Impact of radiotherapy delay on survival in glioblastoma

BACKGROUND: Previous studies in glioblastoma have concluded that there is no decrease in survival with increasing time to initiation of RT up to 6 weeks after surgery. Unfortunately, the number of glioblastoma patients who start RT beyond 6 weeks is not small in some countries. The aim of our study was to evaluate the effect of RT delay beyond 6 weeks on survival of patients who have undergone completed resection of a glioblastoma. METHODS: We reviewed 107 consecutive glioblastoma patients who had a complete surgical resection at our hospital. Clinical data, including delay in initiation of RT, were prospectively collected. The impact of single parameters on overall survival was determined by univariate and multivariate analyses. RESULTS: According to univariate analysis, variables that had a prognostic influence on survival were age (p = 0.036), KPS (p = 0.031), additional treatment with CHT (p < 0.0001), and initiation of RT before 42 days (p = 0.009). Multivariate analysis indicated that Karnofsky performance scale, additional treatment with chemotherapy, and initiation of RT before 6 weeks after surgery were favorable, independent prognostic factors of survival. CONCLUSIONS: Survival is significantly reduced in glioblastoma patients if RT is not initiated within the 6 weeks after complete resection of the tumor (AU)

Simple fMRI postprocessing suffices for normal clinical practice.

BACKGROUND AND PURPOSE: Whereas fMRI postprocessing tools used in research are accurate but unwieldy, those used for clinical practice are user-friendly but are less accurate. We aimed to determine whether commercial software for fMRI postprocessing is accurate enough for clinical practice. METHODS: Ten volunteers underwent fMRI while performing motor and language tasks (hand, foot, and orolingual movements; verbal fluency; semantic judgment; and oral comprehension). We compared visual concordance, image quality (noise), voxel size, and radiologist preference for the activation maps obtained by using Neuro3D software (provided with our MR imaging scanner) and by using the SPM program commonly used in research. RESULTS: Maps obtained with the 2 methods were classified as "partially overlapping" for 70% for motor and 72% for language paradigm experiments and as "overlapping" in 30% of motor and in 15% of language paradigm experiments. CONCLUSIONS: fMRI is a helpful and robust tool in clinical practice for planning neurosurgery. Widely available commercial fMRI software can provide reliable information for therapeutic management, so sophisticated, less widely available software is unnecessary in most cases.

Sarcopenia: An emphasis on occlusion training and dietary protein.

Demographics reveal that the world's population aged 60 years and older will triple from 600 million in 2000 to more 2 billion by the year 2050. To remain independent and healthy, an important factor to consider is the maintenance of skeletal muscle, as the elderly seem to become prone to a progressive loss of skeletal muscle with aging, termed sarcopenia. Interventions should focus on resistance training and optimal nutrition. Low intensity occlusion training may provide a mode of resistance training more applicable to the elderly, due to the lower loads used. Furthermore, an emphasis must be placed on high quality protein adequately distributed throughout the day to maximize protein synthesis. The use of drug therapy may be of some benefit, but it appears exercise and diet likely plays a more prominent role in the preservation of muscle mass and strength than administration of synthetic hormones.

Does gender matter in glioblastoma?

BACKGROUND The clinical outcome of glioblastoma (GBM) patients who receive radiotherapy alone or with chemotherapy is well established. However, little is known about how many patients do not receive this treatment. We consider it is important to investigate why a proportion of operated patients do not receive further treatment after surgery. METHODS We reviewed all consecutive GBM patients operated on in our hospital between January 2000 and December 2008. RESULTS A total of 216 patients with GBM were identified. Fifty-five (25%) did not receive any treatment after surgery. Univariate analysis showed that factors associated with no further treatment after surgery were older than 60 years (p=0.002), of female gender (p=0.03), had a KPS<70 (p<0.001) and had had a biopsy (p<0.001). Multivariate analysis indicated that age =60 years and KPS <70 were independent predictors of no further treatment after surgery. Gender was not an independent variable. However, women in the whole series were older than 60 years (p=0.01), and they had a worse KPS (p=0.02) and more biopsies (p=0.04) than men. In the whole group, median survival time was 10.4 months for men (n=125) vs. 7.2 months for women (n=91), log rank p<0.04. This difference was not observed in the group that was treated after surgery. CONCLUSIONS One out of four patients could not be treated after surgery. Independent predictors were older age and low KPS. These poor risk variables were more frequent in women and their survival was therefore lower than men in our series (AU)

Does gender matter in glioblastoma?

BACKGROUND The clinical outcome of glioblastoma (GBM) patients who receive radiotherapy alone or with chemotherapy is well established. However, little is known about how many patients do not receive this treatment. We consider it is important to investigate why a proportion of operated patients do not receive further treatment after surgery. METHODS We reviewed all consecutive GBM patients operated on in our hospital between January 2000 and December 2008. RESULTS A total of 216 patients with GBM were identified. Fifty-five (25%) did not receive any treatment after surgery. Univariate analysis showed that factors associated with no further treatment after surgery were older than 60 years (p=0.002), of female gender (p=0.03), had a KPS<70 (p<0.001) and had had a biopsy (p<0.001). Multivariate analysis indicated that age =60 years and KPS <70 were independent predictors of no further treatment after surgery. Gender was not an independent variable. However, women in the whole series were older than 60 years (p=0.01), and they had a worse KPS (p=0.02) and more biopsies (p=0.04) than men. In the whole group, median survival time was 10.4 months for men (n=125) vs. 7.2 months for women (n=91), log rank p<0.04. This difference was not observed in the group that was treated after surgery. CONCLUSIONS One out of four patients could not be treated after surgery. Independent predictors were older age and low KPS. These poor risk variables were more frequent in women and their survival was therefore lower than men in our series.

Acute and chronic testosterone response to blood flow restricted exercise.

The American College of Sports Medicine recommends lifting a weight of at least 70% 1RM to achieve muscular hypertrophy as it is believed that anything below this intensity rarely produces substantial muscle growth. At least part of this recommendation is related to elevated systemic hormones following heavy resistance training being associated with skeletal muscle hypertrophy. Despite benefits of high intensity resistance training, many individuals are unable to withstand the high mechanical stresses placed upon the joints during heavy resistance training. Blood flow restricted exercise offers a novel mode of exercise allowing skeletal muscle hypertrophy at low intensities, however the testosterone response to this exercise has yet to be discussed. The acute and chronic testosterone response to blood flow restricted exercise appears to be minimal when examining the current literature. Despite this lack of response, notable increases in both size and strength are observed with this type of exercise, which seems to support that systemic increases of endogenous testosterone are not necessary for muscular hypertrophy to occur. However, definitive conclusions cannot be made without a more thorough analysis of responses of androgen receptor density following blood flow restricted exercise. It may also be that there are differing mechanisms underlying hypertrophy induced by high intensity resistance training and via blood flow restricted exercise.

Potential safety issues with blood flow restriction training.

The focal point of previous literature was establishing the efficacy of blood flow restriction training with respect to muscular strength, muscular hypertrophy, and muscular endurance. After mounting evidence supporting the efficacy of low-intensity blood flow restriction training, research has shifted to the overall safety of this training modality. The aim of this review was to summarize the research on the overall safety of blood flow restriction training, focusing on the cardiovascular system (central and peripheral), muscle damage, oxidative stress, and nerve conduction velocity responses compared with those observed with regular exercise. Although still sparse, the blood flow restriction training research thus far is promising with respect to safety outcomes. Individuals respond similarly to blood flow restriction training and to regular exercise; however, longer term studies are required to better understand the chronic effects of low-intensity blood flow restriction training and possible safety issues.

The perceptual responses to occluded exercise.

The purpose was to determine repetitions to failure and perceptual responses to exercise with and without occlusion. 15 subjects participated in a randomized crossover study of 3 trials. The first determined one repetition maximum (1RM) on the leg extension. Subjects were then assigned to an occlusion (OCC) or control (CON) group. After trial 2, subjects crossed over to the opposite trial. Knee wraps (KW) were placed around the upper thigh of each leg during OCC. Subjects completed 2 sets of leg extensions to failure at 30% 1RM, with 30 s rest between sets. Ratings of perceived exertion (RPE) and pain (P) were taken following each set. Data were analyzed using paired sample t-tests with an alpha level of 0.01. OCC repetitions were lower for the first and second set compared to CON (p=0.001). Total work completed was significantly lower with OCC compared to CON (p=0.001). OCC RPE were higher for both the first (p=0.01) and second set (p=0.003) compared to CON. P was not different following one set but was higher with OCC over CON following the second (p=0.009). In conclusion, KW provide an OCC stimulus allowing failure to occur sooner. However, the higher perceptual responses with OCC may limit its application to the highly motivated.

[Accuracy of pedicle screw insertion in the thoracolumbar spine using image-guided navigation]. / Fiabilidad del navegador en la colocación de tornillos pediculares toracolumbares.

INTRODUCTION: Computer image guidance is one of the most significant technologic advancements in the spine surgery, because preoperative or intraoperative images can be used for multiplanar, three-dimensional intraoperative navigation. MATERIAL AND METHODS: We performed a prospective clinical study to assess the accuracy of pedicle screw insertion using an optoelectronic navigation system (SurgiGATE Spine 2.1 Medivision). The study population included 29 patients with diverse disorders of the thoraco- lumbar spine (degenerative 54%, spondylolisthesis 21%, fractures 14%, scoliosis 7% and spondylodiscitis 4%). One patient was excluded from the study because problems with the specific instruments or the computer system. Pre and post-operative axial computed tomography images were obtained for each patient and analyzed by two independent radiologists to placement accuracy. The correct location was defined accord to Heary scale in 5 grades. RESULTS: 163 image-guided thoraco-lumbar pedicle screws were placed 29 in the thoracolumbar spine and 134 in the lumbosacral spine. We achieved a completely intraosseous placement (Grade I) in 99.4% of lumbosacral spine screws and 100% of thoracolumbar spine screws. Only one misplaced screw (Grade III) in the pedicle of L III in the concavity of a scoliosis was reported. No implant related complications were noted. CONCLUSIONS: The low rate of misplaced screws in this prospective study compares favorably with previously published results. Our initial results indicate that Image-guided spinal surgery is a safe technique which improves surgical performance during posterior transpedicle stabilization.

Fiabilidad del navegador en la colocación de tornillos pediculares toracolumbares / Accuracy of pedicle screw insertion in the thoracolumbar spine using image-guided navigation

Introducción. La cirugía guiada por imagen es uno de los más importantes avances tecnológicos dentro de la cirugía del Raquis ya que permite al cirujano realizar una navegación multiplanar tridimensional en tiempo real en el interior de una vértebra. Material y métodos. Realizamos un estudio clínico prospectivo no randomizado sobre la fiabilidad en la colocación de tornillos pediculares mediante un sistema de navegación optoelectrónico (SurgiGATE Spine 2.1 Medivision). Se estudiaron veintinueve pacientes intervenidos por diferentes patologías en columna toracolumbar incluyendo: degenerativas (54%), espondilolistesis(21%), fracturas (14%), escoliosis (7%) y espondilodiscitis(4%). Un paciente fue eliminado del estudiodebido a un fallo técnico en el equipo de navegación.Se obtuvieron imágenes de TC pre y postoperatorias de cada paciente y éstas fueron evaluadas por dos neurorradiólogos independientes. La colocación correcta se definió de acuerdo a la escala de Heary en 5 grados.Resultados. Se colocaron 163 tornillos, 29 en la columnatoracolumbar y 134 en la columna lumbosacra.Hemos conseguido una colocación totalmente intraósea(Grado I) en el 99,4% de tornillos en la columnalumbosacra y en un 100% en la columna toracolumbar. Se comprobó el error de colocación (Grado III) en un pedículo de L3 en la concavidad de una escoliosis.No se observaron complicaciones relacionadas con los implantes.Conclusiones. El bajo porcentaje de tornillos mal colocados en este estudio se compara favorablemente con los resultados publicados en la literatura. Nuestros resultados indican que la cirugía guiada por imagen aplicada a la cirugía del raquis es una técnica segura para la fijación transpedicular (AU)

Introduction. Computer image guidance is one of the most significant technologic advancements in the spinesurgery, because preoperative or intraoperative images can be used for multiplanar, three-dimensional intraoperative navigation. Material and methods. We performed a prospective clinical study to assess the accuracy of pedicle screw insertion using an optoelectronic navigation system (SurgiGATE Spine 2.1 Medivision). The study population included 29 patients with diverse disorders of the thoracolumbar spine (degenerative 54%, spondylolisthesis 21%, fractures 14%, scoliosis 7% and spondylodiscitis 4%). One patient was excluded from the study because problems with the specific instruments or the computer system. Pre and post-operative axial computed tomography images were obtained for each patient and analyzed by two independent radiologists to place mentaccuracy. The correct location was defined accord to Heary scale in 5 grades. Results. 163 image-guided thoraco-lumbar pedicle screws were placed 29 in the thoracolumbar spine and 134 in the lumbosacral spine. We achieved a completely intraosseous placement (Grade I) in 99.4% of lumbosacral spine screws and 100% of thoracolumbar spinescrews. Only one misplaced screw (Grade III) in the pedicle of L III in the concavity of a scoliosis was reported. No implant related complications were noted. Conclusions. The low rate of misplaced screws in this prospective study compares favorably with previously published results. Our initial results indicate that Image-guided spinal surgery is a safe technique which improves surgical performance during posterior transpedicle stabilization (AU)

Brain nodules with lung mass: are they always metastases?

In a smoking adult with a lung mass, brain masses are usually diagnosed as brain metastases of lung origin. Nevertheless, differential diagnosis between cerebral abscesses cannot be performed based on clinical symptoms or imaging technologies, and histological diagnosis is essential. This case illustrates the advisability of always obtaining histological diagnosis of the primary tumor and/or cerebral lesion before introducing any oncological treatment (AU)

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[Advances in the study of primary auditory cortex. Demostration of its activation by functional magnetic resonance imaging]. / Vanguardia en el estudio del córtex auditivo. Demostración de su activación mediante resonancia magnética funcional.

PURPOSE: The purpose of this preliminary study has been to demonstrate and investigate the activation patterns of the primary auditory cortex (Heschl's gyrus = HG) using functional magnetic resonance imaging (fMRI). MATERIAL AND METHODS: A 2500 Hz tone stimulus was delivered monoaurally to the right and left ear of 15 normal-hearing right-handed volunteers in 20-second on-off cycles. FMRI data were obtained using a 1.5-Tesla scanner and processed with SPM2. RESULTS: Activated pixels were identified in the transverse temporal gyrus (Heschl's gyrus) of both hemispheres in response to pure tone stimuli using cross-correlation analysis (P < 0.001). Bilateral hemispheric activation was observed in all subjects and there was a trend towards contralateral HG activation to the stimulated ear. CONCLUSION: These results demonstrate directly that fMRI is a new and useful imaging technique to study the complex auditory cortex and it will have potential clinical applications in the next future.

Vanguardia en el estudio del córtex auditivo. Demostración de su activación mediante resonancia magnética funcional / Advances in the study of primary auditory cortex. Demostration of its activation by functional magnetic resonance imaging

Objetivo: El objetivo de este estudio preliminar es investigar y demostrar la activación del córtex auditivo primario (Gyrus o circunvolución de Heschl) mediante resonancia magnética funcional (RMf). Material y métodos: Los sujetos a estudio fueron 15 voluntarios normooyentes diestros, a los que se les estimuló auditivamente con tonos de 2500 Hz en ciclos de 20 sg de estimulación, seguidos por 20 sg de reposo. Los datos fueron obtenidos en un escáner de RM de 1.5 Tesla y procesados con SPM2. Resultados: La activación en respuesta a la estimulación tonal, se produjo en todos los sujetos a nivel del Gyrus de Heschl (córtex auditivo primario) en ambos hemisferios cerebrales, con una significación estadística de P<0,001, y una tendencia a una mayor activación en el hemisferio contralateral al oído estimulado. Conclusión: Estos resultados demuestran que la RMf es un útil y novedoso intrumento para el estudio del complejo córtex auditivo, con importantes aplicaciones clínicas en un futuro próximo (AU)

PURPOSE: The purpose of this preliminary study has been to demonstrate and investigate the activation patterns of the primary auditory cortex (Heschl's gyrus = HG) using functional magnetic resonance imaging (fMRI). MATERIAL AND METHODS: A 2500 Hz tone stimulus was delivered monoaurally to the right and left ear of 15 normal-hearing right-handed volunteers in 20-second on-off cycles. FMRI data were obtained using a 1.5-Tesla scanner and processed with SPM2. RESULTS: Activated pixels were identified in the transverse temporal gyrus (Heschl's gyrus) of both hemispheres in response to pure tone stimuli using cross-correlation analysis (P < 0.001). Bilateral hemispheric activation was observed in all subjects and there was a trend towards contralateral HG activation to the stimulated ear. CONCLUSION: These results demonstrate directly that fMRI is a new and useful imaging technique to study the complex auditory cortex and it will have potential clinical applications in the next future (AU)

Clinical and MRI outcome after autologous hematopoietic stem cell transplantation in MS.

The authors report the outcome of 14 patients with severe multiple sclerosis treated with autologous hematopoietic stem cell transplantation (AHSCT) after a median follow-up period of 3 years. The 3-year actuarial probability of progression-free survival was 85.7% and that of disease activity-free survival was 46.4%. On MRI, no T1-enhanced lesions were detected after AHSCT. The mean change in T2 lesion volume from baseline to the third year was -20.2% and that of the corpus callosum area was -12.7%; 50% of this reduction was seen during the first year.

Pre-irradiation semi-intensive chemotherapy with carboplatin and cyclophosphamide in malignant glioma: a phase II study.

We undertook a phase II trial in 17 patients with malignant glioma and large measurable disease to assess response rate and survival with pre-irradiation chemotherapy, using higher doses than standard, trying to improve the outcome. Patients characteristics were: male/female 10/7, age 49 (range 23-59), median Karnofsky index 90% (range 70-100), glioblastoma multiforme/anaplastic astrocytoma 14/3. Treatment consisted of 2 cycles of carboplatin 200 mg/m(2) days 1-3 (or AUC x 8, total dose) plus cyclophosphamide 1000 mg/m(2) days 1-3. One partial response (6.5%) and two stabilizations (13.5%) were observed after pre-irradiation chemotherapy. Twelve out of 15 patients (80%) progressed after chemotherapy. Median survival time was 7.6 months and the survival at 1 year was 33%. Main toxicity was hematologic in the first cycle: neutropenia grade 4 in 100%; thrombocytopenia grade 4 in 73% and grade 3 in 27%; anemia grade 3 in 7%; in the second cycle: neutropenia and thrombocytopenia grade 4 in 100% and anemia grade 3 in 50%). No toxic death was related to treatment. This regimen showed limited activity in malignant glioma with large residual disease after surgery or biopsy.

[Neurocysticercosis: an imported disease?]. / Neurocisticercosis: ¿una enfermedad importada?

BACKGROUND: Neurocysticercosis is the CNS involvement caused by Taenia solium larvae and the most frequent cerebral parasitation. It has a cosmopolitan distribution but endemic in the low income countries. The paper analizes the geographic origin, clinical characteristics of patients and the diagnostic and therapeutic modalities. PATIENTS AND METHOD: Retrospective revision of clinical files in patients with the diagnosis of neurocysticercosis between the period January 1990 to March 2000. RESULTS: Ten patients were included of which only one was of Spanish nationality. The others were immigrants or travellers to Central/South America (7), Africa (1) and South East Asia (1). Nine patients presented with convulsive crisis, generalized in 7 and 3 cases suffered headaches. The diagnosis was obtained through biopsy technique (3 cases) and the rest through CT scan or MR and serology. ELISA specific serology was positive in 60% of cases. Eight patients were treated with praziquantel or albendazol solely with good clinical evolution. CONCLUSIONS: Neurocysticercosis is prevalent among the immigrant population and in our case imported mostly from Latin America. Diagnosis is reached through imaging and serological techniques. Treatment with praziquantel or albendazol improves the clinical picture and controls the convulsive crisis.

MRI and CSF oligoclonal bands after autologous hematopoietic stem cell transplantation in MS.

OBJECTIVE: To analyze the MRI and CSF oligoclonal bands (OB) changes in patients with MS who underwent an autologous hematopoietic stem cell transplantation (AHSCT). BACKGROUND: AHSCT is evaluated as an alternative therapy in severe MS. In previous series of AHSCT for MS, data on MRI or OB outcome were limited or not provided. METHODS: Five patients with a median Kurtzke's EDSS score of 6.5, more than two attacks, and confirmed worsening of the EDSS in the previous year received an AHSCT. Hematopoietic stem cells were mobilized with cyclophosphamide (3 g/m2) and granulocyte colony-stimulating factor (5 microg/kg/d). The graft was T cell depleted by positive CD 34+ selection. Conditioning regimen included BCNU (300 mg/m(2)), cyclophosphamide (150 mg/kg in 3 days), and antithymocyte globulin (60 mg/kg in 4 days). MRI scans were scheduled at baseline and 1, 3, 6, and 12 months and OB analysis at baseline and 3 and 12 months post-AHSCT. RESULTS: Four patients had a stable or improved EDSS after a median follow-up of 18 months (range, 12 to 24 months). The fifth patient's condition deteriorated during AHSCT. She partially improved and remained stable after month 3 after AHSCT. The baseline CSF OB persisted 1 year after AHSCT. MRI studies after AHSCT showed no enhanced T1 lesions and no new or enlarging T2 lesions. The median percentage change of T2 lesion load was -11.8% (range, -26.6 to -4.0%). All patients had a decrease of corpus callosum area at 1 year (median, 12.4%; range, 7.8% to 20.5%) that did not progress in the two patients evaluated at 2 years after AHSCT. CONCLUSIONS: Although the persistence of CSF OB suggests the lymphocytes were not eliminated from the CNS, the follow-up MRI studies showed no enhanced T1 brain lesions and a reduction in the T2 lesion load that correlated with the clinical stabilization of MS after AHSCT.