Bifocal germinomas in the pineal region and hypothalamo-neurohypophyseal axis: Primary or metastasis?

Whether bifocal germinomas (BFGs) synchronously presenting within the pineal region and the hypothalamo-neurohypophyseal axis (HNA) are primary germinomas of dual-origin remains to be elucidated. We analyzed MRI images and clinical features of 95 neurohypophyseal germinomas and 21 BFG patients and developed a tentative definition of the BFGs. We found dual-primary BFGs (true BFGs) do exist. The fundamental difference between primary and metastatic HNA germinomas was the direction of tumor growth. For a true BFG, the primary HNA tumor grew from the neurohypophysis toward the hypothalamus and almost invaded the whole pituitary stalk. For a false BFG (primary pineal germinoma with HNA metastasis), the metastatic HNA tumor first appeared at the third ventricular floor (TVF), grew toward the neurohypophysis, but commonly did not invade the inferior pituitary stalk. Compared to false BFGs, true BFGs commonly had diabetes insipidus as the first symptom, dysfunction of the anterior pituitary, no high-intensity MRI signal at the posterior pituitary, a larger extension of the HNA tumor, and fewer numbers of remote lesions from cerebrospinal fluid seeding. Accordingly, 12.8% (12/96) of our germinoma patients had true BFGs, and of these, 58.3% (7/12) were free of remote metastases and warranted treatment with limited radiotherapy. True BFGs with remote metastases and all false BFGs should be treated with craniospinal irradiation. We provided evidence for the diagnosis of true BFGs that is useful for radiotherapy strategy, suggesting that the existence of metastasis to other locations is not a diagnostic criterion for a true BFG.

A radiopathological classification of dural tail sign of meningiomas.

OBJECT: The completeness of meningioma resection depends on the resection of dura mater invaded by the tumor. The pathological changes of the dura around the tumor can be interpreted by evaluating the dural tail sign (DTS) on MRI studies. The goal of this study was to clarify the pathological characteristics of the DTSs, propose a classification based on the histopathological and radiological correlation, and identify the invasive range of tumor cells in different types of DTS. METHODS: The authors retrospectively reviewed 179 patients with convexity meningiomas who underwent Simpson Grade I resection. All patients underwent an enhanced MRI examination preoperatively. The convexity meningiomas were dichotomized into various subtypes in accordance with the 2007 WHO classification of tumors of the CNS, and the DTS was identified based on the Goldsher criteria. The range of resection of the involved dura was 3 cm from the base of the tumor, which corresponded with the length of DTS on MRI studies. Histopathological examination of dura at 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0 cm from the base of the tumor was conducted, and the findings were correlated with the preoperative MRI appearance of the DTS. RESULTS: A total of 154 (86%) of 179 convexity meningiomas were classified into WHO Grade I subtype, including transitional (44 [28.6%] of 154), meningothelial (36 [23.4%] of 154), fibrous (23 [14.9%] of 154), psammomatous (22 [14.3%] of 154), secretory (10 [6.5%] of 154), and angiomatous (19 [12.3%] of 154). The other 25 (14%) were non-Grade I (WHO) tumors, including atypical (12 [48%] of 25), anaplastic (5 [20%] of 25), and papillary (8 [32%] of 25). The DTS was classified into 5 types: smooth (16 [8.9%] of 179), nodular (36 [20.1%] of 179), mixed (57 [31.8%] of 179), symmetrical multipolar (15 [8.4%] of 179), and asymmetrical multipolar (55 [30.7%] of 179). There was a significant difference in distribution of DTS type between Grade I and non-Grade I tumors (p = 0.004), whereas the difference was not significant among Grade I tumors (0.841) or among non-Grade I tumors (p = 0.818). All smooth-type DTSs were encountered in Grade I tumors, and the mixed DTS (52 [33.8%] of 154) was the most common type in these tumors. Nodular-type DTS was more commonly seen in non-Grade I tumors (12 [48%] of 25). Tumor invasion was found in 88.3% (158 of 179) of convexity meningiomas, of which the range of invasion in 82.3% (130 of 158) was within 2 cm and that in 94.9% (150 of 158) was within 2.5 cm. The incidence of invasion and the range invaded by tumor cells varied in different types of DTS, and differences were statistically significant (p < 0.001). CONCLUSIONS: Nodular-type DTS on MRI studies might be associated with non-Grade I tumors. The range of dural resection for convexity meningiomas should be 2.5 cm from the tumor base, and if this extent of resection is not feasible, the type of DTS should be considered. However, for skull base meningiomas, in which mostly Simpson Grade II resection is achieved, the use of this classification should be further validated. The classification of DTS enables the surgeon to predict preoperatively and then to achieve the optimal range of dural resection that might significantly reduce the recurrence rate of meningiomas.

[Pathological features and origin of primary pineal mixed germ cell tumors].

OBJECTIVE: To investigate the origin of mixed germ cell tumors in the pineal region based on the image data, surgical findings and pathological examination of the tumor. METHODS: The preoperative CT and magnetic resonance imaging (MRI) findings and tumor specimens were retrospectively analyzed in 15 cases of pineal mixed germ cell tumors confirmed by postoperative histological examination between January 2000 and September 2010. RESULTS: Radiographic examination of the tumor revealed calcification in 12 cases, cystic changes in 10 cases, and the presence of lipid in 5 cases. On the anteroposterior images, the tumors appeared round or elliptic with smooth edge in 6 cases, and showed irregular shape with multiple processes on the edge in 9 cases. Surgical exploration found all the tumors located in the the suprapineal recess enclosed by the arachnoidal envelope of the Galen vein. Pathologically, 13 specimens contained germinoma component, 9 contained teratoma component, 4 had embryonic carcinoma component, 3 had choriocarcinoma component, 7 showed yolk sac tumor component, and 3 showed rhabdomyoma component. Germinoma components were found on the tumor margin in 7 specimens, and intermingled germinoma and other components were found in 10 specimens. CONCLUSION: Pineal mixed germ cell tumor originates from the residue germ cells around the pineal gland, and most likely evolves from single primordial germ cells.

[Clinical study of pineal region tumors: experience with 132 patients].

OBJECTIVE: To review the clinical manifestations, imaging, tumor markers, treatment methods, pathology results and clinical curative effects of pineal region tumors and to evaluate the characteristics and intervention strategies for those tumors. METHODS: The clinicopathological data of 132 patients with pineal region tumor treated in our department between January 2000 and May 2008 were retrospectively studied. RESULTS: A moderate predominance in males was presented. The clinical manifestations of the disease included increased intracranial pressure and ocular movement impairment. There were some features but no regularity and specific appearance on imaging including CT and MRI. 88.6% of patients associated with hydrocephalus. A high serum level of alpha-fetoprotein (AFP) was presented in 14 cases and high HCG in 9 cases. Eighteen cases received direct radiation therapy and 7 had radiotherapy post biopsy. 107 cases were treated surgically and 63 cases received postoperative adjuvant treatment. 114 cases had pathology results including 56 germ cell tumors. The patients were followed up for 12 approximately 132 months. Recurrence developed in 23 cases and 12 cases died. The 5-year survival rate was 89.3%. CONCLUSION: Pineal region tumors are often associated with hydrocephalus and this makes preoperative diagnosis difficult. Imaging examination may help diagnosis but less specific. Germ cell tumors may diagnosed by some tumor markers. Radiation therapy is the choice of treatment for pure germinomas. Other types of pineal region tumors should receive surgical treatment. Postoperative adjuvant treatment based on pathology can provide a good prognosis in pineal region tumor.

[Dynamic changes of serum interleukin-6 and interleukin-8 in patients with acute traumatic brain injury and the clinical significance].

OBJECTIVE: To explore the dynamic changes of serum interleukin-6 (IL-6) and IL-8 in acute traumatic brain injury (TBI) and their correlations to the severity of brain injury and the condition of the patients. METHODS: Thirty-four patients with acute TBI were divided into two groups according to the Glasgow Coma Scale (GCS) score, clinical manifestations and the imaging data, namely patients with GCS score < or = 8 and those with GCS score between 9 and 12. Radioimmunoassay was employed to determine the serum levels of IL-6 and IL-8 at 6 different time points within 15 days after the injury in the two groups. RESULTS: The serum IL-6 reached the peak level on the second day after the injury in patients with GCS score < or = 8 and on the 7th day in patients with GCS score of 9-12, showing significant differences in IL-6 variations between the two groups (P=0.046). The peak serum level of IL-8 occurred on the 7th day in patients with GCS score < or = 8 and on the 3rd day in patients with GCS score of 9-12, also showing significant differences (P=0.045). The peak level of IL-6 on the second day after the injury was significantly higher than the peak level of IL-8 that occurred on the 7th day, demonstrating significant differences in the variations of IL-6 and IL-8 after the injury (P=0.000). CONCLUSION: The changes of serum IL-6 and IL-8 levels show positive correlations to the severity of the condition of the patients sustaining TBI. IL-6 variation is more obvious than that of IL-8 without intimate correlations between them. Clinically, serum IL-6 level can be more informative than serum IL-8 level in evaluating the changes of the condition of the TBI patients in early stage following the injury.

[Analysis of the factors contributing to diabetes insipidus after surgeries for craniopharyngiomas].

OBJECTIVE: To analyze the factors contributing to the occurrence of diabetes insipidus after operations for craniopharyngiomas. METHODS: A total of 121 cases of diabetes insipidus following surgeries for craniopharyngiomas were retrospectively analyzed and the factors associated with postoperative diabetes insipidus were analyzed. RESULTS: The incidence of diabetes insipidus was 27.3% (33/121 cases) before the operation, 89.9% (107/1119) early after the operation and 39.8%(37/93) in later stages after the operation. The occurrence of early postoperative diabetes insipidus showed a significant relation to the classification and calcification of the craniopharyngioma. Patients with supradiaphragmatic and extraventricular tumors had the lowest incidence of postoperative diabetes insipidus. Late postoperative diabetes insipidus was closely correlated to such factors as age, classification of craniopharyngioma, and intraoperative treatment of the pituitary stalk, but not to the scope of tumor resection or tumor calcification. Late diabetes insipidus was more frequent in children and patients with severed pituitary stalk. The incidence of late postoperative diabetes insipidus was significantly higher in patients with supradiaphragmatic and extra-intraventricular tumors than in those with tumors beneath the diaphragma sellae and extraventricular tumors. CONCLUSIONS: Postoperative diabetes insipidus following surgeries for craniopharyngiomas is closely related to the tumor classification, calcification and pituitary stalk protection.

[Predisposing factors for postoperative epilepsy in patients with gliomas].

OBJECTIVE: To explore the predisposing factors for postoperative epilepsy in patients with gliomas. METHODS: A total of 258 glioma patients with complete clinical data receiving cranial surgeries were analyzed retrospectively. With gender, age, predominant symptoms, positive signs, history of preoperative epilepsy, time of epilepsy onset, tumor location, surgical approaches, cortical injury, arterial and venous injury, scope of tumor resection, postoperative edema, tumor pathology, tumor recurrence, number of operation, radiation therapy as the independent variables, the occurrence of postoperative epilepsy was analyzed as the dependent variable using logistic regression to identify the risk factors for postoperative epilepsy. RESULTS: History of preoperative epilepsy, surgical approaches, postoperative edema, tumor pathology and tumor recurrence were identified as the risk factors for postoperative epilepsy in glioma patients. CONCLUSIONS: Postoperative epilepsy severely affected the quality of life of glioma patients, and rigorous treatment targeting the risk factors may decrease the occurrence of postoperative epilepsy.

[Combined modality therapy for primary choriocarcinoma in the pineal region: report of two cases].

OBJECTIVE: We report two rare cases of primary choriocarcinoma in the pineal region verified histologically. In both cases, the pre-operative serum level of human chorionic gonadotropin (HCG) was significantly elevated to 128-/+935.7 and 9 -/+088.9 mIU/ml, respectively, and serum alpha-fetoprotein (AFP) was negative. The tumors were microsurgically removed, and postoperative hydrocephalus were treated by endoscopic third ventriculostomy. Both patients underwent chemotherapy and radiotherapy. After adjunctive treatment, the serum HCG decreased within normal range. During the two-year-long follow-up, no radiological (MRI) evidence was found to suggest recurrence in MR imaging, and the serum HCG was normal in one patient, but mildly elevated in the other. HCG measurement can be crucial to the diagnosis and post-treatment monitoring of choriocarcinoma, and radical surgical tumor removal and combined modality therapy including chemotherapy and radiotherapy may ensure good results.

[Growth of craniopharyngioma involving the third ventricular floor in relation to the hypothalamus].

OBJECTIVE: To investigate the growth of craniopharyngioma involving the third ventricular floor with regard to the hypothalamus by detecting expressions of leukocyte common antigen (CD45) and intercellular adhesion molecule (ICAM-1) in the tumor tissue. METHODS: The expressions of CD45 and ICAM-1 proteins in 30 craniopharyngioma samples with third ventricular floor involvement were detected by SP immunohistochemistry. RESULTS: The inflammations labeled by CD45 were identified commonly in the craniopharyngioma tissues involving the third ventricular floor. The expression of ICAM-1 was mainly in the inner tumor cells and interstitial cells, but not detected in the basilar tumor cells growing toward the third ventricular floor. Adamantinomatous craniopharyngiomas showed markedly higher CD45 and ICAM-1 expressions than squamous papillary tumors (P<0.05). CONCLUSION: Inflammatory adhesion largely characterizes the growth of the craniopharyngioma tissues involving the third ventricular floor toward the hypothalamus without the tendency of invasion. The difference in the inflammation between the two types of craniopharyngioma may affect the prognosis of the patients.

Radical microsurgical treatment of intramedullary spinal cord tumors.

BACKGROUND: The surgical treatment of intramedullary spinal cord tumor aims at complete removal and minimal postoperative deficit. This study was undertaken to evaluate the microsurgical features of intramedullary spinal cord tumors and the time for surgery and prognosis. METHODS: Twenty-one patients with intramedullary spinal cord tumor who had been treated at Nanfang Hospital, Guangzhou, China since 2000 were studied retrospectively. Fifteen patients were men and 6 women, aged 2 - 60 years (mean 29.28 years). Thirteen patients had the tumor in the cervical segments, 4 in medulla-cervical segments, 1 in cervicothoracic segment, and 3 in thoracic spine. All the patients underwent microsurgery for the tumor through posterior approaches by laminectomy. The tumor was exposed through dorsal myelotomy, then tumor plane was removed carefully from the entire rostrocaudal area. The dura was sutured routinely. In case of tumors occupying too many spinal segments, titanium strip was applied to reconstruct the vertebral plate and keep the spinal column stable. All the patients were subjected to MR imaging early after operation. RESULTS: Complete removal of the tumor was made in 15 patients, subtotal removal in 5, and partial resection in 1. Neurological recovery was related primarily to preoperative neurological conditions of the patients. Patients with minor neurological deficit showed stable sensory and motor function or minor loss in the early postoperative period, and neurological function tended to improve with time. But those with significant or long-standing deficit could hardly demonstrate any recovery. The dissection interface between the tumor and normal cord tissue was the most important factor influencing the extent of surgical removal. CONCLUSIONS: Intramedullary spinal cord tumor mostly take place in cervical segments, with glioma as the commonest type. Microsurgery is the major treatment of choice, by which tumor plane could be totally resected. Excellent microsurgical expertise and careful recognition of tumor plane are essential to removal of the tumor while retaining neurological functions. Titanium strip fixation is helpful to reconstruct vertebral stability. Preoperative neurological conditions of patients are directly related to their postoperative recovery. We underscore the importance of early diagnosis and radical microsurgical treatment of intramedullary spinal cord tumor.

Association of epileptiform activity with neuronal death in the CA3 subfield of the hippocampus following focally evoked limbic seizures.

OBJECTIVE: To investigate the relationnship between epileptiform activity and cell death in the CA3 subfield of hippocampus following focally evoked limbic seizures through a quantitative study. METHODS: Wistar rats used in this study received intra-amygdaloid injection of kainic acid to induce type epileptiform activity of different duration with continuous electroencephalographic (EEG) monitoring. Terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) was used to detect apoptotic cells. The number of CA3 neurons survived and TUNEL-positive cells were counted to estimate the number of necrotic cells. RESULTS: Epileptiform activity induced necrosis in the major form of apoptosis of the cells in CA3 subfield of the hippocampus following focally evoked limbic seizures. The longer the type epileptiform activity lasted, the less neurons survived, with consequent increase in the number of both necrotic and apoptotic cells. CONCLUSION: Prolongation of type IV seizures dose-dependently causes increase in apoptotic and necrotic cells in CA3 subfield of the hippocampus.