Cranial Pilocytic Astrocytoma With Spinal Drop Metastasis in an Adult: Case Report and Literature Review.

BACKGROUND: Pilocytic astrocytoma (PA) is a benign neoplasm that typically occurs in the brain within the pediatric and adolescent age groups and is uncommon in adults. It rarely occurs within the ventricles, and the overall prognosis is favorable. A PA of the brain with spinal metastasis at presentation has never been reported in an adult. CASE DESCRIPTION: We report a case of a 47-year-old man presenting with sudden-onset frontal headache associated with nausea and lethargy in addition to a background of a longer history of back pain and headache. Radiologic imaging revealed an acute intraparenchymal hemorrhage in the right parieto-occipital lobes with intraventricular extension within a peripherally enhancing heterogeneous lesion. Magnetic resonance imaging of the spine revealed a sacral intradural tumor. The patient underwent surgical resection of the intracranial mass followed by debulking of the spinal lesion. Histopathologic study revealed that both the cranial and spinal tumors were PA. CONCLUSIONS: This case illustrates a unique instance of hemorrhage into a cerebral PA with a spinal metastasis. To our knowledge, this is the first such case reported in an adult. We review the literature on the subject.

Renal lesions with low R.E.N.A.L nephrometry score are associated with more indolent renal cell carcinomas (RCCs) or benign histology: findings in an Australian cohort.

OBJECTIVE: To validate the relationship of the R.E.N.A.L nephrometry score to histological features of renal lesions treated by surgical excision by radical nephrectomy (RN) or nephron-sparing surgery (NSS) at an Australian tertiary referral centre. PATIENTS AND METHODS: Patients undergoing surgery between 2005 and 2009 with imaging studies available were included. The R.E.N.A.L. nephrometry score is an objective measure of factors important in determining suitability for NSS, e.g. size, exophytic nature, proximity to collecting system and polar location, and R.E.N.A.L scoring was done using the online template at http://www.nephrometry.com. Pathological details were collected by retrospective chart review. Comparisons were made using chi-squared or Fisher's exact tests and trends analysed by linear regression. RESULTS: The rate of benign pathology decreased from 12/58 (20.7%) low-complexity lesions to 1/16 (6.2%) high-complexity lesions (P= 0.09), renal cell carcinomas (RCCs) were stable between 45/58 (77.6%) and 13/16 (81.2%), but other malignancies increased (P= 0.058) from 1/58 (1.7%) to 2/16 (12.5%). Among the RCCs, high vs low R.E.N.A.L score was associated with an increasing risk of clear cell histology (84.6% vs 64.4%, P < 0.05), stage ≥ pT3 (76.9% vs 8.9%, P < 0.001) and grade 4 tumours (15.4% vs 2.2%, P < 0.05), and conversely with a lower risk of papillary histology (0% vs 24.4%, P < 0.02) and stage T1a (0% vs 84.4%, P < 0.001). CONCLUSIONS: Increasing R.E.N.A.L score is associated with histological features of tumour aggressiveness, thus reinforcing the need for RN for lesions with a high score, and conversely the safety of NSS or observation for lesions with a low score.

Trends in the use of of nephron-sparing surgery (NSS) at an Australian tertiary referral centre: an analysis of surgical decision-making using the R.E.N.A.L. nephrometry scoring system.

UNLABELLED: Study Type--Therapy (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Nephron-sparing surgery (NSS) is increasingly recognised as a preferred form of management for the incidentally detected small renal mass (SRM). Within the context of equivalent oncological outcomes, patients treated by NSS may have a survival advantage over those treated by radical nephrectomy (RN) through a reduced risk of chronic kidney disease and its associated cardiac morbidity. Despite this, according to Medicare data from the USA, a disproportionate number of patients with SRMs continue to be treated with RN instead of NSS. Similar data from Australia are not yet available. The present study explores the evolving management of SRMs at an Australian tertiary centre over a 5-year period. It utilises the R.E.N.A.L. Nephrometry Score to assess how lesion complexity has influenced surgical decision-making and charts the increasing use of NSS in the management of low-complexity renal masses at our centre. OBJECTIVE: • To examine recent trends in the use of nephron-sparing surgery (NSS) at our centre. Specifically, we sought to examine the process of surgical decision-making by applying the R.E.N.A.L. nephrometry scoring system to assess the complexity of lesions for which surgery was undertaken. PATIENTS AND METHODS: • We performed a retrospective review of renal masses treated by surgery from January 2005 to December 2009, including 79 RN and 70 NSS. • CT images were available for analysis in 50 patients within each group. • Lesions were scored on the basis of their complexity using the R.E.N.A.L. nephrometry scoring system developed by Kutikov and Uzzo. RESULTS: • There was no difference in age between patients undergoing RN and NSS (median age 61 vs 60 years). • RN was performed for significantly larger lesions (mean [sd] 68 [9] vs 29 [2] mm, P < 0.05) of predominantly moderate and high complexity (12% low, 56% moderate, 32% high). • NSS was primarily used for low-complexity lesions, but included four (8%) moderate-complexity lesions in the final 2 years of the study. • The use of NSS increased from 28.6% of cases in 2005 to 60.0% of cases in 2009, which mirrored the increase in the proportion of operations performed for low-complexity lesions (22.2% low-complexity in 2005 to 70.6% in 2009, P < 0.01 for trend). CONCLUSIONS: • The increasing use of NSS at our institution mirrored the increasing treatment of low-complexity renal lesions. • This may reflect an increased detection and referral of such lesions, or a shift towards treatment of lesions that in the past would have been under surveillance. • Practice at our centre reflects a shifting paradigm towards preferential use of NSS for the treatment of suitable renal masses.

Management of recurrent craniopharyngioma.

Craniopharyngioma accounts for approximately 1.2% to 4.6% of all intracranial tumours. Their close proximity to vital structures such as the hypothalamic-pituitary axis and optic apparatus makes them one of the most challenging and controversial management dilemmas in neurosurgery. Recurrence following initial transcranial resection is reported as 9% to 51% at a median time of 26 months to 96 months. Treatment options for recurrent craniopharyngioma include repeat surgery, radiotherapy, radiosurgery and intracystic therapies. We present a series of 54 recurrent craniopharyngiomas treated at The Royal Melbourne Hospital between 1991 and 2008 and discuss the management options now available.