI: 0.951-0.984) (P < 0.05). The discrimination and calibration of the nomogram revealed good predictive ability (C-index: 0.810). CONCLUSION: Elderly meningioma patients might present significant polarization trend in maintaining long-term independence after surgery. Our findings will be helpful for guiding surgical management for the elderly with meningioma and provide proposals for early functional rehabilitation.

[Characteristics of combining loss of heterozygosity of 1p/19q in glioma].

OBJECTIVES: To find possible factors correlated with combined loss of heterozygosity (LOH) of 1p and 19q. METHODS: The status of 1p and 19q of 138 glioma specimen from January 2009 to December 2009 was evaluated by Fluorescence in situ hybridization (FISH) method, and the frequencies of combining LOH of 1p/19q were compared between different pathologies, brain sub-regions, genders and ages. RESULTS: The frequencies of combined LOH of 1p and 19q of oligodendroglial (81.3%) and oligo astrocytic tumors (55.8%) were significantly higher than that of astrocytic tumor (22.2%) (P < 0.01), and the frequency of oligodendroglial tumor was significantly higher than that of oligo astrocytic tumor (P < 0.05). The frequency of combining LOH of 1p and 19q in frontal lobe (61.8%) was higher than that in temporal (31.8%) and insular lobes (34.6%) (P < 0.05). CONCLUSION: Combining LOH of 1p and 19q has significant correlation with the pathologies and brain sub-regions.

Microneurosurgical management of carotid-ophthalmic aneurysms.

OBJECTIVE: To evaluate the management of carotid-ophthalmic segment aneurysms (COA) with modern microneurosurgical techniques and instruments. METHOD: Sixty patients with COA undergoing microsurgical clipping between March 1994 and June 2002 in the Department of Neurosurgery, Tiantan Hospital, Beijing, were analyzed retrospectively. Neuroimaging included digital subtraction angiography (DSA), MRI, CT, three-dimensional CT angiography and three-dimensional DSA. From 1998, intraoperative Doppler ultrasound monitoring and endoscope-assisted techniques were used. RESULT: All aneurysms were completely obliterated without either recurrence or death. The morbidity rate of surgery prior to 1998 was 21.7%, which decreased to 13.7% after 1998 (mean 18.3% for the whole study period). CONCLUSION: Preoperative planning based on neuroimaging is very valuable. Advances in neuroimaging, endoscope-assisted techniques and intraoperative Doppler ultrasound monitoring are useful to decrease postoperative complications. Microneurosurgical techniques are optimal for the management of COA with ever lessening morbidity.

Circulating tumor cell is a common property of brain glioma and promotes the monitoring system.

Brain glioma is the most common primary intracranial tumor characterized by dismal prognosis and frequent recurrence, yet a real-time and reliable biological approach to monitor tumor response and progression is still lacking. Recently, few studies have reported that circulating tumor cells (CTCs) could be detected in glioblastoma multiform (GBM), providing the possibility of its application in brain glioma monitoring system. But its application limits still exist, because the detection rate of CTCs is still low and was exclusively limited to high- grade gliomas. Here, we adopted an advanced integrated cellular and molecular approach of SE-iFISH to detect CTCs in the peripheral blood (PB) of patients with 7 different subtypes of brain glioma, uncovering the direct evidences of glioma migration. We identified CTCs in the PB from 24 of 31 (77%) patients with glioma in all 7 subtypes. No statistical difference of CTC incidence and count was observed in different pathological subtypes or WHO grades of glioma. Clinical data revealed that CTCs, to some extent, was superior to MRI in monitoring the treatment response and differentiating radionecrosis from recurrence of glioma. Conclusively, CTCs is a common property of brain gliomas of various pathological subtypes, which has provided an ultimate paradox for the hypothesis "soil and seed". It can be used to monitor the microenvironment of gliomas dynamically, which will be a meaningful complement to radiographic imaging.

Clinical characteristics and surgical results of patients with cerebral arteriovenous malformations.

BACKGROUND: Cerebral arteriovenous malformation (AVM) is a common vascular disease in neurosurgery, and the indication for alternative treatments remains controversial. In a review of a series of 2086 patients with AVMs, the clinical characteristics and surgical results were assessed. METHODS: Collected data of 2086 consecutive patients with AVMs from January 1956 to October 2001 were analyzed. All patients were divided into 2 groups: traditional surgery group (from 1956 to 1991) and microsurgery group (from 1992 to 2001). The variables assessed for clinical characteristics in our study included age (at presentation), sex, Spetzler-Martin grade, and first presentations. Surgical complications were assessed between different surgery groups by chi(2) test. RESULTS: Cerebral AVMs are more commonly diagnosed at age of 20 to 40 years, which comprises almost one half of the whole population. The size of the AVMs ranged from 1 to 9 cm. There were 77 cases of giant AVMs in this series that were treated by a combination of surgical resection and intraoperative embolization. Hemorrhage (43.4%), headache (24.9%), and seizure (17.3%) were the first 3 common presentations. Regarding Spetzler-Martin grading system, the percentage of grade 3 to 5 patients increased, whereas that of grade 1 patients decreased in the microsurgery group (P = .00). However, compared with the traditional surgery group, the incidence of main surgical complications (death, hemiparalysis, cranial nerve dysfunction, and gastrointestinal hemorrhage) decreased significantly in the microsurgery group (P = .00). Although the incidence of main surgical complications had no statistical difference between early (from 1992 to 1996) and late microsurgery subgroup (from 1997 to 2001) (P = .796), the incidence really decreased with increase of higher-grading patients (grade 3-5) in the late microsurgery group (P = .00). CONCLUSIONS: Cerebral AVM is one of the important reasons for spontaneous intracranial hemorrhage in patients younger than 40. Spetzler-Martin grading system is helpful to predict the surgical risk. Microsurgical technique has made surgical treatment safer and become the best choice for patients with cerebral AVM.

[Microsurgery for intracranial aneurysm, clinical analysis of 1,041 cases].

OBJECTIVE: To study the effect of microsurgery on incranial aneurysm and factors influential in prognosis. METHODS: A retrospective analysis was made on the clinical data of 1,041 patients, 505 males and 536 females, aged 44.2 +/- 12.6, with incranial aneurysm treated by microsurgery 1988 approximately 2001, including clipping of aneurysm (982 cases, 94.3%), isolating of the aneurysm (32 cases, 3.1%), and coating of the aneurysm (27 cases, 2.6%). RESULTS: 93 patients (8.9%) had multiple aneurysms. 357 aneurysms (31.2%) were in the posterior communicating artery, 261 (22.8%) in the anterior communicating artery, 210 (18.4%) in the internal carotid artery, 158 (13.8%) in the middle cerebral artery, 63 (5.5%) in the anterior cerebral artery, 59 (5.2%) in the vertebral-basilar artery, and 35 (3.1%) in the posterior cerebral artery. The overall operative mortality was 1.8%. Angiography performed post-operationally showed that the aneurysm was occluded in 978 patients (99.6%). The prognosis was related to the age of patient (P = 0.001), Hunt and Hess grading before operation (P = 0.001), diameter of aneurysm (P = 0.000), and whether the aneurysm ruptures during operation (P = 0.006), and was not related to the gender of patient (P = 0.059). CONCLUSION: Clipping of the aneurysm is considered the best treatment. Microinvasive neurosurgery has improved significantly the effect of treatment of intracranial aneurysm. Factors influencing prognosis after operation include the age of patient, Hunt and Hess grading before operation, diameter of aneurysm, and whether the aneurysm ruptures during operation.

Intracranial intraparenchymal and intraventricular schwannomas: report of 18 cases.

OBJECTIVE: Intracranial schwannomas of the brain, which are unrelated to the cranial nerves, are extremely rare. In this article, we present a series of eighteen cases of intracranial intraparenchymal and intraventricular schwannomas, which is the largest series to date. METHODS: During the 10-year period from January 2000 to October 2010, we encountered 2491 histologically established cases of intracranial schwannomas, of which only 18 were not related to the cranial nerves. Clinical profiles, radiological features, surgical procedures, intraoperative findings and outcomes were extracted from the patient records and neuroimaging data. RESULTS: No patients were preoperatively diagnosed with schwannoma. The diagnosis of schwannoma was made by pathological examination with H&E staining and immunohistochemical examination. The 18 cases with intracranial ectopic schwannomas account for 0.8% of all the intracranial schwannomas that were observed within the same time period at our hospital. The age distribution of the patients ranged from 7 to 78 years. There was a slight male predominance: 11 male and 7 female patients (M:F=1.6:1). Headaches were the most common presenting symptom and were found in most cases. Common neuroradiological characteristics included peritumoral edema and intralesional cysts. CONCLUSION: Intracranial intraparenchymal and intraventricular schwannomas are rare, benign neoplasms that cannot be preoperatively differentiated from other parenchymal tumors. Surgical excision is curative, and the long-term prognosis is good. Additional studies are needed to confirm the histogenesis of this schwannoma type.

Analysis of CD137L and IL-17 expression in tumor tissue as prognostic indicators for gliblastoma.

Glioblastoma multiforme (GBM) is the most common form of malignant glioma, characterized by genetic instability and unpredictable clinical behavior. GBM is marked by an extremely poor prognosis with median overall survival of 12~14 months. In this study, we detected the CD137L-expressing cells and IL-17-expressing cells in tumor tissues resected from patients with GBM. Expression of CD137L and IL-17 were assessed by immunohistochemistry, and the prognostic value of CD137L and IL-17 expression within the tumor tissues were assessed by Cox regression and Kaplan-Meier analysis. Immunohistochemical detection showed that positive cells of CD137L and IL-17 in glioblastoma tissue samples were 46.3% (19/ 41) and 73.2% (30/41) respectively. Expression of CD137L was not correlated with overall survival of GBM patients (P=0.594), while significantly longer survival rate was seen in patients with high expression of IL-17, compared to those with low expression of IL-17 (P=0.007). In addition, we also found that IL-17 expression was significantly correlated with Progression-free survival (PFS) (P=0.016) and death rate (P=0.01). Furthermore, multivariate Cox proportional hazard analyses revealed that IL-17 (P=0.018) and PFS (P=0.028) were independent factors affecting the overall survival probability. Kaplan-Meier analysis showed that PFS of high expression of IL-17 group were significantly longer (P=0.004) than low expression group with GBM. It is concluded that high levels of IL-17 expression in the tumor tissues may be a good prognostic marker for patients with GBM.

Co-polysomy of chromosome 1q and 19p predicts worse prognosis in 1p/19q codeleted oligodendroglial tumors: FISH analysis of 148 consecutive cases.

BACKGROUND: This study aimed to evaluate the prognostic significance of co-polsomy of chromosome 1q and 19p in 1p/19q codeleted oligodendroglial tumors (ODGs). METHODS: In a series of 148 ODGs with 1p/19q deletion, co-polysomy of 1q and 19p was detected by fluorescence in situ hybridization (FISH). Log-rank analysis and Cox regression methods were used to compare Kaplan-Meier plots and identify factors associated with worse prognosis. RESULTS: There were 104 (70.3%) low-grade ODGs and 44 (29.7%) high-grade ODGs. Co-polysomy was independently associated with shorter progression-free survival and overall survival in 1p/19q codeleted ODGs, irrespective of tumor grades. The odds ratio of without and with co-polysomy was 0.263 (95% confidence interval [CI], 0.089-0.771; P = .015) for progression-free survival and 0.213 (95% CI, 0.060-0.756; P = .017) for overall survival. Subgroup analysis confirmed this trend in both low-grade and high-grade ODGs, although the P value for high-grade ODGs was marginally significant. CONCLUSIONS: Co-polysomy of 1q and 19p could be used as a marker to independently predict worse prognoses and guide individual therapy in 1p/19q codeleted ODGs.

Co-deletion of chromosome 1p/19q and IDH1/2 mutation in glioma subsets of brain tumors in Chinese patients.

OBJECTIVE: To characterize co-deletion of chromosome 1p/19q and IDH1/2 mutation in Chinese brain tumor patients and to assess their associations with clinical features. METHODS: In a series of 528 patients with gliomas, pathological and radiological materials were reviewed. Pathological constituents of tumor subsets, incidences of 1p/19q co-deletion and IDH1/2 mutation in gliomas by regions and sides in the brain were analyzed. RESULTS: Overall, 1p and 19q was detected in 339 patients by FISH method while the sequence of IDH1/2 was determined in 280 patients. Gliomas of frontal, temporal and insular origin had significantly different pathological constituents of tumor subsets (P<0.001). Gliomas of frontal origin had significantly higher incidence of 1p/19q co-deletion (50.4%) and IDH1/2 mutation (73.5%) than those of non-frontal origin (27.0% and 48.5%, respectively) (P<0.001), while gliomas of temporal origin had significantly lower incidence of 1p/19q co-deletion (23.9%) and IDH1/2 mutation (41.7%) than those of non-temporal origin (39.9% and 63.2%, respectively) (P = 0.013 and P = 0.003, respectively). Subgroup analysis confirmed these findings in oligoastrocytic and oligodendroglial tumors, respectively. Although the difference of 1p/19q co-deletion was not statistically significant in temporal oligodendroglial tumors, the trend was marginally significant (P = 0.082). However, gliomas from different sides of the brain did not show significant different pathological constituents, incidences of 1p/19q co-deletion or IDH1/2 mutation. CONCLUSION: Preferential distribution of pathological subsets, 1p/19q co-deletion and IDH1/2 mutation were confirmed in some brain regions in Chinese glioma patients, implying their distinctive tumor genesis and predictive value for prognosis.

Clinical, radiological, and pathological features of 24 atypical intracranial epidermoid cysts.

OBJECT: Most intracranial epidermoid cysts typically present with long T1 and T2 signals on MR images. Other epidermoid cysts with atypical MR images are often misdiagnosed as other diseases. In this study the authors aimed to analyze the incidence and the clinical, radiological, and pathological features of atypical epidermoid cysts. METHODS: Among 428 cases of intracranial epidermoid cysts that were surgically treated between 2002 and 2008 at Beijing Tiantan Hospital, cases with an atypical MR imaging appearance were chosen for analysis. Clinical and pathological parameters were recorded and compared in patients with lesions demonstrating typical and atypical MR appearance. RESULTS: An atypical epidermoid cyst accounts for 5.6% of the whole series. Radiologically, 58.3% of atypical epidermoids were misdiagnosed as other diseases. Compared with a typical epidermoid cyst, atypical epidermoid lesions were significantly larger (p = 0.016, chi-square test). Pathologically, hemorrhage was found in 21 patients with atypical epidermoid cyst and is significantly correlated with granulation (p = 0.010, Fisher exact test). Old hemorrhage was found in 13 cases and was significantly correlated with cholesterol crystals. Twenty-one patients were followed up for 1.3-8.6 years after surgery. The 5- and 8-year survival rates were both 100%. Three patients experienced cyst recurrence. The 5- and 8-year recurrence-free rates were 95% and 81.4%, respectively. CONCLUSIONS: Radiologically, an atypical epidermoid cyst should be differentiated from dermoid cyst, teratoma, schwannoma, glioma, craniopharyngioma, and cavernous angioma. A tendency toward spontaneous hemorrhage is confirmed in atypical epidermoid cysts, and a hypothesis was proposed for spontaneously intracystic hemorrhage in atypical epidermoid cysts. Follow-up confirmed long-term survival of patients with atypical epidermoid cysts.