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PURPOSE: Stereotactic brain biopsies are highly efficient for diagnosing intracerebral pathologies, particularly when surgical resection is infeasible. Fluorescence-based agents such as 5-aminolevulinic acid (5-ALA) and fluorescein sodium (NaFl) can enhance diagnostic accuracy and safety, improving the visualization of lesional tissues. This meta-analysis aimed to evaluate their effect on diagnostic yield and complication rates of brain biopsies. METHODS: This study adhered to Cochrane and PRISMA guidelines. We assessed studies for diagnostic yield and complication rates. Data was analyzed using a random-effects model in RStudio. Diagnostic accuracy measures such as sensitivity and predictive values were calculated based on fluorescence visibility in biopsy samples. RESULTS: Thirty-two non-randomized studies were included, comprising 947 patients, with a mean age ranging from 37 to 77 years, and a mean sample number ranging from 1 to 15 specimens. Diagnostic yields were high: 93% for NaFl and 96% for 5-ALA. Major complications occurred in 3% of procedures with both agents, while minor complications were reported in 7% and 5% with NaFl and 5-ALA respectively. The Negative-predictive-value (NPV) of 5-ALA and NaFl were 8-11% and 60-80% respectively. NaFl demonstrates higher sensitivity and specificity at 84% and 100% compared to 5-ALA's 66%. and 85% respectively. CONCLUSION: 5-ALA and NaFl provide high diagnostic yields with acceptable safety profiles in stereotactic biopsies. NaFl showed higher sensitivity and specificity. NaFl outperforms 5ALA in terms of NPV making it more efficient for small lesions near eloquent regions or major blood vessels. The significance of these findings can be further ascertained through randomized trials.
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PURPOSE: Recent studies have investigated if the sodium fluorescein-guided (SFg) improves the extent of resection of BMs when compared to standard white light (sWL). Therefore, we aimed to assess the comparative efficacy and safety of SFg and sWL for resection of BMs. METHODS: We searched Medline, Embase, and Cochrane Library databases following Cochrane and PRISMA guidelines for studies reporting comparative data of SFg and WL resection of BMs. We pooled odds ratios (OR) with 95% confidence intervals under random effects and applied I² statistics and leave-one-out sensitivity analysis to assess heterogeneity. I² > 40% was considered significant for heterogeneity. RESULTS: Five studies involving 816 patients were included, of whom 390 underwent BMs resection with SFg and 426 with sWL, and ages ranging between 26 and 86.2 years old. Analysis revealed a statistically significant higher likelihood of complete resection in the SFg group when compared to the sWL group (OR = 2.15, 95%CI: 1.18-3.92, p = 0.01; I² = 47%). Sensitivity analysis revealed a consistent result in all five scenarios, with low heterogeneity in two of the five scenarios. Three studies reported significant improvement in OS in the SFg group, and the qualitative assessment of complications and procedure-related mortality did not provide sufficient information for conclusions. CONCLUSION: This systematic review and meta-analysis identified a higher likelihood of complete resection in the SFg group when compared to the standard sWL group. This study is the first to directly compare the impact of SFg and sWL on resection outcomes for BMs.
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BACKGROUND: Traditionally, patients undergoing craniotomy were subject to extended hospital stays for intensive monitoring and management of potential complications. However, with the evolution of surgical methods, anesthesia, and postoperative protocols, the feasibility and interest in same-day discharge (SDD) are growing. This study aimed to evaluate whether same-day discharge is a safe and feasible approach in craniotomy through a meta-analysis of the available literature. METHODS: Following PRISMA guidelines, a comprehensive search was conducted across Medline, Embase, Cochrane, and Web of Science databases from inception to December 2023. Eligible studies comprised reports in English with a minimum of 4 patients who underwent craniotomies and were discharged with same-day discharge, whether single-arm or comparative with normal discharge. Single proportion analysis with 95 % confidence interval (CI) was used to pool the studies and Odds Ratio (OR) with 95 % CI was used to measure effects in comparative analysis. A random-effects model was adopted. Endpoints included success and failure of pre-planned same-day discharge, and postoperative complications throughout the hospital stay (until discharge), these complications were further categorized into major and minor complications. Also, need for reoperation, readmission within 24 h, readmission after 24 h, and mortality. RESULTS: Seven observational studies were included. Five studies were included in the single-arm analysis, comprising data from 715 patients. Four studies comprising 731 patients were included in the comparative analysis, of whom 233 were discharged on SDD, and 498 were discharged normally. The analysis revealed a success rate of 88 % (95 % CI, 83 %-94 %), readmission to the hospital within the initial 24 h rate of 2 % (95 % CI, 1 %-2 %), readmission after 24 h rate of 1 % (95 % CI, 0 %-2 %;), total postoperative complications until discharge rate of 2 % (95 % CI, 1 %-4 %), major complications rate of 0 % (95 % CI, 0 %-0 %), minor complications rate of 2 % (95 % CI, 1 %-4 %), and mortality rate of 0 % (95 % CI, 0 %-0 %). Comparative analysis for complications and mortality showed no difference between both approaches. CONCLUSION: This systematic review and meta-analysis identified that same-day discharge in craniotomy for selected patients, as well as for tumor resection craniotomies, is highly feasible and safe, with a high success rate, low failure, and reoperation rates. Moreover, for selected patients, no evidence of harm in same-day discharge was identified when compared with normal discharge. Consequently, same-day discharge may be considered a viable option, provided appropriate selection criteria are employed.
Subject(s)
Craniotomy , Patient Discharge , Humans , Craniotomy/methods , Craniotomy/adverse effects , Patient Discharge/statistics & numerical data , Postoperative Complications/epidemiology , Length of Stay/statistics & numerical dataABSTRACT
BACKGROUND: High-grade gliomas (HGGs) present a challenge in neuro-oncology, often necessitating surgical resection for optimal management. Ultrasound holds promise in achieving better gross total resection (GTR) and improving outcomes. This meta-analysis systematically evaluates literature providing robust evidence on the use of intraoperative ultrasonography (iUSG) in HGG resection. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines a comprehensive search was made across PubMed, Embase, Cochrane, and Web of Science utilized terms related to iUSG for HGG resection. The meta-analysis examined randomized trials and observational cohort studies on iUSG-guided HGG resection. GTR, subtotal resection, and postresection complications were assessed. Statistical analysis, employing R software for a single proportion analysis with confidence intervals of 95%, I2 statistics for heterogeneity, and the instrumental variables method with restricted maximum likelihood for a random effects model. RESULTS: A total of 178 patients were included in our study. The GTR overall rate in patients with iUSG-guided resection was found to be 64% (95% confidence interval: 46%-81%). Two-dimensional ultrasound remains dominant at 80% against other options of ultrasound. Complications were reported at a 15% rate (95% confidence interval: 7%-23%). CONCLUSIONS: Our study provided robust data on the utilization of iUSG-guided resection regarding the attainment of GTR and the complications related to resection. However, challenges such as outcome heterogeneity and limited complication reporting highlight the need for further research to optimize iUSG in HGG treatment. Long-term follow-up studies on patient survival and postsurgery quality of life will complement existing literature, guiding clinical practices in managing HGG.
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Brain Neoplasms , Glioma , Humans , Brain Neoplasms/surgery , Brain Neoplasms/diagnostic imaging , Glioma/surgery , Glioma/diagnostic imaging , Neurosurgical Procedures/methods , Surgery, Computer-Assisted/methods , Ultrasonography, Interventional/methodsABSTRACT
INTRODUCTION: Numerous studies have demonstrated Fractionated Stereotactic Radiotherapy's (FSRT) effectiveness in tumor control post-resection for craniopharyngiomas. Nevertheless, past literature has presented conflicting findings particularly regarding endocrine and visual function outcomes. This study aims to elucidate FSRT's efficacy and safety for this population. METHODS: Adhering to PRISMA, a systematic review and meta-analyses was conducted. Included studies had to report the effects of FSRT for treating craniopharyngiomas in a sample greater than four patients, addressing at least one of the outcomes of interest: improvement in visual acuity or field, new-onset hypopituitarism, effectiveness, and tumor progression. Relative risk with 95% confidence intervals were used to assess the outcomes. RESULTS: After retrieving a total of 1292 studies, 10 articles met the predefined criteria and thus were finally selected, amounting to a total of 256 patients. The improvement in visual acuity was estimated at 45% (95% CI: 6-83%), while the improvement in the visual field was 22% (95% CI: 0-51%). Regarding endocrine function, the new-onset hypopituitarism rate was found to be 5% (95% CI: 0-11%). Relative to FSRT effectiveness, the pooled estimate of the complete tumor response rate was 17% (95% CI: 4-30%), and the tumor progression rate was 7% (95% CI: 1-13%). Also, a 3-year progression-free survival rate of 98% (95% CI: 95-100%) was obtained. CONCLUSION: Despite limitations and risks, FSRT shows promise as a viable therapeutic option for craniopharyngiomas, offering notable benefits for visual functions and tumor control. Further research is required to better understand the associated risks, benefits, and clinical utility.
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Craniopharyngioma , Pituitary Neoplasms , Radiosurgery , Craniopharyngioma/radiotherapy , Craniopharyngioma/surgery , Humans , Radiosurgery/methods , Radiosurgery/adverse effects , Pituitary Neoplasms/radiotherapy , Pituitary Neoplasms/surgery , Dose Fractionation, RadiationABSTRACT
BACKGROUND: Glioblastoma (GBM) is an aggressive tumor known for its poor prognosis. Despite extensive research into its molecular and clinical aspects, the current management strategies have shown limited efficacy in improving survival rate. Despite some preclinical studies exploring the combination of temozolomide (TMZ) with biguanides such as metformin (MET) and others, the potential benefits of this combination remain uncertain. The aim of this study is to evaluate the overall survival (OS) in GBM murine-models treated with a combination of TMZ + biguanide compared to those treated with TMZ alone. METHODS: We systematically searched Medline, Embase, and Lilacs databases for studies comparing TMZ + biguanide versus TMZ alone in GBM models and reporting OS data. The mean difference (MD) with 95% confidence interval and random-effects model was adopted. RESULTS: Nine studies were included in this systematic review. The meta-analysis comprised 6 studies involving 85 rat-models, with 45 subjects undergoing combined-treatment. GBM-murine models treated with TMZ + biguanide exhibited notably superior OS rates compared to those who received TMZ alone, showing an MD of 21.0 days (6.9-35.0). Within the subgroup of orthotopic models, the OS was also significantly better in combination-therapy with an MD of 23.7 days (6.5-40.9). Similarly, in the subgroup where MET was used as biguanide therapy, TMZ + MET demonstrated a significant increase in OS, with an MD of 27.4 days (6.0-48.8). In immunocompromised models, the combination-therapy also exhibited higher survival rates, with an MD of 13 days (9.4-16.6). CONCLUSIONS: This systematic review and meta-analysis provide compelling evidence regarding the beneficial effects of TMZ + biguanide in GBM models compared with TMZ alone, resulting in a significant improvement in OS.
Subject(s)
Antineoplastic Agents, Alkylating , Biguanides , Brain Neoplasms , Glioblastoma , Temozolomide , Temozolomide/therapeutic use , Glioblastoma/drug therapy , Glioblastoma/mortality , Animals , Biguanides/therapeutic use , Brain Neoplasms/drug therapy , Brain Neoplasms/mortality , Humans , Antineoplastic Agents, Alkylating/therapeutic use , Dacarbazine/analogs & derivatives , Dacarbazine/therapeutic use , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Antineoplastic Combined Chemotherapy Protocols/pharmacology , Rats , MiceABSTRACT
Meningiomas are among the most common central nervous system tumors, with an incidence that ranges from 15% to 40% of intracranial tumors. Of these, only 0.5% to 3% are intraventricular, and the rarest of them occurs in the fourth ventricle. Fourth-ventricle meningiomas originate generally fromthe choroid plexus and have no dural adhesions. Most often, they manifest in young patients, around 41 years of age, with a possible predominance in females, through intracranial hypertension and cerebellar syndromes. The treatment consists of surgical resection, which commonly presents good results due to the characteristics of the tumor. So, for better preoperative planning, the radiological differentiation of the most frequent tumors in this location is important. Themost common histologic subtypes are fibroblastic and meningothelial, both grade I according to the World Health Organization (WHO), although there are reports of tumors of grades II and III. We report a case ofmeningioma of the fourth ventricle operated in our institution, and we have conducted a literature review, through which we found that 57 cases have been reported so far, with the first one reported in 1938.
Subject(s)
Humans , Male , Adult , Fourth Ventricle/pathology , Meningioma/surgery , Meningioma/epidemiology , Meningioma/diagnostic imaging , Cerebellar Neoplasms/epidemiology , Meningioma/physiopathologyABSTRACT
Craniofaringiomas são tumores histologicamante benignos, extrínsecos ao parênquima cerebral. Visando ao controle da doença, preconiza-se, como tratamento padrão, a tentativa de ressecção completa, meticulosamente planejada com vistas a preservar as funções habituais do paciente. Outras formas de terapias podem ser utilizadas como alternativas ou comoadjuvantes à cirurgia. Considerando-se quemuitos craniofaringiomas apresentam componente cístico, a utilização de cateteres posicionados no interior do lúmen cístico para aplicação de agentes quimioterapêuticos, como o interferon alfa (IFNa), tem-se mostrado promissora. Administração intratumoral de 3 milhões de unidades de IFNa em dias alternados, totalizando doze ciclos, tem sido utilizada empiricamente. Relatamos o caso de uma paciente de 12 anos de idade, com diagnóstico de craniofaringioma de predomínio cístico, tratada no Hospital de Câncer de Barretos (HCB) utilizando a aplicação de IFNa semanalmente, que apresentou evolução favorável.
Craniopharyngiomas are histologicaly benign tumors, whose ideal brain treatment requires its complete surgical resection, while preserving most of the usual functions of the patient. Due to the complexity of the surgical procedure, related to location (surrounded by paraselar structures), it is often difficult to achieve its complete resection. Thus, alternative therapies have been reported, including the use of intracystic IFNa on alternate days. We report the case of a 12 year-old female, diagnosed with cystic craniopharyngioma, weekly treated with intracystic IFNa, for a total of 12 cycles, with favorable outcome.
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Humans , Female , Child , Interferon-alpha/administration & dosage , Craniopharyngioma/drug therapyABSTRACT
Introdução: Meduloblastoma é uma das neoplasias do Sistema Nervoso Central (SNC) mais freqüente na população infantil e de baixa incidência na população adulta. Recidivas locais são freqüentes em ambas as populações, metástase sistêmica é evento raro. Objetivos: Relatar caso de meduloblastoma de evolução pouco usual, com metástase para tórax após seis anos de quiescência e comparar dados aos da literatura. Método: Realizado levantamento de prontuário de pacientes previamente operados de meduloblastoma de fossa posterior, que tenham apresentado metástase em tórax. Os dados obtidos foram analisados e comparados aos da literatura. Relato do caso: FRS, 22 anos, operado de meduloblastoma de fossa posterior. Seis anos após o procedimento, apresentou quadro astênico e vertiginoso, sendo diagnosticada lesão em ápice de campo pulmonar esquerdo à radiografia, confirmada por Tomografia computadorizada. Submetido a toracoscopia para biopsia excisional da lesão evidenciou-se tumoração infiltrativa, aderida à pleura parietal, friável, bem vascularizada, cujo exame anátomo-patológico foi compatível com metástase de meduloblastoma. Conclusão: Na população adulta, recidivas são freqüentes , especialmente no sítio primário, seguido pela região subfrontal. Cerca de 5% das metástases do meduloblastoma são sistêmicas, em especial para tecidos ósseos (77%), sendo, portanto, evento pouco comum, mais ainda quando localizadas no tórax.