Age and bromodeoxyuridine labelling index as prognostic factors in high-grade gliomas treated with surgery and radiotherapy.

AIMS: To determine the prognostic value of proliferative potential and DNA ploidy in 72 brain tumours (36 grade III and 36 grade IV astrocytomas) using bromodeoxyuridine (BrdUrd) incorporation and flow cytometry. MATERIAL AND METHODS: All 72 patients underwent excision, mostly incomplete of the tumour. After surgery, eight patients received conventionally fractionated radiotherapy, 11 patients received accelerated radiotherapy, and 53 patients received hypofractionated radiotherapy. Tumour samples taken during surgery from each patient were incubated in vitro for 1 h at 37 degrees C with BrdUrd using the high pressure oxygen method. The percentage of BrdUrd-labelled cells (BrdUrd labelling index [BrdUrd LI]), and the total DNA content were evaluated: RESULTS: The tumours showed variability in the BrdUrd LI values, which ranged from 0.3 to 19.1%. No difference was observed in mean BrdUrd LI between grade III and grade IV sub-groups. A significantly higher percentage of DNA aneuploidy was observed in grade III gliomas (69.4%) than in grade IV gliomas (52.8%). Univariate analysis showed that younger patients (< or = 51 years) (P = 0.021) with grade III gliomas (P = 0.030) and low tumour proliferation rate (BrdUrd LI < or = 2.7%, P = 0.028) had significantly higher 5-year survival rates. Tumour ploidy had no influence on patients' survival (P = 0.591). However, Cox multi-variate analysis showed that only age over 51 years, and high tumour proliferation rate (BrdUrd LI > 2.7%), were significant unfavourable prognostic factors in patient survival. CONCLUSION: In this study, independent prognostic factors for patients with high-grade gliomas treated with surgery and post-operative radiotherapy are age and tumour proliferation rate assessed according to the BrdUrd LI.

Meningioma with the unique coexistence of secretory and lipomatous components: a case report with immunohistochemical and ultrastructural study.

Meningiomas exhibit a broad spectrum of differentiation potency corresponding to different histological subtypes. The separate secretory or lipomatous transformation of meningothelial cells is uncommonly encountered in meningiomas classified into distinct secretory or lipomatous variants. The coexistence of these two different histological subtypes is extremely rare. We report an exceptional case of secretory meningioma associated with extensive lipomatous component in a 58-year-old woman. CT scan and MRI of the brain showed a well-defined tumor mass in the right temporal lobe with areas of adipose tissue and extensive surrounding brain edema. Microscopically, the tumor was composed of two components: whorls of meningothelial cells with numerous PAS-positive hyaline inclusions (pseudopsammoma bodies) and numerous mature adipocyte-like cells. The presence of neutral fat was confirmed by oil-red-O staining. The hyaline inclusions and tumor cells surrounding them showed strong immunoreactivity for EMA and CEA. Ultrastructural findings confirmed both secretory and lipomatous differentiation of tumor cells. The majority of lipidized neoplastic cells shared the features of meningothelial cells and adipocytes. Our result supports the opinion that lipomatous component ought to be considered as an advanced lipidization of neoplastic meningothelial cells rather than true metaplastic transformation of meningothelial cells into mature fat tissue. The present case of meningioma demonstrates a unique coexistence of secretory and lipomatous meningothelial components, reflecting the multipotency of phenotypic transformation of primary meningothelial cells.

Meningiomas and gliomas in juxtaposition: casual or causal coexistence? Report of two cases.

Two cases of meningioma and glioma established in biopsy material from one or more than one operation are reported. In these cases, an originally benign meningioma was followed by the development of anaplastic astrocytoma in close juxtaposition to the site of first operation. The close juxtaposition of two histologically different tumors suggested that one of them might lead to local proliferation and independent growth of the other.

A long term follow-up of fetal dopaminergic neurons transplantation into the brain of three parkinsonian patients.

In three parkinsonian patients ages 48, 53, and 50, human fetal dopaminergic cells taken from the ventral part of mesencephalon of 11-12-week-old fetuses were implanted into the head of caudate nucleus. The operation was carried out with a specially designed device to enable safe and precise graft implantation. All patients had been suffering from severe Parkinson's disease for about 10-15 years (stage 4/5 according to Hoehn and Yahr scale) with bradykinesia, rigidity and tremor as the main symptoms. Long-lasting L-dopa therapy resulted in side effects with ON/OFF syndrome and dyskinesias. A detailed clinical examination was performed before and every 3 months after the operation according to the CAPIT battery of standarized tests. The patients were under post-operational observation lasting 30, 20 and 12 months, respectively. Improvement was observed in all patients starting between 3 and 6 months after operation and is still sustained. Significant increases in movement speed for repeated pronation-supination, finger dexterity and foot lifting tests were found. The speed of walking also increased with decreased rigidity. The OFF phase during the day is of shorter duration and less severe; dyskinesias are markedly reduced. Our results indicate that fetal grafting seems to be a valuable experimental approach towards the treatment of selected parkinsonian patients.

Phenotypic characteristics of GFAP-immunopositive oligodendroglial tumours Part I: immunohistochemical study.

Oligodendrogliomas are believed to derive from oligodendrocyte lineage but the expression of different immunohistochemical markers indicates some variability in their differentiation potency. It has been documented that some heterogeneity of the tumour cells exists and that oligodendrogliomas can display a spectrum of histological, immunohistochemical and fine structural features. The expression of glial fibrillary acidic protein (GFAP) in various types of neoplastic cells in oligodendroglial tumours has been well established, however the nature of these cells in relation to tumour malignancy remains controversial. The current histopathological and immunohistochemical study (with a panel of antibodies for GFAP, vimentin, S-100 protein, MBP, NSE) has been performed on biopsy specimens from 12 cases of GFAP-immunopositive oligodendroglial tumours to evaluate their phenotypic characteristics. The majority of tumours showed a variable pattern of GFAP expression in morphologically different tumour cells responding to typical neoplastic oligodendrocytes (gliofibrillary oligodendrocytes-GFOC), miniature form of gemistocytes (minigemistocytes) and neoplastic or reactive astrocytes. The majority of cases exhibited negative staining for vimentin whereas there was no evident correlation between GFAP expression and other immunohistochemical markers. The present immunohistochemical findings support the opinion that the majority of GFAP-positive neoplastic cells in oligodendroglial tumours represent the transitional cell types between oligodendroglial and astrocyte lineage. The difficulties in differential diagnosis of oligodendroglial tumours exhibiting the various patterns of GFAP expression are emphasised.

Phenotypic characteristics of GFAP-positive oligodendroglial tumours. Part II: ultrastructural study.

Five cases of anaplastic oligodendrogliomas containing numerous GFAP-positive cells have been analysed by electron microscopy to establish the fine structural characteristics of neoplastic cells. Ultrastructurally, all tumours have revealed monotonous appearance typical of oligodendrogliomas, however some structural variability, particularly with reference to astrocytic differentiation, has been observed. The majority of neoplastic cells have shown the fine structural features of oligodendrocytes, accompanied by various numbers of intermediate cytoplasmic filaments. These filaments have been usually distributed in the perinuclear, less often in the peripheral, parts of the cytoplasm. The cells exhibiting features common to both oligodendroglial and astroglial cells might be regarded as an intermediate morphological form between these two cell types. True neoplastic astrocytes could be encountered only sporadically. The present electron microscopic studysupports the opinion that GFAP-positive oligodendroglial tumours contain heterogeneous neoplastic cell populations with the transitional cell types between oligodendroglial and astroglial lineage.

Disseminated spinal and cerebral ependymoma with unusual histological pattern: clinicopathological study of a case with retrograde tumor spread.

The subject of this study is a case of anaplastic ependymoma originally arising from the central canal of the lower spinal cord followed by the 13 years history of events of upper spinal dissemination and retrograde intracranial spread. The specimens from four subsequent surgeries generally displayed the same microscopic features of neoplastic tissue and were consistent with the diagnosis of anaplastic ependymoma. The histological diagnosis was based upon the high cellularity, considerable nuclear atypia and pleomorphism, brisk mitotic activity, focally exhibited vascular endothelial proliferation and extensive necrosis. Apart from the typical pattern of ependymoma, the tumors contained areas composed almost entirely of large, uniform clear cells or pseudogemistocytes indicating the morphological heterogeneity of neoplastic cells population. The surgical specimens from four surgical resections shared light microscopic similarities suggesting spinal and intracranial dissemination from the primary spinal tumor. Since the retrograde spread via the cerebrospinal fluid (CSF) pathway is extremely rare, the authors of this study discuss the mechanism of such way of tumor metastases.

Giant cervico-thoracic schwannoma with long clinical history. Case report.

An unusual case of a giant intraspinal schwannoma in a 45-year-old woman with 14-year history of preoperative symptoms was presented. MRI of the spine revealed an intradural, extramedullary tumor extending from the intervertebral space C4/C5 to T4 vertebral body level (2 x 1.2 x 12 cm) and filling almost the entire spinal canal. Microscopical examination showed a typical neurinoma pattern with two distinct zones of Antoni A and Antoni B tissue. Some areas exhibited nuclear atypia and hyperchromasia reflecting the degenerative changes in this slowly growing nerve sheath tumor. A rich pericellular reticulin network was seen in the areas composed of Antoni A tissue. Immunohistochemically, the tumor cells were strongly positive for S-100 protein. The diagnostic difficulties in the presented case of longstanding schwannoma resulted in the late surgical treatment. The importance of the early diagnosis of spinal nerve sheath tumors for the patient's quick recovery is stressed.

Multilocular cysticeral and hydatid cysts of the brain: a report of three cases.

Three cases of multilocular parasitic brain cysts are presented; two cases of specific form of neurocysticercosis and one case of multilocular hydatid cyst. MRI shows features seen in other cystic lesions of the CNS. In all cases the diagnosis was established by neurosurgical brain biopsy. The authors indicate that the parasitic disease should be taken into consideration in differential diagnosis of tumor-like cystic brain lesions.

Neurofibromatosis type 2. Case report.

A case of a 24-year-old woman with peripheral paresis of the facial nerve, balance disturbance, hearing loss and epileptic seizures for many years is presented. At time of admission to hospital cerebral magnetic resonance imaging (MRI) showed several large tumors situated supra- and infratentorially. Histological examination of the operated tumors revealed bilateral acoustic schwannomas in the cerebellopontine angles and mixed meningioma in the others. The patient was diagnosed as neurofibromatosis type 2 (NF2) according to clinical criteria for neurofibromatoses. Several months after the last operation, she exhibited weakness of all extremities. On spinal MRI an intramedullary tumor in the cervical region and additional focal lesions along central canal were found. Surgical therapy was not performed because of clinical improvement after dexamethasone treatment and location of lesion in cervical medulla. Our case confirms frequently occurring lack of neurocutaneous changes and late appearance of significant neurological symptoms in NF2.

Embryonal carcinoma of the pineal gland with yolk sac tumor differentiation. A case report.

Twenty three old male patient was diagnosed as a pineal gland tumor and was operated in neurosurgical ward. He died four weeks later due to pneumonia and respiratory failure. Clinical diagnosis was based on computer tomography (CT) and magnetic resonance image (MRI) examination. Histological study of a biopsy and autopsy specimens showed embryonal carcinoma with yolk sac tumor differentiation. The diagnosis was supported by positive cytokeratin, placental alkaline phosphate and alpha-fetoprotein immunostainings.

Disseminating histologically benign multiple papilloma of the choroid plexus: case report.

A rare case of extensively disseminating multiple benign choroid plexus papilloma is shown. The patient first reported with high-grade hydrocephalus and two tumours in the 3rd and 4th ventricle was treated by atrioventricular shunt insertion, subtotal resection of the 4th ventricle tumour, and adjuvant 60Co irradiation of the posterior fossa. The dissemination that followed was revealed by computerised tomography and magnetic resonance imaging, and involved both the supra- and infratentorial ventricular systems, spinal canal, and brain parenchyma. Three years after the resection of the 4th ventricle tumour, the patient underwent excision of a temporal lobe lesion for relief of neurological symptoms, but showed no improvement and died 5 years after the primary diagnosis of CNS tumour. An autopsy was not performed. Analysis of the primarily resected mass showed distinct papillary pattern with no anaplasia, mitoses, multinucleation orgiant cell formation, and cytokeratin positivity at the absence of vimentin and glial fibrillary acidic protein. Analysis ofthe temporal lobe tumour again showed definite papillary formation with no signs of malignisation and virtually no mitotic figures, and the presence of cytokeratin, but not vimentin or glial fibrillary acidic protein. On both occasions, the diagnosis was choroid plexus papilloma (WHO grade I).

Dysembryoplastic neuroepithelial tumor. A case report.

Dysembryoplastic neuroepithelial tumor (DNT) is a rare, benign tumor encountered in the cortex. It is characterized by the presence of cells of different histogenesis. Due to its mixed nature (glial-neuronal), WHO histological classification of brain tumors included it into the group of neuronal and glial-neuronal mixed tumors. Case of tumor in a 19-year-old woman experiencing for three years seizure of temporal lobe epilepsy is presented. A cranial magnetic resonance imaging (MRI) showed "pseudocystic" tumor in temporal lobe. Histological and immunocytochemical examinations of the tumor fragment removed during surgery revealed large numbers of neuronalglial nodules occurring in the cerebral cortex. Columns of glial-neuronal structures crossing parallely to the cortex surface, surrounded by oligodendrocyte-like cells (OLC) were a characteristic feature of the tumor texture. In the tumor interstitium, "floating" maturated, dysplastic-free ganglionic cells were visible in numerous bright spaces. In addition, numerous lobuliform--structured areas consisted of oligodendrocyte-like cells. Oligodendrocyte-like cells were characterized by positive immunoreaction to the presence of S-100 protein and synaptophysin. Basing on clinical manifestation and histopathological findings dysembryoplastic neuroepithelial tumor was diagnosed.

Middle superficial cerebral vein.

The microanatomical study present the anatomy of the middle cerebral vein. On the basis of the anatomical data we distinguished concentric and nonconcentric types of tributaries of the middle superficial cerebral vein. The nonconcentric type prevails.

[Anatomy of the middle cerebral artery and the angiographic image of its aneurysms]. / Anatomia tetnicy srodkowej mózgu a obraz angiograficzny jej tetniaków.

The study is based on conclusions drawn from the microanatomical analysis of 200 middle cerebral arteries and angiographic findings in 40 aneurysms of the artery. The angiograms were analysed considering the site of the aneurysm with respect to the division of the artery at the limen insulae and presence of early temporal arteries. Correlating these data with the anatomical observations, especially with regard to the site of origin of the perforating arteries it was tried to define more strictly the facts relevant to the operation which can be obtained by angiography.

Influence of intraoperative using of recombinant tissue plasminogen activator on the development of cerebral angiospasm after subarachnoid haemorrhage in patients with ruptured intracranial aneurysms.

For a few years conducted experimental studies and clinical trials set one's hopes on the role of the fibrynolytic treatment using recombinant tissue plasminogen activator (rt-PA) in preventing cerebral vasospasm. In our study the target population was 45 patients with ruptured saccular aneurysms causing severe SAH. In the group of 24 patients treatment consisted of a single intraoperative injection of 10 mg of rt-PA into the opened basal subarachnoid cisterns following aneurysm clipping. The patients underwent surgery with aneurysm clipping within 72 hours from subarachnoid haemorrhage in all patients. Control group of 21 patients underwent early operation after SAH and rt-PA was not given. All patients had significant basal cistern blood accumulation seen on CT scans preoperatively according to Fisher's grade III. Patients in our study were classified in clinical grade I and II according to classification of Hunt/Hess. Transcranial Doppler Daily examinations in postoperative course were performed in all patients. The postoperative results were evaluated according to Glasgow Outcome Scale. Postoperatively patients were evaluated by daily transcranial Doppler and serial CT scans. TCD demonstrated reduction in the development of vasospasm to a greater degree in the rt-PA treated group. Serial CT examinations demonstrated radical blood clot removal in all rt-PA treated patients. The postoperative results according to the Glasgow Outcome Scale in the rt-PA treated group were as follow: 22 patients were grades I and II, 2 patients were grade III. In the control group 13 patients were grades I and II, 6 patients were grade III, and 2 patients died. In the rt-PA treated group only one patient presented delayed ischemic deficit.

[Our method of creating experimental aneurysms and its use in the training in microsurgical operations]. / Wlasna metoda wytwarzania tetniaków doswiadczalnych oraz ich zastosowanie w cwiczeniu techniki operacji mikrochirurgicznych.

An original method is presented used for production of experimental aneurysms in rats. The method may be useful in training for microneurosurgical treatment of aneurysms.

[Late growth of supratentorial meningioma after radiotherapy of cerebellar tumor]. / Odlegly wzrost oponiaka nadnamiotowego po radioterapii guza mózdzku.

The authors report a case of supratentorial meningioma of the brain developing after radiotherapy for cerebellar astrocytoma. On the basis of a survey of the literature and own speculations the authors try to demonstrate a cause-and-effect relationship between radiotherapy and meningioma development.

[Extensive bifocal location of ependymoma of the spinal cord]. / Rozlegle, dwuogniskowe umiejscowienie wysciólczaka rdzenia kregowego.

Spinal cord ependymomas belong to rare tumours of the central nervous system. Their malignancy is usually low although anaplastic forms are known also to occur. Surgical treatment is the method of choice supplemented often with radiotherapy. An exceptionally rare form of ependymoma with two foci of origin in the spinal cord is reported. The large extent of the tumour caused that laminectomy at 15 levels was necessary. The mechanism of ependymoma development at two levels is discussed.

[Neurotransplantation. III. Intracerebral grafting of fetal substantia nigra in Parkinson's disease]. / Neurotransplantacje. III. Domózgowe przeszczepy plodowej istoty czarnej w chorobie Parkinsona.

The paper reports the results of fetal substantia nigra transplantations into the brain of patients suffering from Parkinson's disease, performed in different neurosurgical centers in the world. Commonly accepted Ethical Guidelines for Fetal Tissue Transplantations are presented. The criteria regarding patients selection for therapeutic transplantation are also discussed. The results of studies concerning the problem of optimal fetal age for transplantations are presented. The optimal age seems to cover the period between the 7th gestational week when dopamine synthesis begins and the 11th week when protoplasmic processes start to grow intensively. The damage of these processes during transplantation procedure is thought to make the fetal cells survival difficult. The discussion concerning controversial problem of immunosuppression treatment after the neurotransplantation is also reported. The paper presents the principles of signs and symptoms assessment before and after operation including CAPIT system which emphasises the role of movement ability tests, PET-scanning with [18F]-6-L-fluorodopa and magnetic resonance imaging. The PET-scanning allows to follow up the changes in patient's brain resulting from the graft survival and its dopamine synthesis ability. The methods of donor woman examination to avoid the transmission of infections into the patient's brain are reviewed. The analysis of yet published results of about 100 operated on parkinsonian patients show marked improvement due to human fetal substantia nigra transplantation. The improvement lasts, at least 46 months postoperatively (the longest period of observation). Many of the grafted patients returned to normal self-dependent living activities and some of them resumed even their professional jobs. Most authors present the opinion that the therapeutic effects of fetal substantia nigra transplantations are more valuable and longer lasting than those after adrenal medulla autografts. However it should be borne in mind that both methods are yet only the experimental approach in Parkinson's disease therapy.