Tumor size, treatment patterns, and survival in neuro-oncology patients before and during the COVID-19 pandemic.

The COVID-19 pandemic has disrupted healthcare delivery worldwide, leading to significant delays in cancer diagnosis and treatment. This study aimed to investigate the impact of the pandemic on the diagnosis and treatment of malignant brain tumors, specifically glioblastoma (GBM) and cerebral metastasis (CM), in a specialized neuro-oncology center. We analyzed data from 236 patients diagnosed with previously unknown malignant brain tumors between January 2018 and December 2021. Patients were classified into two groups: pre-COVID (January 2018 to December 2019) and COVID (January 2020 to December 2021). Tumor volumes were compared between the two groups and factors affecting tumor volumes were studied. Of 236 patients diagnosed with previously unknown malignant brain tumors, 114 were in the pre-COVID group and 122 were in the COVID group. Median tumor volumes at first diagnosis were significantly larger in the COVID group compared to the pre-COVID group (21.7 vs 15.7 cm3; p < 0.05). The survival times for the overall cohort and the GBM and CM subgroups did not differ significantly between the pre-COVID and COVID periods. Delays in diagnosis and treatment during the COVID-19 pandemic led to larger tumor volumes at diagnosis for patients with malignant brain tumors. However, these larger tumors did not result in worse survival outcomes. This counterintuitive finding highlights the crucial role of specialized neuro-oncological centers in mitigating the potential negative impact of delayed treatment and emphasizes the need for continued access to specialized care during times of crisis.

Development and implementation of a student tumor board as a teaching format for medical students.

PURPOSE: Tumor boards serve as established platforms for interdisciplinary expert discussions and therapeutic recommendations tailored to individual patient characteristics. Despite their significance, medical students often lack exposure to such interdisciplinary discussions as tumor boards are currently not integrated into medical curricula. To address this, we aimed to enhance future physicians' interdisciplinary communication skills and subject-specific knowledge by introducing an interactive series of five linked tumor board seminars within the domain of neuro-oncology. METHODS: We developed a neuro-oncological student tumor board using a flipped-classroom format. The primary objectives of this case-centered approach included fostering an understanding of the tumor board process, active participation in multidisciplinary case discussions, honing appropriate communication strategies, and creating personalized therapy plans that consider inputs from all relevant disciplines, individual patient factors, and ethical considerations. To gauge the effectiveness of the seminar series, we administered structured pre- and post-course questionnaires. RESULTS: Fourteen medical students in third to fifth year participated in the pilot series. Despite its organizational complexity, the interdisciplinary seminars were feasible. Students demonstrated significant growth in competence, aligned with predefined learning objectives. Notably, they appreciated the supportive learning environment and interactive teaching format, which kindled their interest in interdisciplinary oncology. CONCLUSION: Active participation in a student tumor board can empower students to tackle the diverse challenges of caring for cancer patients within an interdisciplinary team during the early stages of their careers. The student tumor board represents an innovative, learner-centered approach to teach interdisciplinary cancer treatment, communication strategies, and ethical aspects of medical practice.

Inter-Rater Reliability of Hounsfield Units as a Measure of Bone Density: Applications in the Treatment of Thoracolumbar Fractures.

OBJECTIVE: The study sought to investigate the reliability of computed tomography (CT)-derived Hounsfield unit (HU) measurements and ascertain the correlation between HU with quantitative CT (qCT)-derived bone mineral density (BMD) in cases of traumatic thoracolumbar fracture, based on native CT scans. METHODS: This study is a retrospective cross-sectional analysis of data sets from patients who received native CT scans and bone mineral density measurements (qCT) of the same vertebral body. Two different CT scanner models were used. The inter-rater reliability of 4 raters, which measured HU in native CT scans, was calculated using intraclass correlation coefficient for absolute agreement (ICC(3,1)). For the correlation between HU and qCT values, respectively the prediction of qCT based on HU, linear regression was used. Bland-Altman plots were used for visual comparison of predicted and measured qCT values. RESULTS: In total 305 data sets were analyzed. CT scanner model was found to have no significant impact on HU (P = 0.125). The inter-rater reliability for HU measurements from native CT scans was ICC(3,1)=0.932 (95% confidence interval 0.919-0.943, P < 0.001). The linear regression showed significant correlation of HU and qCT values for each rater (P < 0.001). The equation for qCT prediction with averaged coefficient and constant is qCT = 0.8 HU + 5. In the Bland-Altman plots no bias of predicted qCT values could be found, but a trend to overestimate predicted higher qCT values and underestimate lower qCT values, respectively. CONCLUSIONS: HU measurement shows very high inter-rater reliability. The HU values correlate closely with qCT BMD values. In summary, it seems that HU measurement is a suitable tool to readily and accurately assess bone quality without further scans or effort in cases of thoracolumbar spinal trauma.

Proposed definition of competencies for surgical neuro-oncology training.

OBJECTIVE: The aim of this work is to define competencies and entrustable professional activities (EPAs) to be imparted within the framework of surgical neuro-oncological residency and fellowship training as well as the education of medical students. Improved and specific training in surgical neuro-oncology promotes neuro-oncological expertise, quality of surgical neuro-oncological treatment and may also contribute to further development of neuro-oncological techniques and treatment protocols. Specific curricula for a surgical neuro-oncologic education have not yet been established. METHODS: We used a consensus-building approach to propose skills, competencies and EPAs to be imparted within the framework of surgical neuro-oncological training. We developed competencies and EPAs suitable for training in surgical neuro-oncology. RESULT: In total, 70 competencies and 8 EPAs for training in surgical neuro-oncology were proposed. EPAs were defined for the management of the deteriorating patient, the management of patients with the diagnosis of a brain tumour, tumour-based resections, function-based surgical resections of brain tumours, the postoperative management of patients, the collaboration as a member of an interdisciplinary and/or -professional team and finally for the care of palliative and dying patients and their families. CONCLUSIONS AND RELEVANCE: The present work should subsequently initiate a discussion about the proposed competencies and EPAs and, together with the following discussion, contribute to the creation of new training concepts in surgical neuro-oncology.

Utility of image-guided external ventriculostomy: analysis of contemporary practice in the United Kingdom and Ireland.

OBJECTIVE: Freehand external ventricular drain (EVD) insertion is associated with a high rate of catheter misplacement. Image-guided EVD placement with neuronavigation or ultrasound has been proposed as a safer, more accurate alternative with potential to facilitate proper placement and reduce catheter malfunction risk. This study aimed to determine the impact of image-guided EVD placement on catheter tip position and drain functionality. METHODS: This study is a secondary analysis of a data set from a prospective, multicenter study. Data were collated for EVD placements undertaken in the United Kingdom and Ireland from November 2014 to April 2015. In total, 21 large tertiary care academic medical centers were included. RESULTS: Over the study period, 632 EVDs were inserted and 65.9% had tips lying free-floating in the CSF. Only 19.6% of insertions took place under image guidance. The use of image guidance did not significantly improve the position of the catheter tip on postoperative imaging, even when stratified by ventricular size. There was also no association between navigation use and drain blockage. CONCLUSIONS: Image-guided EVD placement was not associated with an increased likelihood of achieving optimal catheter position or with a lower rate of catheter blockage. Educational efforts should aim to enhance surgeons' ability to apply the technique correctly in cases of disturbed cerebral anatomy or small ventricles to reduce procedural risks and facilitate effective catheter positioning.

Risk Factors for Adjacent Fractures After Cement-Augmented Thoracolumbar Pedicle Screw Instrumentation.

BACKGROUND: The aim of our study was to identify factors that influence the occurrence of adjacent fractures in patients with cement-augmented pedicle screw instrumentation. METHODS: Data were retrospectively collected from medical charts and operative reports for every surgery in which cement-augmented instrumentation was used in our hospital of 4 consecutive years. A total of 93 operations were included and examined for gender, age, T-score, number of fused segments, number of implanted screws, broken screws, loosening of screws, leakage and distribution pattern of cement, pre- and postoperative kyphosis angle, revision surgery and adjacent fractures in follow-up. Categorical data were compared using the χ2 test or by Fisher's exact test, as appropriate. Continuous variables conforming to a normal distribution were compared using Student's t test. Otherwise the Mann-Whitney U test was applied. A P-value of <.05 was considered statistically significant. A trend was defined as a P < .2. RESULTS: The mean age was 68.1 years with a mean T-score of -3.12. Nineteen adjacent fractures occurred during follow-up and the median follow-up was 12 months (range, 1-27). Patients showed a higher risk for adjacent fractures following revision surgery (P = .016). Most fractures occurred superior to the instrumented level (P = .013) and in the first 12 months. Difference of T-score between the group "no adjacent fracture" and the group "adjacent fracture" was 0.7 (P = .138). Another trends were found in greater age (P = .119) and long instrumentations (P = .199). CONCLUSIONS AND CLINICAL RELEVANCE: Revision surgeries are associated with a higher risk of adjacent fractures. In these cases, prophylactic kyphoplasty of the superior vertebra should be considered. This study is a retrospective, nonrandomized cohort/follow-up study. LEVEL OF EVIDENCE: 3.

Prediction of 30-day mortality in spontaneous cerebellar hemorrhage.

BACKGROUND: Cerebellar hemorrhage is a potentially life-threatening condition and an understanding of the factors influencing outcome is essential for sound clinical decision-making. METHODS: We retrospectively evaluated data from 50 consecutive patients who suffered a first spontaneous cerebellar hemorrhage (SCH) from 2005 to 2014, analysing their short-term outcomes and identifying possible clinical, radiological and therapeutic risk factors for poor prognosis and death within 30 days. RESULTS: Among 50 patients with first SCH, the mean age was 72 ± 10 years. Median Glasgow Coma Scale (GCS) score on admission was 11 [interquartile range (IQR) = 7-11]. Among 50 patients, 19 patients (38%) underwent surgical hemorrhage evacuation with placement of an external ventricular drain (EVD), 12 patients (24%) received an EVD only and 19 patients (38%) were treated conservatively. The 30-day mortality rate was 36%. In multivariate analysis only the GCS score on admission was a significant predictor of 30-day mortality [odds ratio (OR) = 0.598; 95% confidence interval (CI) = 0.406-0.879; P = 0.009]. For prediction of 30-day mortality, receiver operating characteristic curve analysis confirmed that the best cut-off point was a GCS score of 10 on admission [area under the curve: 0.882, 95% CI = 0.717-1, P < 0.001]. CONCLUSION: Lower GCS score on admission was associated with increased 30-day mortality and poorer short-term outcome in patients with SCH. For patients with a GCS score <10 on admission, it is important to balance the possibility of survival afforded by further therapy against the formidable risk of significant functional disability and poor quality of life.

NANOG overexpression and its correlation with stem cell and differentiation markers in meningiomas of different WHO grades.

NANOG, as a key regulator of pluripotency and acting synergistically with other factors, has been described as a crucial transcription factor in various types of cancer. In meningiomas the expression of this marker has not yet been described. With our study, we aimed to identify and localize NANOG and other possible markers of pluripotency, stem cell properties and differentiation in meningioma tissue, to elucidate a possible effect on tumorigenesis. The gene expression levels of NANOG (NANOG1 and NANOGP8), SOX2, OCT4, KLF4, ABCG2, CMYC, MSI1, CD44, NOTCH1, NES, SALL4B, TP53, and EPAS1 were quantitatively examined using RT-qPCR in 33 surgical specimens of low- (WHO grade I) as well as in high-grade (WHO grade II/III) meningiomas with dural tissue as reference. Immunofluorescence co-localization analysis following confocal fluorescence microscopy for NANOG, OCT4, SOX2, Nestin, KI-67, and CD44 was also performed. There was a significant overexpression of NANOG, MSI1, and EPAS1 and a downregulation of NES in all examined tumors. Subgroup analysis (WHO grade I versus grade II/III) revealed differences in the expression of NANOG, CD44, and MSI1. We found 1% NANOG-positive (NANOG+) cells in low-grade and 2% in grade II/III meningiomas co-expressing the other mentioned markers in various compositions. In particular, NANOG+ cells expressing SOX2 and OCT4 were successfully identified (26% low-grade versus 20% high-grade). Our data reveal an overexpression of NANOG and other markers of pluripotency and stemness in meningiomas. Such potentially pluripotent "stem cell-like" cells may have an impact on tumorigenesis and progression in human meningiomas.

Evaluating vestibular schwannoma size and volume on magnetic resonance imaging: An inter- and intra-rater agreement study.

OBJECTIVES: In the management of patients with vestibular schwannoma it is essential to reliably assess tumor size. In respect to volumetric and linear measurements of these tumors we evaluated a) the inter-rater reliability, b) the intra-rater variability, c) the concordance of volume measurements derived from axial versus those from coronal MRI datasets, and d) the correlation of one-dimensional and volumetric measurements. PATIENTS AND METHODS: We selected gadolinium-enhanced T1-weighted MRI datasets from 20 patients who had both axial and coronal datasets available with the same slice thickness in each of these orientations. Tumor volumes and diameters were independently determined by two investigators. RESULTS: The inter-rater reliability was determined based on the intra-class correlation coefficient, which was 0.998 for volumetric measurements and 0.950 for diameters. The relative smallest detectable difference between both raters was 21.2% for volumetric and 21.2% for linear measurements. Regarding the intra-rater variability we found a relative smallest detectable difference of 17.5% (rater 1) and 24.3% (rater 2) for volumetric measurements. The correlation between measurements on axial and those on coronal datasets was ρ=0.999. In order to find a function that reliably predicts tumor volume from diameter, we fitted a series of equations based on linear and polynomial regression, with the highest regression coefficient being r(2)=0.79. CONCLUSION: The longitudinal use of semi-automated volumetric measurements has the potential to accurately inform vestibular schwannoma disease management. We have quantified the reliability of this technique. A strict MRI protocol for follow-up investigations should be adhered to in order to minimize measuring errors.