Intra-parenchymal tumor biopsy using neuroendoscopy with navigation.

BACKGROUND AND OBJECTIVES: Neuroendoscopy has allowed us to biopsy tumors located in the ventricle and the para-ventricle. With this technique we can obtain specimens under direct visual monitoring and examine tumor dissemination. For intra-parenchymal tumors, however, we normally use stereotactic procedures to collect tissues or perform open biopsies. We now report that we have successfully combined neuroendoscopy with navigational guidance to biopsy intra-parenchymal tumors. We explain our methods and discuss the advantages and disadvantages of this technique. CASES AND METHODS: We carried out intra-parenchymal tumor biopsies or resection using neuroendoscopy and guided navigation in three patients. We advanced a transparent sheath, containing a removable inner tube on which a navigation tool was mounted, to target tissues. We directly monitored procedures with a neuroendoscope placed in the transparent sheath. We collected specimens just in front of and in the tumor by forceps. In one patient with bleeding, we used the aspirator tip as a monopolar coagulator. We were also able to check for bleeding along the sheath tract using endoscopy. Without causing any new neurological deficits, we collected tissues for histological diagnosis of astrocytoma in two patients and radiation necrosis in one. CONCLUSIONS: We believe that combining neuroendoscopy with navigation guidance is a safe and precise method for obtaining biopsies of intra-parenchymal tumors. Tumors with rich vasculature will not benefit from this procedure until better hemocoagulation instruments have been developed.

Surgical pathology of spinal schwannoma: has the nerve of its origin been preserved or already degenerated during tumor growth?

OBJECTIVE: This study was aimed to understand ultrastructural pathology of nerves of tumor origin of spinal schwannomas, which has not been reported so far, in order to understand the mechanism of the postoperative functional restoration after the nerve transection. METHODS: From 13 patients who underwent sacrifice of an affected nerve root at total removal of spinal schwannomas (C2 conus), the proximal (spinal cord side, n = 12) and distal (dorsal root ganglion side, n = 10) stumps of the nerves of the tumor origin were collected and examined by light and electron microscope, followed by morphometric analysis (n = 9). RESULTS: Almost all of affected nerves at both proximal and distal to the lesion were composed of well-preserved myelin sheath and axons with mild disturbance of endo- and perineurial structures at light microscopic level except one case, which showed severe fibrosis. Electron-microscopically, regenerated axons with thin myelin were found in part in the proximal and distal nerves with few macrophages in three cases. The area of nerves (mm2), density of myelinated axons (axons/mm2) and total number of myelinated axons in the proximal stump (0.552 +/- 0.430, 10,400 +/- 5,240 and 5,480 +/- 4,790) was approximately 70%, 80% and 60%, respectively, of those in the distal stump (0.765 +/- 0.333, 12,400 +/- 5,180 and 9,970 +/- 8,630). CONCLUSIONS: This data combined with no permanent deficits after nerve transection suggest that the nerves of tumor origin are in the processes of slowly progressed deterioration with repeated degeneration and regeneration/remyelination, and the postoperative rapid recovery from the transient neurological deficit may be explained by functional compensation by the adjacent non-affected nerves with slow tumor growth.

MRI evaluation of the diaphragmal opening: using MRI parallel to the transsphenoidal surgical approach.

Twenty-six adult diaphragma sellae and infundibulae were examined by MRI parallel to the transsphenonidal surgical plane with attention given to the diaphragmal opening. The diaphragmal opening was observed in 11 cases (42.3%). The anteroposterior diame ter of the opening ranged from 4.0 to 14.0 mm (mean 8.8 mm), and the lateral diameter ranged from 6.0 to 14.0 mm (mean 9.5 mm). In the cases of open diaphragma sellae, the infundibulum tended to be located in the posterior part of the diaphragma sellae but this was not statisticallysignificant. On MRI parallel to the transsphenoidal surgical approach, the anatomy of the dia phragma sellae was well evaluated.

Expression of E-cadherin-catenin complex in human benign schwannomas.

The Ca2+-dependent cell adhesion molecule E-cadherin has been known to express in normal and reactive Schwann cells in rodents, and to play an important role in Schwann cell-Schwann cell adhesion and maintenance of peripheral nervous tissue architecture. However, little is known about expression of E-cadherin in schwannomas. The aim of the present study was to investigate the cellular expression and localization of E-cadherin, and its associated protein, alpha E-, alpha N- and beta-catenins in human schwannomas, which are supposed to derive from Schwann cells. We tested the hypothesis that these proteins might show an altered expression/distribution in schwannoma cells which correlates with their neoplastic behavior, including sparse cell-cell contact, as seen those in meningiomas and various carcinomas. In human schwannomas, however, E-cadherin, alpha E-catenin, and beta-catenin were detected by western blotting and immunohistochemistry, whereas alpha N-catenin was not. Immunoprecipitation using anti-E-cadherin antibody resulted in alpha E-catenin forming a complex with E-cadherin. SSCP analysis revealed no mutations in the transmembrane domain or in intracellular catenin-binding site of E-cadherin. These data suggest that the E-cadherin-alpha E-catenin complex is well preserved in human schwannoma cells, which is compatible with its benign behavior, and these molecules might be used as additional cell markers of Schwann cell-derived tumors.

Contrast-enhanced fluid-attenuated inversion recovery MRI is useful to detect the CSF dissemination of glioblastoma.

We present three cases of glioblastoma with CSF dissemination that contrast-enhanced fluid-attenuated inversion recovery MRI was sensitive enough to detect compared with contrast-enhanced T1-weighted MRI. An autopsy was performed on one patient, and its histologic findings proved the existence of CSF dissemination.

Malignant transformation of a gangliocytoma/ganglioglioma into a glioblastoma multiforme: a molecular genetic analysis. Case report.

A gangliocytoma/ganglioglioma with no atypical or malignant features was subtotally resected from the right temporal lobe of a 16-year-old woman. A second resection was performed 8 years later to treat a locally recurrent lesion with increased cellularity that was diagnosed as a World Health Organization Grade II ganglioglioma on the basis of neuropathological examination. Molecular analysis of the recurrent tumor revealed a TP53 gene mutation, but no amplification of the epidermal growth factor receptor (EGFR) gene. Radiotherapy (60 Gy) was administered after the second resection. The patient returned 1 year later with a second focal recurrence. The specimen obtained during the third resection of tumor exhibited exclusively astrocytic differentiation, cellular pleomorphism with multinucleated cells, high mitotic activity, and endothelial proliferation. Therefore, the tumor was diagnosed to be a glioblastoma multiforme (GBM). Molecular analysis of tumor DNA from the second recurrent tumor demonstrated the presence of the TP53 mutation, which previously had been observed in the first recurrent tumor, but again no evidence of EGFR amplification. Findings demonstrate that the presence of TP53 mutation in progressed gangliogliomas should be interpreted as a progression-associated mutation rather than a consequence of treatment. This is the first report to indicate that the molecular pathways of gangliocytomas/gangliogliomas progressing to become GBMs may parallel those of diffuse astrocytomas progressing to become GBMs.

Homozygous deletion of INK4a/ARF genes and overexpression of bcl-2 in relation with poor prognosis in immunocompetent patients with primary central nervous system lymphoma of the diffuse large B-cell type.

Only a few reports have been published on molecular genetic alterations in primary central nervous system lymphomas (PCNSLs) of the diffuse large B-cell type and no reports have addressed the correlation between the genetic alterations and clinical course of the patients with this neoplasm. Thus, the molecular background of the PCNSL and its importance for the clinical course of the patients are still unclear. We investigated a series of 14 patients with PCNSL to determine structural alterations of the INK4a/ARF, MDM2, and TP53 genes, the status of bcl-2 and bcl-6 protein expression, and the clinical course of the patients (i.e. their survival time after diagnosis). No structural alterations of MDM2 and TP53 genes were found. Only INK4a/ARF genes whose expression affects both the p161NK4a-Rb and p14ARF-mdm2-p53 pathways in the regulation for cell cycle and apoptosis, showed an alteration of the homozygous deletions at a high frequency (nine of 14 patients: 64%). This specific alteration was not related with the bcl-6 expression, but a relation was shown with overexpression of the bcl-2 anti-apoptotic protein (p = 0.036, chi-square test), as well as a shorter patient survival (p = 0.044, Wilcoxon test). There was only a tendency, not a significant correlation, in which the patients with bcl-2 overexpression resulted in poor prognosis (p = 0.149). The present study is the first to suggest that the INK4a/ARF gene homozygous deletions and overexpression of the bcl-2 protein may be correlated with each other and together serve as important predictors for the prognosis of patients with PCNSL.

Surgical pathology of spinal schwannomas: a light and electron microscopic analysis of tumor capsules.

OBJECTIVE: Although spinal schwannomas are often encountered, the pathology of the tumor capsule has not been reported. In this study, we describe the ultrastructural pathology of the tumor capsule of spinal schwannomas. METHODS: In 18 patients who underwent total removal of spinal schwannomas (C2-conus), the tumor capsule was collected and examined by light and electron microscopy. RESULTS: The thickness of the tumor capsule ranged from 15 to 800 microm (mostly 30-100 microm) and was composed of three layers from the surface to the center: 1) a thinly stretched nerve tissue layer; 2) a fibrous layer of fibrocytes, abundant collagen fibers, and tumor vessels; and 3) a thin transitional layer intermingled with fibrous components and tumor cells. The thickness of each layer varied in different regions of the surface. There was no clear separation between the tumor capsule and the neoplastic tissue, even on the electron microscopic level. A number of nerve fibers ran through the fibrous layer and beneath the capsule as well as in the nerve tissue layer. CONCLUSION: Compared with vestibular schwannomas, which have been reported to be covered by an extremely thin layer (3-5 microm) of connective tissue, spinal schwannomas were well encapsulated. The capsule was composed of three distinct components; however, the cleavage between thin capsule and tumor cells was indistinct, and the thickness of the axon-containing capsule varied from site to site. Therefore, resection of the nerve of tumor origin, rather than enucleation, would be justified to avoid tumor recurrence. Surgeons should be aware of this pathology when performing the procedure.

Alterations of the INK4a/ARF locus in human intracranial germ cell tumors.

Little is known about the molecular mechanisms responsible for the development of intracranial germ cell tumors (ICGTs). Recently, we demonstrated that the balance of the p53-mdm2 interactions is disrupted in ICGTs. The p14ARF product, a tumor suppresser gene located on the INK4a/ARF locus, acts as one of the major factors affecting p53-mdm2 interactions via its binding to mdm2 and the stimulation of mdm2 degradation. To evaluate whether genetic alterations of the INK4a/ARF locus occur in the genesis of ICGTs, we analyzed the INK4a/ARF genes in 21 ICGTs-10 pure germinomas and 11 nongerminomatous germ cell tumors. Fifteen (71%) of the 21 ICGTs displayed genetic alterations, including 14 homozygous deletions and 1 frameshift mutation. Furthermore, the frequency of the alterations was higher in pure germinomas [9 (90%) of the 10] than in nongerminomatous germ cell tumors [6 (55%) of the 11; P = 0.09]. These data suggested that INK4a/ARF gene abnormalities could play an important role in the genesis of ICGTs, especially in pure germinoma.

Molecular analysis for p53 and mdm2 in intracranial germ cell tumors.

Intracranial germ cell tumors (ICGTs) are uncommon neoplasms. The histological appearance of ICGTs is indistinguishable from that of the usual testicular germ cell tumors (TGTs). Recently, several reports have associated molecular abnormalities of p53 and mdm2 in TGTs with their malignancies. However, whether ICGTs are associated with molecular abnormalities is still unknown. We analyzed a series of 16 ICGTs for mutations in the TP53 gene by single-strand conformation polymorphisms, and for amplification of the MDM2 gene using differential PCR. In addition, the same 16 tumors were examined for p53 and mdm2 protein overexpression using antibodies directed against p53 [monoclonal antibodies (mAb) 1801 and DO7] and mdm2 (IF2), respectively. Twelve (75%) and 2 (13%) of the 16 ICGTs reacted with DO7 and PAb1801, respectively, and 1 (6%) carried a TP53 gene mutation. Thirteen (81%) of the 16 ICGTs reacted with IF2, and 3 (19%) carried MDM2 gene amplification. The less frequent TP53 gene mutation compared with MDM2 gene amplification, and the frequently expressed p53 and mdm2 protein, are similar to the case for TGTs. It is tempting to speculate that ICGTs might have the same cellular origins as TGTs with abnormalities in p53 and mdm2, which could play an important role of tumorigenesis.

De novo spinal teratoma after treatment of an intracranial germ cell tumor.

The authors report an extremely rare case of de novo spinal teratoma after treatment for intracranial germ cell tumor. A 17-year-old male developed pain of bilateral lower extremities and urinary retention 18 months after complete remission of intracranial mixed germ cell tumor. Magnetic resonance imaging revealed a huge spinal tumor associated with spina bifida occulta. Total resection was performed, and histogenetical findings led to the diagnosis of a mature teratoma with normal p16 gene, whereas analysis of intracranial tumor showed p16 deletion. The spinal anomaly and genetic analysis strongly suggest that the spinal teratoma was a de novo tumor rather than a metastasis or dissemination of the original intracranial germ cell tumor.

Rathke cleft cyst: MR and biomedical analysis of cyst content.

PURPOSE: At least one type of Rathke cleft cyst has unique MR findings, specifically, high intensity on T1-weighted images and iso- to low intensity on T2-weighted images relative to white matter. To clarify the influence of cyst content on MR images, we analyzed the cyst content by biomedical methods after surgical removal. METHOD: We studied five patients diagnosed with Rathke cleft cyst, whose MR images showed high intensity on T1-weighted images and iso- to low intensity on T2-weighted images. After surgery, total protein and cholesterol levels were quantified, and correlations of protein and cholesterol content with T1 and T2 signal intensities were performed in vitro. RESULTS: All five cysts had very high concentrations of protein (11,700-26,600 mg/dl, mean 17,940 mg/dl) with nearly no cholesterol (at most 2.0 mg/dl). Along with increases in protein concentration in vitro, the signal intensity of T1-weighted images increased, while that of T2-weighted images decreased. In contrast, the cholesterol concentration sequence influenced the signal intensity of neither T1- nor T2-weighted images. CONCLUSION: The unique MR finding of Rathke cleft cysts--high signal intensity on T1-weighted images and low signal intensity on T2-weighted images--might depend mainly on protein concentration, not on cholesterol.

Expression of fas antigen in the normal mouse brain.

The Fas antigen (Fas/Apo-1/CD95) is a cell surface receptor protein that mediates apoptosis-inducing signals and plays an important role in the immune system. In the central nervous system, during the period of naturally occurring cell death many neurons appear to die by apoptosis. We investigated the involvement of Fas in these events. The expression of Fas transcripts and protein was examined in the juvenile mouse brain. By RT-PCR analysis, Fas mRNA was detected in the cerebrum, cerebellum, and hippocampus of the brain. By immunohistochemistry, we found Fas in neurons localized in the CA2 and CA3 sectors of the hippocampus and in the cortical III layer of the cerebrum, but not neurons in the cerebellum. Furthermore, Fas was expressed on the primary cultured hippocampal and cerebral cells using immunofluorescence and flow cytometry. These results suggest that Fas is specifically expressed on neurons in the mouse brain during postnatal development.

Necrogenesis and Fas/APO-1 (CD95) expression in primary (de novo) and secondary glioblastomas.

Glioblastomas may develop rapidly without clinical and histopathological evidence of a less malignant precursor lesion (de novo or primary glioblastoma) or through progression from low-grade or anaplastic astrocytoma (secondary glioblastoma). Primary glioblastomas typically show overexpression of EGFR, but rarely p53 mutations, while secondary glioblastomas frequently carry a p53 mutation, but usually lack overexpression of EGFR, suggesting that these glioblastoma subtypes develop through distinct genetic pathways. In the present study, we assessed the expression of Fas/APO-1 (CD95), an apoptosis-mediating cell membrane protein, and its relation to necrosis phenotype in primary and secondary glioblastomas. Large areas of ischemic necroses were observed in all 18 primary glioblastomas, but were significantly less frequent in secondary glioblastomas (10 of 19, 53%; p = 0.0004). Fas expression was predominantly observed in glioma cells surrounding large areas of necrosis and was thus significantly more frequent in primary glioblastomas (18 of 18, 100%) than in secondary glioblastomas (4 of 19, 21%; p < 0.0001), suggesting that these clinically and genetically defined subtypes of glioblastoma differ in the extent and mechanism of necrogenesis. Necrosis and microvascular proliferation are histologic hallmarks of the glioblastoma. Following incubation of glioblastoma cell lines under hypoxic/anoxic conditions for 24-48 hours, Fas mRNA levels remained unchanged, whereas VEGF expression was markedly upregulated. This suggests that in contrast to VEGF Fas expression is not induced by ischemia/hypoxia. Analysis of Fas mRNA levels in a glioblastoma cell line containing a p53 mutation and an inducible wild-type p53 gene showed little difference under induced and noninduced conditions, suggesting that in glioblastomas, Fas expression is not directly linked to the p53 status.

[An enlarging dysembryoplastic neuroepithelial tumor during a 6-year period: a case report].

A 16-year-old boy who had been found at the age of 9 years to have complex partial seizures was referred to our department by a psychiatrist for evaluation for surgical treatment of epilepsy, in 1994. A diagnosis of multiple cerebral infarction accompanied with arachnoid cyst was made when he was 11 years old, in 1988, by computed tomography (CT) and magnetic resonance imaging (MRI) findings. Results of a neurological examination on admission revealed marked mental and speech retardation. MRI and CT studies demonstrated an enlarged Sylvian fissure and a mass lesion in the left frontal lobe which was enlarged, compared to the findings of MRI in 1988. A left fronto-temporal craniotomy with excision of the frontal lesion was performed. Histological examination revealed cortical dysplasia, multi-nodular pattern, and glioneuronal components, whose findings coincide with criteria for diagnosing dysembryoplastic neuroepithelial tumors. MIB1 antibody immunostaining study revealed no positivity, but immunostaining study for PCNA (proliferation of cell nuclear antigen) revealed from 0 to 6.5% positivity in each nodule. PCNA high positivity was observed in the nodules which were composed of packed oligodendrocyte-like cells. Enlargement in the size of the lesion in our case suggests increased cell proliferation activity during a 6-year period.

Fas ligand expression in glioblastoma cell lines and primary astrocytic brain tumors.

Fas/APO-1 (CD95) is a cell surface receptor that mediates apoptosis when it reacts with Fas ligand (FasL) or Fas antibody. We previously reported that Fas expression is predominantly induced in perinecrotic glioma cells, suggesting that Fas induction is associated with apoptosis and necrosis formation, a histological hallmark of glioblastomas. In this study, we assessed the expression of FasL in 10 glioblastoma cell lines and in 14 astrocytic brain tumors (three low-grade astrocytomas and 11 glioblastomas). Reverse transcriptase (RT)-PCR revealed that all glioblastoma cell lines and primary astrocytic brain tumors express FasL. Immunohistochemically, FasL was predominantly expressed on the plasma membrane of glioma cells. These results suggest that FasL expression is common in human astrocytic brain tumors and may cause apoptosis of glioma cells if Fas expression is induced.