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BACKGROUND: Intramedullary spinal cord tumors (IMSCTs) are a rare subgroup of neoplasms, encompassing both benign, slow-growing masses, and malignant lesions; radical surgical excision represents the cornerstone of treatment for such pathologies regardless of histopathology, which, on the other hand, is a known predictor of survival and neurologic outcome postsurgery. The present study aims to investigate the relevance of other factors in predicting survival and long-term functional outcomes. METHODS: We conducted a review of current literature on functional outcomes of IMSCTs, as well as a 10-years prospective analysis of a wide cohort of patients with diagnosis of IMSCTs who underwent surgical resection at our institution. RESULTS: Our series encompasses 60 patients with IMSCTS, among which 36 ependymomas, 6 cavernous angiomas, 5 hemangioblastomas, 6 WHO Grade I-IV astrocytomas, 3 intramedullary spinal metastases and 4 miscellaneous tumors. GTR was achieved in 76,67% of patients, with high preoperative McCormick grade, syringomyelia and changes at neurophysiologic monitoring being the strongest predictors at multivariate analysis (P = 0.0027, P = 0.0017 and P = 0.001 respectively). CONCLUSIONS: Consistently with literature, preoperative neurologic function is the most important factor predicting long-term functional outcome (0.17, CI 0.069-0.57 with P = 0.0018), advocating for early surgery in the management of IMSCTs, whereas late complications such as myelopathy and neuropathic pain were present regardless of preoperative function.
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Supervivencia sin Progresión , Neoplasias de la Médula Espinal , Humanos , Neoplasias de la Médula Espinal/cirugía , Neoplasias de la Médula Espinal/mortalidad , Masculino , Femenino , Persona de Mediana Edad , Adulto , Anciano , Adulto Joven , Estudios de Cohortes , Adolescente , Ependimoma/cirugía , Ependimoma/mortalidad , Resultado del Tratamiento , Procedimientos Neuroquirúrgicos/métodos , Hemangioblastoma/cirugía , Estudios Prospectivos , Astrocitoma/cirugía , Astrocitoma/mortalidad , Astrocitoma/patologíaRESUMEN
BACKGROUND: The prognostic value of the extent of resection in the management of Glioblastoma is a long-debated topic, recently widened by the 2022 RANO-Resect Classification, which advocates for the resection of the non-enhancing disease surrounding the main core of tumors (supramaximal resection, SUPR) to achieve additional survival benefits. We conducted a retrospective analysis to corroborate the role of SUPR by the RANO-Resect Classification in a single center, homogenous cohort of patients. METHODS: Records of patients operated for WHO-2021 Glioblastomas at our institution between 2007 and 2018 were retrospectively reviewed; volumetric data of resected lesions were computed and classified by RANO-Resect criteria. Survival and correlation analyses were conducted excluding patients below near-total resection. RESULTS: 117 patients met the inclusion criteria, encompassing 45 near-total resections (NTR), 31 complete resections (CR), and 41 SUPR. Median progression-free and overall survival were 11 and 15 months for NTR, 13 and 17 months or CR, 20 and 24 months for SUPR, respectively (p < 0.001), with inverse correlation observed between survival and FLAIR residual volume (r -0.28). SUPR was not significantly associated with larger preoperative volumes or higher rates of postoperative deficits, although it was less associated with preoperative neurological deficits (OR 3.37, p = 0.003). The impact of SUPR on OS varied between MGMT unmethylated (HR 0.606, p = 0.044) and methylated (HR 0.273, p = 0.002) patient groups. CONCLUSIONS: Results of the present study support the validity of supramaximal resection by the new RANO-Resect classification, also highlighting a possible surgical difference between tumors with methylated and unmethylated MGMT promoter.
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Neoplasias Encefálicas , Glioblastoma , Isocitrato Deshidrogenasa , Humanos , Glioblastoma/cirugía , Glioblastoma/patología , Glioblastoma/genética , Glioblastoma/mortalidad , Estudios Retrospectivos , Persona de Mediana Edad , Masculino , Neoplasias Encefálicas/cirugía , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/mortalidad , Neoplasias Encefálicas/diagnóstico por imagen , Femenino , Anciano , Adulto , Isocitrato Deshidrogenasa/genética , Procedimientos Neuroquirúrgicos/métodosRESUMEN
BACKGROUND: The operative microscope (OM) represents, to date, the standard for neurosurgical procedures. However, new technologies have been proposed during the latest years to overcome its limitations, from high-quality exoscopes to complex robotised visualisation systems. We report our preliminary experience with a novel digital robotised microscope, the BHS RoboticScope (RS), for minimally invasive spinal surgery. METHODS: We employed the RS in five consecutive patients who underwent bilateral lumbar spine decompression through a monolateral approach. Patient outcomes, device technical characteristics and the surgeon's personal perspectives have been evaluated. RESULTS: No complications occurred. All procedures were concluded without switching to the microscope. Image quality, lightning, depth perception and freedom of movement were judged satisfactory as compared to the standard microscope. CONCLUSION: The easy maneuverability and the high quality of pictures provided by the RS device improve the surgeon's comfort in deep fields, representing an effective option for minimally invasive spinal procedures.
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Vértebras Lumbares , Procedimientos Neuroquirúrgicos , Humanos , Vértebras Lumbares/cirugía , Procedimientos Neuroquirúrgicos/métodos , Descompresión Quirúrgica/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Chronic neuropathic pain can be severely disabling and is difficult to treat. The medial thalamus is believed to be involved in the processing of the affective-motivational dimension of pain, and lesioning of the medial thalamus has been used as a potential treatment for neuropathic pain. Within the medial thalamus, the central lateral nucleus has been considered as a target for stereotactic lesioning. OBJECTIVE: To study the safety and efficacy of central lateral thalamotomy using Gamma Knife radiosurgery (GKRS) for the treatment of neuropathic pain. METHODS: We retrospectively reviewed all patients with neuropathic pain who underwent central lateral thalamotomy using GKRS. We report on patient outcomes, including changes in pain scores using the Numeric Pain Rating Scale and Barrow Neurological Institute pain intensity score, and adverse events. RESULTS: Twenty-one patients underwent central lateral thalamotomy using GKRS between 2014 and 2021. Meaningful pain reduction occurred in 12 patients (57%) after a median period of 3 months and persisted in 7 patients (33%) at the last follow-up (the median follow-up was 28 months). Rates of pain reduction at 1, 2, 3, and 5 years were 48%, 48%, 19%, and 19%, respectively. Meaningful pain reduction occurred more frequently in patients with trigeminal deafferentation pain compared with all other patients (P = .009). No patient had treatment-related adverse events. CONCLUSION: Central lateral thalamotomy using GKRS is remarkably safe. Pain reduction after this procedure occurs in a subset of patients and is more frequent in those with trigeminal deafferentation pain; however, pain recurs frequently over time.
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Causalgia , Radiocirugia , Neuralgia del Trigémino , Humanos , Estudios Retrospectivos , Resultado del Tratamiento , Estudios de Seguimiento , Radiocirugia/métodos , Causalgia/etiología , Causalgia/cirugía , Tálamo/cirugía , Neuralgia del Trigémino/cirugía , Dolor/cirugíaRESUMEN
BACKGROUND: Surgical treatment of dumbbell jugular foramen schwannomas can be challenging. The main goals of surgery are maximal resection with preservation of function and overall patient quality of life. METHODS: In this paper, we present a step-by-step technical description of a microsurgical resection of dumbbell-shaped JF schwannoma using a modified retrosigmoid infra-jugular approach. CONCLUSION: The modified retrosigmoid infra-jugular is a safe and suitable approach in selected cases. This technique, however, must be limited only to those tumors with minimal extension into the jugular foramen.
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Foramina Yugular , Neurilemoma , Humanos , Foramina Yugular/diagnóstico por imagen , Foramina Yugular/cirugía , Calidad de Vida , Procedimientos Neuroquirúrgicos/métodos , Microcirugia/métodos , Neurilemoma/diagnóstico por imagen , Neurilemoma/cirugía , Neurilemoma/patologíaRESUMEN
OBJECTIVE: The study aimed at evaluating the efficacy and the ability of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) to predict functional outcomes in intramedullary spinal cord tumor (IMSCT) surgery. METHODS: Between December 2011 and December 2020, all patients harboring IMSCT who underwent surgery at our institution were prospectively collected in a surgical spinal registry and retrospectively analyzed. Patient charts and surgical and histological reports were analyzed. The multimodal IONM included SSEPs, MEPs, and-whenever possible-D-waves. All patients were evaluated using the modified McCormick and Frankel grade at admission and 3, 6, and 12 months of follow-up. RESULTS: Sixty-four patients were enrolled in the study. SSEP and MEP monitoring was performed in all patients. The D-wave was not recordable in seven patients (11%). Significant IONM changes (at least one evoked potential modality) were registered in 26 (41%) of the 64 patients. In five cases (8%) where the SSEPs and MEPs lost and the D-wave permanently dropped by about 50%, patients experienced a permanent deterioration of their neurological status. Multimodal IONM (SSEP, MEP, and D-wave neuromonitoring) significantly predicted postoperative deficits (p = 0.0001), with a sensitivity of 100.00% and a specificity of 95.65%. However, D-waves demonstrated significantly higher sensitivity (100%) than MEPs (62.5%) and SSEPs (71.42%) alone. These tests' specificities were 85.10%, 13.89%, and 17.39%, respectively. Comparing the area under ROC curves (AUCs) of these evoked potentials in 53 patients (where all three modalities of IONM were registered) using the pairwise t-test, D-wave monitoring appeared to have higher accuracy and ability to predict postoperative deficits with strong statistical significance compared with MEP and SSEP alone (0.992 vs. 0.798 vs. 0.542; p = 0.018 and p < 0.001). CONCLUSION: The use of multimodal IONM showed a statistically significant greater ability to predict postoperative deficits compared with SSEP, MEP, and D-wave monitoring alone. D-wave recording significantly increased the accuracy and clinical value of neurophysiological monitoring in IMSCT tumor resection.
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During the Greco-Italian War (World War II [WWII], 1940-1941), an Italian field hospital was set up in Sinanaj, Albania. The hospital's military surgeons carefully collected information about the characteristics and management of patients with war-related injuries. In 1942, they published a detailed report, with a section dedicated to the management of war-related head injuries. The aim of this report is to analyze that section, to describe the characteristics and neurosurgical management of war-related head injuries, and to depict the status of war neurosurgery in the Royal Italian Army during WWII. The analysis revealed that, during the Greco-Italian War (November 1940-April 1941), 149 patients with war-related head injuries were admitted to the Sinanaj hospital, and 48 patients underwent surgery. Head injuries were caused by bomb fragments in 126 patients, bullets in 5 patients, and other causes (falls from height, vehicle accidents, or rock fragments) in 18 patients. Six patients (12.5%) died after surgery. Before surgery, patients underwent resuscitation with blood transfusions and fluid. Preoperatively, a plain head radiograph was usually acquired to locate metallic and bone fragments. The surgical technique consisted of craniotomy or craniectomy, aggressive debridement of metallic and bone fragments, and watertight dural closure. Surgical drainage, overall aseptic technique, serial spinal taps, and perioperative antibiotics were used to prevent infections. The surgical aims and technique used by the Italian surgeons for the management of head injuries were similar to those of the Allied surgeons during WWII. Operative mortality was also comparable. Although the surgical technique for war-related head injuries has evolved since WWII, many aspects of the technique used by the Italian and Allied surgeons during WWII are still in the standard of care today.
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Traumatismos Craneocerebrales , Medicina Militar , Neurocirugia , Heridas Relacionadas con la Guerra , Albania , Traumatismos Craneocerebrales/etiología , Traumatismos Craneocerebrales/cirugía , Humanos , Italia , Unidades Móviles de Salud , Neurocirugia/historia , Heridas Relacionadas con la Guerra/complicaciones , Segunda Guerra MundialRESUMEN
BACKGROUND: Surgical resection represents the mainstay of treatment in skull base meningiomas (SBMs). Considering the high recurrence rate reported, an adjuvant radiation therapy (RT) treatment should be considered. The aim of this study was to evaluate the progression-free survival (PFS), overall survival (OS), and prognostic factors conditioning outcome. METHODS: Patients receiving surgical resection for grade I SBMs were included. The extent of resection (EOR) was dichotomized as gross total resection (GTR) and subtotal resection (STR). RT was administered only in patients receiving STR. Clinical outcome was evaluated by brain magnetic resonance imaging (MRI) performed every 6 months for the first year and yearly thereafter. RESULTS: From January 2000 to December 2015, 123 patients were treated. The majority were females (70.7%), with a Karnofsky Performance Score (KPS) ≥80 (95%), and symptoms at diagnosis (91%). GTR was performed in 30% of cases and STR in 70%. RT was performed in 18 (20.9%) patients at diagnosis and in 29 (33.7%) patients at progression. Improvement or stability of neurologic status was obtained in 78.9% of patients. The median follow-up time was 91 months (range: 40-230 months). Local recurrence occurred in 34 (27.6%) patients at a median time of 45 months (range: 6-214 months). The median, 2-, 5-, and 10-year PFS were 193 months, 89.3, 81.8, and 72.5%, respectively. On univariate and multivariate analyses, factors impacting on PFS were EOR, tumor location, neurologic postoperative status, and adjuvant RT in STR. CONCLUSIONS: A safe surgical resection followed by RT adjuvant treatment could represent the better choice to obtain local control maintaining neurologic integrity. Our data underlined the value of adjuvant RT in incompletely resected meningiomas.
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Neoplasias Meníngeas , Meningioma , Neoplasias de la Base del Cráneo , Femenino , Humanos , Niño , Masculino , Meningioma/diagnóstico por imagen , Meningioma/radioterapia , Meningioma/cirugía , Pronóstico , Estudios Retrospectivos , Neoplasias de la Base del Cráneo/diagnóstico por imagen , Neoplasias de la Base del Cráneo/radioterapia , Neoplasias de la Base del Cráneo/cirugía , Base del Cráneo/patología , Neoplasias Meníngeas/diagnóstico por imagen , Neoplasias Meníngeas/radioterapia , Neoplasias Meníngeas/cirugía , Resultado del TratamientoRESUMEN
Medial thalamotomy using stereotactic radiosurgery (SRS) is a potential treatment for intractable pain. However, the ideal treatment parameters and expected outcomes from this procedure remain unclear. The aim of this systematic review is to provide further insights on medial thalamotomy using SRS, specifically for intractable pain. A systematic review was performed to identify all clinical articles discussing medial thalamotomy using SRS for intractable pain. Only studies in which SRS was used to target the medial thalamus for pain were included. For centers with multiple publications, care was taken to avoid recounting individual patients. The literature review revealed six studies describing outcomes of medial thalamotomy using SRS for a total of 125 patients (118 included in the outcome analysis). Fifty-two patients were treated for cancer pain across three studies, whereas five studies included 73 patients who were treated for nonmalignant pain. The individual studies demonstrated initial meaningful pain reduction in 43.3-100% of patients, with an aggregate initial meaningful pain reduction in 65 patients (55%) following SRS medial thalamotomy. This effect persisted in 45 patients (38%) at the last follow-up. Adverse events were observed in six patients (5%), which were related to radiation in five patients (4%). Medial thalamotomy using SRS is effective for select patients with treatment-resistant pain and is remarkably safe when modern radiation delivery platforms are used. More posteriorly placed lesions within the medial thalamus were associated with better pain relief. More studies are warranted to shed light on differences in patient responses.
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Dolor en Cáncer , Dolor Intratable , Radiocirugia , Humanos , Dolor Intratable/cirugía , Estudios Retrospectivos , Tálamo/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Cranioplasty is a surgical intervention aiming to re-establish the integrity of skull defects. Autologous bone and different heterologous materials are used for this purpose, with various reported related complications. The aim of the study was to evaluate the complication rate in a multicentric cohort of patients underwent porous hydroxyapatite (PHA) cranioplasty implantation and to assess the validity of company post-market clinical analysis. METHODS: Authors analyzed a company-based register of 6279 PHA cranioplasty implanted all over the world. In these adult patients only self-reported complications were available. We then obtained the data of adult patients treated with custom-made porous HA prostheses (CustomBone Service) in 20 institutions from different European countries through an on-site interview with the physicians in charge of the patients (N.=494). The endpoints were the incidence of adverse events and of related implant removal. RESULTS: The groups of patients had similar demographics characteristics. The average follow-up was 26.7 months. A significantly higher number of complications was recorded in the group of patients underwent on-site interview. Thirty-nine complications were reported (7.89%) with an explantation rate of 4.25% (21 cases) in the series, compared to the data reported from the Company (complications rate of 3.3% and explantation rate of 3.1%). The most common complications were infection (4.86%), hematomas (1.22%), fractures (1.01%), mobilization (0.4%) and scar retraction (0.4%). CONCLUSIONS: Our data confirm that porous HA cranioplasty is at least as effective as other heterologous materials to repair cranial defects. Another interesting finding is that self-reporting complications by surgeons does not give a precise picture of the real rate of complications of the devices. These data in future studies need to be re-confirmed with on-site interviews.
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Durapatita , Procedimientos de Cirugía Plástica , Adulto , Durapatita/uso terapéutico , Estudios de Seguimiento , Humanos , Porosidad , Complicaciones Posoperatorias/etiología , Prótesis e Implantes , Procedimientos de Cirugía Plástica/efectos adversos , Estudios Retrospectivos , Autoinforme , Cráneo/cirugíaRESUMEN
BACKGROUND: An appreciation for complex three-dimensional relationships in neuroanatomy forms a fundamental tenet of neurosurgical education. The value of experience in the cadaver lab is indisputable; however, it is expensive and often inaccessible. The wide availability of 3D technologies has opened new possibilities, although scientific inaccuracy has hitherto limited their use. OBJECTIVE: In the present study, we aim to describe a novel, literature-based process of scientific 3D modeling for the creation of neuroanatomical models adapted for mobile technology. METHODS: A systematic literature review regarding current resources in neuroanatomy education was performed according to PRISMA guidelines. The composition of the team and the workflow behind the 3D Head Atlas app are also described. RESULTS: A total of 101 manuscripts were reviewed, and 24 included. Cadaveric dissections improve the learning process, although high costs limit their availability. Digital advancements have partially overcome the limitations of dissection, and have been associated with improved knowledge retention. Nevertheless, 3D models are often inaccurate, poorly adapted to mobile hardware, and expensive. Recent technological advances provide a new way to widely disseminate complex 3D models, with a revolutionary impact on learning. The approach behind the 3D Head Atlas app, based on the synergistic work of scientific and development teams, facilitates the creation of interactive 3D scientific material with high accuracy and wide accessibility. CONCLUSION: The study of neuroanatomy is intimately related to the evolution of digital technology. Traditional methods (i.e. cadaveric dissections) have undisputed value but high costs. High-fidelity 3D scenarios and mobile devices may revolutionize learning if based on a sound evidence-based approach.
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Neuroanatomía/educación , Neurocirugia/educación , Cadáver , Disección , Humanos , Modelos NeurológicosRESUMEN
OBJECTIVE: Trigeminal neuralgia (TN) in patients with multiple sclerosis (MS) is a challenging condition to manage that is treated with Gamma Knife radiosurgery (GKRS). The aim of this report is to assess the safety, efficacy, and durability of GKRS for the treatment of TN in patients with MS. Our findings are compared with those of the existing literature and discussed. METHODS: We retrospectively reviewed all patients at our institution who underwent GKRS for the treatment of TN secondary to MS and had 1 or more years of follow-up. Preoperative and postoperative pain intensities and facial numbness were evaluated with the Barrow Neurological Institute scores. Durability of successful pain relief was statistically evaluated with Kaplan-Meier analysis. The prognostic role of perioperative factors was investigated and analyzed using Cox proportional hazards regression. RESULTS: There were 29 patients with MS-TN who underwent GKRS at our institution. Two patients underwent bilateral treatment. Four patients underwent repeat GKRS for pain recurrence. The median period of follow-up assessment was 33 months. Rates of reasonable pain reduction at 1, 3, and 5 years were 70%, 57%, and 57% respectively. All patients who underwent repeat GKRS had durable pain reduction. No prognostic factor for successful pain reduction was found. CONCLUSIONS: Our study shows that GKRS for the treatment of TN secondary to MS is a safe and effective procedure in controlling pain in the short term but often fails to provide long-term pain control. GKRS can be safely repeated to prolong the time of pain reduction.
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Esclerosis Múltiple/complicaciones , Manejo del Dolor/métodos , Radiocirugia/métodos , Neuralgia del Trigémino/cirugía , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Neuralgia del Trigémino/etiologíaRESUMEN
INTRODUCTION: Acromegaly is commonly complicated by arthropathy and skeletal fragility with high risk of vertebral fractures (VFs). OBJECTIVE: This study aimed to assess whether VFs may be associated with sagittal spine deformities, arthropathy, impaired quality of life (QoL), pain, and disability. METHODS: Thirty-eight patients with acromegaly (median age: 55 years, 20 males) and 38 matched control subjects were evaluated by a low-dose sagittal and coronal planes, X-ray imaging system (EOS®-2D/3D) for morphometric VFs, radiological signs of spine arthropathy, and spine deformities (Cobb thoracic index ≥40°, pelvic incidence minus lumbar lordosis ≥10°, pelvic tilt >20°, and sagittal vertical axis ≥4 cm) determining sagittal spine imbalance. Acromegalic patients were also evaluated by questionnaires for QoL (Acromegaly QoL Questionnaire [AcroQoL] and Short Form-36 [SF-36]) and pain and disability (Western Ontario and McMaster University [WOMAC]). RESULTS: Acromegalic patients showed higher prevalence of thoracic hyperkyphosis (i.e., Cobb thoracic index ≥40°; p = 0.04) and pelvic tilt >20° (p = 0.02) than control subjects. VFs were found in 34.2% of acromegalic patients (p = 0.003 vs. control subjects), in relationship with higher prevalence of hyperkyphosis (p = 0.03), pelvic tilt >20° (p = 0.04), sagittal vertical axis ≥4 cm (p = 0.03), and moderate/severe subchondral degeneration (p = 0.01). Moreover, patients with VFs had lower AcroQoL general health (p = 0.007) and SF-36 general health (p = 0.002) scores and higher WOMAC pain (p = 0.003) and global (p = 0.009) scores than patients who did not fracture. CONCLUSIONS: In acromegaly, VFs may be associated with spine deformities and sagittal imbalance, spine arthropathy, impaired QoL, and disability.
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Acromegalia/diagnóstico por imagen , Imagenología Tridimensional , Artropatías/diagnóstico por imagen , Calidad de Vida , Fracturas de la Columna Vertebral/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Acromegalia/complicaciones , Acromegalia/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Artropatías/etiología , Artropatías/patología , Masculino , Persona de Mediana Edad , Fracturas de la Columna Vertebral/etiología , Fracturas de la Columna Vertebral/patología , Adulto JovenRESUMEN
BACKGROUND: The standard of care for elderly, newly-diagnosed glioblastoma patients consists, if feasible, of surgical resection followed by a short course of radiation therapy (RT) with concomitant and adjuvant temozolomide chemotherapy (TMZCHT). To date, the literature lacks of consistence in the definition of elderly, if older than 65 years, or 70 years. Aim of this study was to explore whether differences exist between these two cohorts, comparing outcomes using a propensity score matched analysis (PSM). MATERIALS AND METHODS: Two hundred twenty-one elderly newly diagnosed glioblastoma patients were included. All patients received surgery followed by RT with concurrent and adjuvant TMZCHT. The RT dose prescribed was 60 Gy/30 fractions for patients 65-69-year-old or 40.5 Gy/15 fractions for ≥70-year-old. After 1:1 matching there were 86 patients in each group. Distribution of covariates was adequately balanced in the matched data set. RESULTS: After PSM median PFS time, 1,2,3-year PFS rates were 10 months, 33.3%, 13.1%, and 6.6% for the 65-69-year group, 9 months, 34.7%, 11% and 4.8% for the ≥70-year group (p = 0.530). Median OS time, and 1,2,3-year OS rates were 14 months, 54.1%, 23.4%, 13.9% for the 65-69-year old group, and 12 months, 49.3%, 21.5%, 10% for the ≥70-year group (p = 0.357). No differences were recorded in relation to different groups of age. CONCLUSIONS: The PSM analyses showed a similar outcome in 65-69-year old patients compared to older ones notwithstanding a more burdensome RT schedule. Hypofractionated RT treatment has to be considered also in this group of younger elderly, newly-diagnosed GBM patients.
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Neoplasias Encefálicas , Glioblastoma , Anciano , Antineoplásicos Alquilantes/uso terapéutico , Neoplasias Encefálicas/tratamiento farmacológico , Estudios de Casos y Controles , Glioblastoma/tratamiento farmacológico , Humanos , Puntaje de PropensiónRESUMEN
OBJECTIVE: Anaplastic gliomas (AGs) are an extremely heterogeneous group of primary brain tumors. More recently, new discoveries have indicated that isocitrate dehydrogenase (IDH) mutation status is the most important parameter predicting survival. The primary aim of the present analysis was to identify prognostic factors, other than IDH status, that eventually impact survival. METHODS: Patients with available clinical, imaging, and molecular profile data who were amenable to resection were evaluated. The extent of resection (EOR) was defined as gross-total resection (GTR), near-total resection (NTR), subtotal resection (STR), or partial resection (PR). Residual tumor volume (RTV) was quantified. Following surgery, patients received adjuvant chemotherapy alone, radiation therapy plus concomitant and adjuvant temozolomide (TMZ), or sequential radio-chemotherapy. Clinical outcome was evaluated by neurological examination and MRI 1 month after treatment and every 4 months thereafter. Tumor progression was defined according to the Response Assessment in Neuro-Oncology (RANO) working group. RESULTS: Among 402 patients referred to the authors' institution for AG, 142 were included in the present analysis. Eighty-eight (62%) were male and 54 (38%) were female, with a median age of 43 years (range 19-70 years). At admission, most patients had a Karnofsky Performance Scale score of 90-100 (84.5%) and were symptomatic (93.7%). Forty-eight (33.8%) patients had newly diagnosed anaplastic oligodendrogliomas (AOs), and 94 (66.2%) had anaplastic astrocytomas (AAs). Most of them had mutant IDH tumors (67.6%) and methylated O 6-methylguanine-DNA-methyltransferase (MGMT) promoter status (71.8%). GTR was performed in more than half of the patients (56.3%). RTV was detected in 83 (58.5%) patients. Following surgery, 72 (50.7%) patients received radiotherapy with concomitant and adjuvant TMZ, 48 (33.8%) received sequential radio-chemotherapy, and 22 (15.5%) received adjuvant chemotherapy alone. The median follow-up time was 40 months (range 16-146 months). The median PFS time and the 1-, 3-, and 5-year PFS rates were 35 months (95% CI 27-76) and 78.9% ± 3.4%, 49.7% ± 4.6%, and 42.7% ± 5.4%, respectively. The median OS time and the 1-, 3-, and 5-year OS rates were 91 months (95% CI 66-95) and 90.1% ± 2.5%, 70.9% ± 4.2%, and 61.8% ± 4.9%, respectively. Prognostic factors predicting survival other than molecular profile were the EOR and the RTV (p < 0.0001). Sequential radio-chemotherapy was the more effective treatment administered. CONCLUSIONS: In addition to IDH status, EOR and the RTV have proved to statistically impact survival. The pivotal role of adjuvant radiotherapy has been recorded in all AG patients, regardless of tumor features.
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BACKGROUND: Cranioplasty is a common neurosurgical procedure with the goal of restoring skull integrity. Custom-made porous hydroxyapatite prostheses have long been used for cranial reconstruction in patients with traumatic brain injury. We present a large consecutive series of 2 groups of patients undergoing cranioplasty with hydroxyapatite custom bone and compare the adverse events (AEs) between the 2 groups. METHODS: We examined a series of consecutive patients who underwent cranioplasty using custom-made porous hydroxyapatite implants following tumor resection and traumatic brain injury at a single center between March 2003 and May 2018. The implants were designed and produced according to the surgeon's specifications and based on the patient's computed tomography scan data obtained through a standardized protocol. AEs were recorded. RESULTS: Information on 38 patients with tumor and 39 patients with traumatic brain injury was collected and analyzed. A significant difference in the timing of surgery was found between the 2 groups; single-stage surgery was performed in 84% of patients in the tumor versus 8% of those in the traumatic brain injury group (P < 0.0001). The rate of AEs was not significantly different between the 2 groups (P = 0.4309) and was not related to the timing of surgery. CONCLUSIONS: Custom-made hydroxyapatite cranioplasty is a solution for cranial reconstruction in patients with cranial tumors. The low incidence of AEs in a consecutive series of patients with either trauma or tumors demonstrates that these prostheses represent a safe solution independent of the characteristics of cases.
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Lesiones Traumáticas del Encéfalo/cirugía , Neoplasias Encefálicas/cirugía , Procedimientos Neuroquirúrgicos/métodos , Procedimientos de Cirugía Plástica/métodos , Adulto , Durapatita , Femenino , Humanos , Masculino , Persona de Mediana Edad , Porosidad , Procedimientos de Cirugía Plástica/instrumentación , Resultado del TratamientoRESUMEN
INTRODUCTION: The choice of heterologous materials for cranioplasty after decompressive craniectomy is still difficult. The aim of this study is to examine the association between material of choice and related complications to suggest the best treatment option. EVIDENCE ACQUISITION: A systematic review was performed for articles reporting cranioplasty comparing the following heterologous implants: titanium, poli-methyl-methacrylate (PMMA), polyetheretherketone (PEEK) and hydroxyapatite (HA). Extracted data included implant materials and incidence of the most frequent complications. EVIDENCE SYNTHESIS: The final selection resulted in 106 papers but according to our rules only 27 studies were included in the final analysis. Among a total of 1688 custom-made prosthesis implanted, 649 were titanium (38.49%), 298 PMMA (17.56%), 233 PEEK (13.82%), and 508 were HA (30.13%). A total of 348 complications were recorded out of 1688 reported patients (20.64%). In the titanium group, 139 complications were recorded (21.42%); in the PMMA group 57 (19.26%), in the PEEK group 49 (21.03%) and in the HA group 103 (20.3%). If we examine a summary of the reported complications clearly related to cranioplasty (postoperative infections, fractures and prosthesis displacement) versus type of material in multicentric and prospective studies we can see how HA group patients have less reported infections and cranioplasty explantation after infections than PMMA, PEEK and titanium. On the contrary HA patients seem to have a higher number of prosthesis displacement again if compared with the other materials. Since these data are not derived from a statistically correct analysis they should be used only to help to differentiate the properties of the various heterologous cranioplasties. CONCLUSIONS: The ideal material for all heterologous cranioplasty has not yet been identified. The choice of material should be based on the clinical data of patients, such as the craniectomy size, presence of seizures, possibility of recovery, good long-term outcome associated with a cost analysis.