Approaching glioblastoma during COVID-19 pandemic: current recommendations and considerations in Brazil.

BACKGROUND: Cancer patients in general and glioblastoma patients, in particular, have an increased risk of developing complications from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and reaching a balance between the risk of exposure to infection and the clinical benefit of their treatment is ideal. The aggressive behavior of this group of tumors justifies the need for a multidisciplinary team to assist in clinical decisions during the current pandemic. Brazil is now ranked #2 in the number of cases and deaths from COVID-19 pandemic, and existing disparities in the treatment of neuro-oncology patients in Brazil will challenge the clinical and surgical decisions of this population, possibly affecting global survival. OBJECTIVE: To search the literature about the management of glioblastomas during COVID-19 pandemic to guide surgical and clinical decisions in this population of patients in Brazil. METHODS: We performed a systematic search on the PubMed electronic database targeting consensus statements concerning glioblastoma approaches during COVID-19 pandemic up to July 18, 2020. RESULTS: When approaching glioblastoma during the COVID-19 pandemic, important parameters that help in the decision-making process are age, performance status, tumor molecular profile, and patient consent. Younger patients should follow the standard protocol after maximal safe resection, mainly those with MGMT methylated tumors. Aged and underperforming patients should be carefully evaluated, and probably a monotherapy scheme is to be considered. Centers are advised to engage in telemedicine and to elaborate means to reduce local infection. CONCLUSION: Approaching glioblastoma during the COVID-19 pandemic will be challenging worldwide, but particularly in Brazil, where a significant inequality of healthcare exists.

Approaching glioblastoma during COVID-19 pandemic: current recommendations and considerations in Brazil / Abordando glioblastomas durante a pandemia pelo COVID-19: recomendações atuais e considerações no Brasil

ABSTRACT Background: Cancer patients in general and glioblastoma patients, in particular, have an increased risk of developing complications from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and reaching a balance between the risk of exposure to infection and the clinical benefit of their treatment is ideal. The aggressive behavior of this group of tumors justifies the need for a multidisciplinary team to assist in clinical decisions during the current pandemic. Brazil is now ranked #2 in the number of cases and deaths from COVID-19 pandemic, and existing disparities in the treatment of neuro-oncology patients in Brazil will challenge the clinical and surgical decisions of this population, possibly affecting global survival. Objective: To search the literature about the management of glioblastomas during COVID-19 pandemic to guide surgical and clinical decisions in this population of patients in Brazil. Methods: We performed a systematic search on the PubMed electronic database targeting consensus statements concerning glioblastoma approaches during COVID-19 pandemic up to July 18, 2020. Results: When approaching glioblastoma during the COVID-19 pandemic, important parameters that help in the decision-making process are age, performance status, tumor molecular profile, and patient consent. Younger patients should follow the standard protocol after maximal safe resection, mainly those with MGMT methylated tumors. Aged and underperforming patients should be carefully evaluated, and probably a monotherapy scheme is to be considered. Centers are advised to engage in telemedicine and to elaborate means to reduce local infection. Conclusion: Approaching glioblastoma during the COVID-19 pandemic will be challenging worldwide, but particularly in Brazil, where a significant inequality of healthcare exists.

RESUMO Introdução: Pacientes com câncer, em geral, e particularmente pacientes com glioblastoma estão sob elevado risco de desenvolver síndrome respiratória aguda grave devido à infecção pelo SARS-CoV-2, e alcançar um equilíbrio entre risco de exposição à infecção e benefício clínico do tratamento seria o ideal. O comportamento agressivo desse grupo de tumores justifica a necessidade de equipe multidisciplinar para auxiliar nas decisões clínicas durante a pandemia vigente. O Brasil ocupa hoje o segundo lugar em número de casos e óbitos pela COVID-19, e as atuais disparidades no tratamento de pacientes neuro-oncológicos desafiarão as decisões clínicas e cirúrgicas dessa população, possivelmente afetando a sobrevida global. Objetivo: Guiar decisões clínicas e cirúrgicas relacionadas ao manejo de glioblastoma durante a pandemia pelo COVID-19 no Brasil por meio de pesquisa em literatura. Métodos: Busca sistemática no banco de dados eletrônico da PubMed por estudos ou consensos quanto à abordagem de glioblastoma durante a pandemia por COVID-19 até 18/07/2020. Resultado: Ao abordar o glioblastoma durante a pandemia pela COVID-19, parâmetros importantes que auxiliam no processo de tomada de decisão são idade, desempenho, perfil molecular tumoral e consentimento do paciente. Pacientes jovens devem seguir protocolo padrão após máxima ressecção cirúrgica, principalmente aqueles com metilação do promotor MGMT. Idosos e pacientes debilitados devem ser cuidadosamente avaliados, e monoterapia deve ser provavelmente considerada. Centros de saúde são orientados a utilizar-se da telemedicina e de meios para reduzir infecção local. Conclusão: A abordagem do glioblastoma durante a pandemia por COVID-19 será mundialmente desafiadora, mas particularmente no Brasil, onde ainda existe significativa inequidade no cuidado com a saúde.

Methodology for creating and validating object naming and semantic tests used by Verst-Maldaun Language Assessment during awake craniotomies.

Verst-Maldaun Language Assessment (VMLA) is a new intraoperative neuropsychological test (NT) within our local culture, e.g., native Portuguese speaking Brazilians. It aims to fill the specific need of an objective and dynamic approach for assessing the language network during awake craniotomies. The test includes object naming (ON) and semantic functions. This paper describes the process of validation, allowing for other centers to create their own language assessment. The validation process included 248 volunteers and the results were associated with age, gender and educational level (EL). The factor with the greatest impact was EL, followed by age. Intraoperative image learning by repetition is unlikely, since it is composed of 388 items and 70 combinations. The test will be available for free use under http://www.vemotests.com/ (beginning in February 2021).

Social determinants of health and survival on Brazilian patients with glioblastoma: a retrospective analysis of a large populational database.

Background: The majority of patients diagnosed with glioblastoma develop recurrent disease resulting in poor prognoses. The current study aimed to determine the survival rates of patients diagnosed with glioblastoma in Brazil accounting for the influence of age, treatment modalities, public and private practices, and educational level using a population-based national database. Methods: Patients diagnosed with glioblastoma from 1999-2020 were identified from The Fundação Oncocentro de São Paulo database to create a retrospective cohort. Patients were described according to age, education level treatment modalities and medical practice. In a Cox proportional hazards model, controlled for confounding factors for overall survival, the hazard ratio and 95% CI of overall survival in adults was evaluated. Findings: A total of 4,511 patients were included. The median lengths of survival for patients treated in the public and private settings were 8 and 17 months (p<0.001), respectively. Young patients had longer median overall survival (OS: 18 to 40 years, 41 to 60 years, 61 to 65 years, 66 to 70 years and over than 70 years was 22 months, 10 months, 6 months, 5 months, 4 months, respectively (p<0.001). In general, combined treatments were associated with higher median survival compared to monotherapy. The higher educational level, the higher median survival was observed (4 months for illiterate versus 14 months for university degree). In the multivariable analyses, the significant independent predictors for overall survival were practice setting, educational level, age and treatment modalities. Interpretation: Public practice, older patients, less intensive treatment, and lower educational level were associated with worse survival outcomes in Brazilian glioblastoma patients.

Foramen magnum meningioma: Series of 20 cases. Complications, risk factors for relapse, and follow-up.

INTRODUCTION: Meningiomas account for 2.2% to 2.5% of all cerebral tumors, of which only 2% are located in the foramen magnum. Foramen magnum meningiomas (FMMs) are commonly found in women, with a mean age at onset of 52 years old. They generally behave more aggressively than other meningiomas. MATERIALS AND METHODS: We performed epidemiological, anatomical and surgical analyses of 20 patients diagnosed with FMMs who underwent surgical treatment from 1999 to 2019 at Santa Paula Hospital in Sao Paulo. This case series was compared with previously published ones to better understand this relatively rare disease. RESULTS: Twenty patients were included, with a mean follow-up of 110 months. Their mean age was 37.8 years old. The mean preoperative Karnofsky performance status scale (KPS) was 84%. We found a female (65%) and left hemisphere predominance (50%). Involvement of both hemispheres was found in 25% of patients. FMM locations were anterior, anterolateral, lateral and posterior, in 45%, 35%, 10%, and 10%, respectively. Simpson resection grades I, II, and III were achieved in 25%, 60%, and 15% of cases, respectively. Mean postoperative KPS was 79%. Three patients with anterior and bilateral located meningiomas had a worse postoperative KPS in comparison to the preoperative one. CONCLUSION: Anterior and bilateral FMMs seem to be related to a worse prognosis. A gross total resection can reduce the recurrence rates. The KPS is worse in patients with recurrence.

Associations of VEGFA and KDR single-nucleotide polymorphisms and increased risk and aggressiveness of high-grade gliomas.

Angiogenesis, induced by the vascular endothelial growth factor A through its ligation to the vascular endothelial growth receptor 2, has been described as a crucial point in high-grade glioma development. The aim of this study was to evaluate the influence of VEGFA-2578C/A, -2489C/T, -1154G/A, -634G/C, and -460C/T, and KDR-604T/C, -271G/A, +1192G/A, and +1719A/T single-nucleotide polymorphisms on risk and clinicopathological aspects of high-grade glioma. This case-control study enrolled 205 high-grade glioma patients and 205 controls. Individuals with VEGFA-2578 CC or CA, VEGFA-1154 GG, VEGFA-634 GC or CC, and VEGFA-460 CT or TT genotypes were under 2.56, 1.53, 1.54, and 1.84 increased risks of high-grade glioma, compared to others, respectively. And 1.61, 2.66, 2.52, 2.53, and 2.02 increased risks of high-grade glioma were seen in individuals with VEGFA-2578 CC plus VEGFA-1154 GG, VEGFA-2578 CC or CA plus VEGFA-634 GC or CC, VEGFA-2578 CC or CA plus VEGFA-460 CT or TT, VEGFA-1154 GG or GA plus VEGFA-634 GC or CC, and VEGFA 634 GC or CC plus VEGFA-460 CT or TT combined genotypes, respectively, when compared to others. The "CAGT" haplotype of KDR single-nucleotide polymorphisms was more common in patients with grade IV than in those with grade III tumors, and individuals carrying this haplotype were at 1.76 increased risk of developing grade IV tumors than others. We present, for the first time, preliminary evidence that VEGFA-2578C/A and VEGFA-1154G/A single-nucleotide polymorphisms increases high-grade glioma risk, and "CAGT" haplotype of the KDR gene alters high-grade glioma aggressiveness and risk of grade IV tumors in Brazil.

Giant dumbbell C2C3 neurofibroma invading prebulbar cistern: Case report and literature review.

BACKGROUND: Neurofibromatosis 1 (NF1) has a broad spectrum of clinical manifestations, most typically involving café-au-lait spots and skin neurofibromas. Only 2% of patients with NF1 have symptomatic spinal tumors. CASE DESCRIPTION: A patient with a previous diagnosis of NF1 presented with cervicalgia, dysphagia/mild dysphonia, gait alteration, and progressive hypoesthesia involving all four limbs. The magnetic resonance documented a giant dumbbell neurofibroma arising between the C2 and C3 levels which extended toward the foramen magnum, causing medullary and bulbar compression. The major challenge of surgical management was the enormous size and location this C2-C3 (5 cm × 4 cm × 5.1 cm) lesion. CONCLUSIONS: Compression of the foramen magnum attributed to a dumbbell giant spinal neurofibroma at the C2C3 level resulting in prebulbar cisterns should be among the differential diagnostic considerations for patients presenting with tetraparesis and underlying NF1.

Spinal Cord Stimulation in Pregnant Patients: Current Perspectives of Indications, Complications, and Results in Pain Control: A Systematic Review.

Spinal cord stimulation (SCS) has been described as a valuable neuromodulator procedure in the management of chronic medically untreated neuropathic pain. Although the use of this technique has been published in many papers, a question still remains regarding its applicability in pregnant patients. The goal of this paper is to discuss the risks, complications, and results as well as the prognosis of SCS in pregnant patients. We performed a systematic review from 1967 to 2018 using the databases MEDLINE, LILACS, SciELO, PubMed, and BIREME, utilizing language as selection criteria. Eighteen studies that met our criteria were found and tabulated. SCS is a reversible and adjustable surgical procedure, which results in patients that demonstrated a significant effect in the reduction of pain intensity in pregnant patients. The etiologies most frequent were complex regional pain and failed back pain syndromes, which together represented 94% of analyzed cases. The technical complications most frequent were lead migration (3%, n = 1). Regarding the risks, the authors did not show significative factors among the categorical variables that can suggest a teratogenicity, while the maternal risks have been associated to the consequences of technical complications due to, among other factors, improvement of abdominal pressure during pregnancy and delivery. Finally, although there are not significative cohorts of pregnant patients, the procedure is still an effective surgical approach of neuropathic pain associated to lower rates of complications and significative improvement in the quality of life of patients during pregnancy.

Microsurgical Management of Trigeminal Schwannoma: Cohort Analysis and Systematic Review.

Background Trigeminal schwannomas are benign tumors with a predilection for women between 40 and 60 years of age and account for less than 0.5% of all intracranial tumors. Clinical presentation depends on size and location, and typical symptoms are ipsilateral hypesthesia, headache, and facial pain. Clinical features and imaging usually make the Diagnosis. Methods A retrospective cohort analysis of 14 patients treated at our institution between January 1999 and October 2016 was performed, with a critical and systematic review of data from the literature, focusing on articles published over the same period. Results Fourteen patients were included in our series comprised of mostly women with a mean age of 40 years. Lesion size ranged from 3 to 6.5 cm (mean 4.6 cm). Clinical status of patients was evaluated and also rated based on the Karnofsky Perfomance Scale with values greater than 90% found in all patients pre and postoperatively. Surgery was our treatment of choice, and gross total resection was achieved in 71% of patients. Associated morbidity was high at 57%, predominantly from cranial nerve palsy, and no deaths were encountered. Conclusions Microsurgery is a suitable treatment for large symptomatic trigeminal schwannomas, achieving good local control rates over the observation period at acceptable morbidity. Therefore, microsurgery appears to a suitable option. During the study period, a significant evolution in the availability of treatment methods occurred. Radiosurgery emerged as an alternative treatment for unresectable lesions. A comprehensive review of the available literature was performed, and results were compared according to treatment modality.

Metastasis from glioblastoma multiforme: a meta-analysis.

OBJECTIVE: Extracranial metastases of glioblastoma multiforme (GBM) are rare due to the short survival experienced by the patients. Therefore, the natural history of GBM metastases remains elusive. The identification of clinical factors promoting GBM metastases may help elucidate the mechanisms of tumor cell invasion in the brain. The aims of this study were to perform a meta-analysis evaluating the survival, characteristics, prognostic factors, and predictors of treatment outcome in patients with metastatic GBM and describe a case of metastatic extracranial GBM. METHODS: We report the case of a patient diagnosed with GBM metastatic to the lungs and the results of a meta-analysis of 114 other cases of metastatic GBM identified through a MEDLINE and BIREME search. RESULTS: The mean age of the patients was 38.2±16.1 years and 70.4% were male. The time elapsed between the identification of the metastasis and death was significantly increased in patients undergoing surgery (p=0.019), whereas the time from the diagnosis of the primary tumor to death was significantly increased in patients receiving radiation therapy (p=0.050). The time elapsed from metastasis to death and diagnosis to death was significantly longer in patients receiving chemotherapy (p<0.001 and p=0.027, respectively). The liver was the metastatic site associated with the shortest time elapsed from diagnosis to death (p=0.024). CONCLUSIONS: In GBM, surgical resection is important in reducing the risk of metastasis, and chemotherapy and radiation therapy help to prolong survival in metastatic GBM. Metastases to the liver are associated with shorter survival compared with metastases to other sites.

Systemic dissemination of glioblastoma: literature review.

INTRODUCTION: Glioblastoma (GBM) is the most frequent primary malignant tumor from the central nervous system in adults. However, the presence of systemic metastasis is an extremely rare event. The objective of this study was to review the literature, evaluating the possible biological mechanisms related to the occurrence of systemic metastasis in patients diagnosed with GBM. RESULTS: The mechanisms that may be related to GBM systemic dissemination are the blood-brain barrier breach, often seen in GBM cases, by the tumor itself or by surgical procedures, gaining access to blood and lymphatic vessels, associated with the acquisition of mesenchymal features of invasiveness, resistance to the immune mechanisms of defense and hostile environment through quiescence. CONCLUSIONS: Tumor cells must overcome many obstacles until the development of systemic metastasis. The physiologic mechanisms are not completely clear. Although not fully understood, the pathophysiological understanding of the mechanisms that may be associated with the systemic spread is salutary for a global understanding of the disease. In addition, this knowledge may be used as a basis for a therapy to be performed in patients diagnosed with GBM distant metastasis.

Metastasis from glioblastoma multiforme: a meta-analysis

SUMMARY OBJECTIVE: Extracranial metastases of glioblastoma multiforme (GBM) are rare due to the short survival experienced by the patients. Therefore, the natural history of GBM metastases remains elusive. The identification of clinical factors promoting GBM metastases may help elucidate the mechanisms of tumor cell invasion in the brain. The aims of this study were to perform a meta-analysis evaluating the survival, characteristics, prognostic factors, and predictors of treatment outcome in patients with metastatic GBM and describe a case of metastatic extracranial GBM. METHODS: We report the case of a patient diagnosed with GBM metastatic to the lungs and the results of a meta-analysis of 114 other cases of metastatic GBM identified through a MEDLINE and BIREME search. RESULTS: The mean age of the patients was 38.2±16.1 years and 70.4% were male. The time elapsed between the identification of the metastasis and death was significantly increased in patients undergoing surgery (p=0.019), whereas the time from the diagnosis of the primary tumor to death was significantly increased in patients receiving radiation therapy (p=0.050). The time elapsed from metastasis to death and diagnosis to death was significantly longer in patients receiving chemotherapy (p<0.001 and p=0.027, respectively). The liver was the metastatic site associated with the shortest time elapsed from diagnosis to death (p=0.024). CONCLUSIONS: In GBM, surgical resection is important in reducing the risk of metastasis, and chemotherapy and radiation therapy help to prolong survival in metastatic GBM. Metastases to the liver are associated with shorter survival compared with metastases to other sites.

RESUMO OBJETIVO: Metástases extracranianas do glioblastoma multiforme (GBM) são raras devido à baixa sobrevida dos pacientes. Portanto, a história natural das metástases do GBM permanece incerta. A identificação de fatores clínicos que promovem metástases no GBM pode ajudar a elucidar os mecanismos de invasão das células tumorais no cérebro. O objetivo deste estudo foi realizar uma meta-análise avaliando a sobrevida, características, fatores prognósticos e preditores de desfechos do tratamento em pacientes com GBM metastático e descrever um caso de GBM extracraniano metastático. MÉTODOS: Relatamos o caso de uma paciente diagnosticada com GBM metastático para os pulmões e os resultados de uma meta-análise de 114 outros casos de GBM metastático identificados por meio de uma pesquisa no Medline e Bireme. RESULTADOS: A média de idade dos pacientes foi de 38,2±16,1 anos e 70,4% eram do sexo masculino. O tempo decorrido entre a identificação da metástase e o óbito foi significativamente maior em pacientes submetidos à cirurgia (p = 0,019), enquanto que o tempo do diagnóstico do tumor primário até o óbito aumentou significativamente em pacientes submetidos à radioterapia (p = 0,050). O tempo decorrido da metástase até o óbito e do diagnóstico até o óbito foi significativamente maior nos pacientes que receberam quimioterapia (p < 0,001 e p = 0,027, respectivamente). O fígado foi o local metastático associado ao menor tempo decorrido do diagnóstico até a morte (p = 0,024). CONCLUSÕES: No GBM, a ressecção cirúrgica é importante para redução do risco de metástase, e a quimioterapia e a radioterapia ajudam a prolongar a sobrevida no GBM metastático. Metástases para o fígado estão associadas a uma sobrevida mais curta quando comparadas a metástases para outros locais.

Systemic dissemination of glioblastoma: literature review

SUMMARY INTRODUCTION: Glioblastoma (GBM) is the most frequent primary malignant tumor from the central nervous system in adults. However, the presence of systemic metastasis is an extremely rare event. The objective of this study was to review the literature, evaluating the possible biological mechanisms related to the occurrence of systemic metastasis in patients diagnosed with GBM. RESULTS: The mechanisms that may be related to GBM systemic dissemination are the blood-brain barrier breach, often seen in GBM cases, by the tumor itself or by surgical procedures, gaining access to blood and lymphatic vessels, associated with the acquisition of mesenchymal features of invasiveness, resistance to the immune mechanisms of defense and hostile environment through quiescence. CONCLUSIONS: Tumor cells must overcome many obstacles until the development of systemic metastasis. The physiologic mechanisms are not completely clear. Although not fully understood, the pathophysiological understanding of the mechanisms that may be associated with the systemic spread is salutary for a global understanding of the disease. In addition, this knowledge may be used as a basis for a therapy to be performed in patients diagnosed with GBM distant metastasis.

RESUMO INTRODUÇÃO: Glioblastoma (GBM) é o tumor maligno mais comum do sistema nervoso central em adultos. Entretanto, metástase a distância de GBM é um evento extremamente raro. O presente estudo teve o objetivo de realizar uma revisão da literatura para avaliar os possíveis mecanismos biológicos relacionados com a ocorrência de metástase a distância de pacientes com diagnóstico de GBM. RESULTADOS: Os mecanismos que podem estar relacionados com a capacidade de disseminação sistêmica do GBM são a quebra de barreira hematoencefálica (BHE) frequentemente vista em GBM, seja pela doença, seja por procedimentos cirúrgicos, dando acesso aos vasos sanguíneos e linfáticos, associada à aquisição de características mesenquimais de invasividade, resistência aos mecanismos de defesa do sistema imunológico e adaptação a hostilidades dos meios distantes por meio de quiescência. CONCLUSÕES: As células tumorais necessitam vencer diversos obstáculos até a formação de uma metástase distante. Apesar de não totalmente esclarecido, o entendimento fisiopatológico dos mecanismos pelos quais podem estar associados à disseminação sistêmica do GBM é salutar para a compreensão global da doença. Além disso, esse conhecimento pode servir de base para a terapia a ser empregada diante do paciente com diagnóstico de GBM com metástase a distância.

Tumor Reduction with Pazopanib in a Patient with Recurrent Lumbar Chordoma.

INTRODUCTION: Chordomas are rare malignancies of bone origin that occur in the axial skeleton, typically the skull base and lumbar/sacral regions. Although often classified as low-grade neoplasms, its locally infiltrative behavior may result in significant morbidity and mortality. Optimal surgical resection may be curative, but up to 50% of the cases relapse within 5 years, and currently there are no systemic treatments approved in this setting. A large proportion of these tumors express stem-cell factor receptor (c-KIT) and platelet-derived growth factor receptors (PDGFRs), providing a rationale for the use of tyrosine-kinase inhibitors (TKIs). CASE REPORT: A 27-year-old male presented with recurrent chordoma of the lumbar spine 4 years after initial diagnosis. Salvage therapies in the interval included repeat resections and radiation therapy. He ultimately developed multifocal recurrence not amenable to complete excision or reirradiation. A comprehensive genomic profiling assay was performed and revealed nondrugable alterations. Decision was made to proceed with systemic treatment with pazopanib 800 mg/day, resulting in tumor reduction (-23.1% reduction in size) and prolonged disease control. CONCLUSION: For this patient with a multiple recurrent chordoma and limited treatment options, pazopanib resulted in sustained clinical benefit following initial tumor reduction.

Biological subtypes and survival outcomes in breast cancer patients with brain metastases in the targeted therapy era.

BACKGROUND: There is recognition that breast cancer is a collection of heterogeneous diseases divided in subtypes based on combined molecular features such as hormonal receptors (HR) and human epidermal growth factor receptor 2 (HER2) status. We aimed to study clinical differences among biological subtypes in brain metastasis from breast cancer after targeted therapy introduction. METHODS: This was a retrospective study with 406 consecutive patients with brain metastasis from breast cancer treated at MD Anderson Cancer Center from 1998 to 2013. Overall, 315 of these patients met the study criteria and were analyzed. Subtypes were classified as HER2-/HR+ (96 patients), HER2+/HR+ (57 patients), HER2+/HR- (63 patients), and triple negative (HER2-/HR-) (99 patients). End points were time to development of brain metastasis (TDBM), brain metastasis-free survival (BMFS), and overall survival from start of treatment of brain metastasis (OSBM). Univariate and multivariate Cox proportional hazard regression models were used to analyze the data. RESULTS: TDBM was 41 months for HER2-/HR+; 58 months for HER2+/HR+; 30 months for HER2+/HR-; and 27 months for triple negative (P < .001). BMFS was 9 months for HER2-/HR+; 24 months for HER2+/HR+; 9 months for HER2+/HR-; and 7 months for triple negative (P = .06). OSBM was 20 months for HER2-/HR+; 22 months for HER2+/HR+; 24 months for HER2+/HR-; and 9 months for triple negative (P < .001). On multivariate analyses, triple negative showed lower OSBM compared with other subtypes, with a hazard ratio of 1.9 (P < .001). CONCLUSION: Comparing all breast cancer subgroups we noticed that HR and HER2 are the most significant biomarkers in brain metastasis behavior. Patients who received targeted therapy had better outcomes, but not in the triple negative group. Prospective studies with different treatment modalities for each subgroup are recommended.

Interfascial Dissection for Protection of the Nerve Branches to the Frontalis Muscles during Supraorbital Trans-Eyebrow Approach: An Anatomical Study and Technical Note.

Introduction Preservation of the temporal branches of the facial nerve during anterolateral craniotomies is important. Damaging it can inflict undesirable cosmetic defects to the patient. The supraorbital trans-eyebrow approach (SOTE) is a versatile keyhole craniotomy but still has a high rate of frontalis muscle (FM) palsy. Objective Anatomical study to implement the interfascial dissection during the SOTE to preserve the nerves to the FM. Methods Slight modification of the standard technique of the SOTE was performed in 6 cadaveric specimens (12 sides). Results Distal rami to the FM were exposed. The standard "u-shape" incision of the FM can cross over the nerves. Alternatively, an "l-shape" incision was performed until the superior temporal line (STL). An interfascial dissection was performed near to the STL and the interfascial fat pad was used as a protective layer for the nerves. Conclusion Various pathologies can be addressed with the SOTE. In the majority of the cases the cosmetic results are good, but FM palsy remains a drawback of this approach. The interfascial dissection may be used in an attempt to prevent frontalis rami palsy.

Giant pseudoaneurysm originated from distal middle cerebral artery dissection treated by trapping under sensitive evoked potential and motor evoked potential monitoring: Case report and discussion.

BACKGROUND: Dissecting giant pseudoaneurysm of the middle cerebral artery (MCA) is a rare lesion often presenting challenges to neurosurgical teams dealing with this specific pathology. Giant pseudoaneurysm originating from a dissecting distal segment of the MCA treated with aneurysm trapping under motor and sensitive evoked potential monitoring with a successful outcome is presented in the article followed by a brief discussion on the subject. CASE DESCRIPTION: A case of a previously healthy young female patient admitted at the emergency room of Santa Paula Hospital with a history of a sudden headache and syncope, dysphasia, and Grade 4 right hemiparesis due to a large brain hemorrhage secondary to a 25 mm ruptured pseudoaneurysm originated from a distal left MCA dissecting segment is described. Because the patient risked neurological worsening, aneurysm was treated with parent and efferent vessel trapping technique and no changes on the sensitive and motor evoked potential (MEP) from baseline informed on this decision. Hemorrhage was completely drained after aneurysm was secured. CONCLUSION: Neurophysiological sensitive and MEP monitoring, on this specific case was a valuable tool and informed on the decision of trapping of this large vascular lesion.

Effectiveness of C5 or C6-Cz assembly in predicting immediate post operative facial nerve deficit.

BACKGROUND: Intraoperative neurophysiology monitoring (IOM) is a valuable tool in cerebellopontine angle (CPA) surgeries posing risk to the cranial nerves. Transcranial electrical stimulation (TES) for cranial nerves has been performed in the last 7 years, for obtaining the facial nerve motor evoked potential (MEP), using either C3/C4-Cz or C3-C4 (or inverse) stimulating points, which have been correlated with facial nerve functional outcome. METHOD: Intraoperative surgical and electrophysiological findings were documented prospectively. Patient files were reviewed for clinical data. We studied 23 patients undergoing CPA tumor resection using C5 or C6-Cz montage for TES, and were able to determine the correlation between facial nerve functional outcome and the amplitude drop of facial MEP above 50 %. Patients were evaluated for immediate facial nerve outcome and 6 months after the surgery. Follow-up was performed by structured telephone interviews with local physicians. RESULTS: The sensibility of the studied parameters was 92.8 % for amplitude drop of facial nerve MEP, with positive predictive value of 81.2 %. The absence of changes during IOM has shown a negative predictive value of 100 %. CONCLUSION: In this series, the used montage was effective in predicting new facial deficit.

Comparison between the C5 or C6-Cz electrode assembly and C3 or C4-Cz assembly for transcranial electric motor activation of muscular response of the contralateral facial nerve.

OBJECTIVE: We used an assembly of electrodes C3 and C4-Cz in order to activate the motor cortical area of the corticobulbar tract to elucidate the motor-evoked potential of the contralateral mentalis muscle. METHOD: We compared this setup to that of an assembly with electrodes C5 or C6-Cz using a train of electrical pulses and a single electrical pulse. This analysis was made in 23 consecutive patients who underwent several varied surgeries and were prospectively operated on at Santa Paula Hospital between January and June 2011. RESULTS: The results showed that the assembly with C5 or C6-Cz produced a multisynaptic motor-evoked potential in the contralateral mentalis muscle in 86.9 % of the patients, whereas 82.6 % of patients stimulated at points C3 or C4-Cz presented the same response. However, both assemblies showed similar behavior with the use of a single electrical pulse for peripheral contralateral nerve stimulation. CONCLUSION: We concluded that the C5 or C6-Cz assembly was similar to C3 or C4-Cz in obtaining a multisynaptic response in the contralateral mentalis muscle, although it required less intensive stimulation than the C3 or C4- Cz assembly.

Radiosurgery in the treatment of brain metastases: critical review regarding complications.

Stereotactic radiosurgery (SRS) has been described as an effective treatment option for brain metastases. In general, SRS has been indicated for the treatment of lesions smaller than 3 cm in maximum diameter and for lesions considered not surgically treatable, owing to the patient's clinical status or because the lesion was located in or near eloquent brain areas. In several studies, SRS has been associated with clinical and radiographic improvement of the lesions and has been compared with surgery as the modality of choice for brain metastases. Beyond the high rate of local disease control with SRS, the few complications that have been described occurred mainly in the acute post treatment period. Most publications have addressed the outcome and effectiveness of this treatment modality but have not critically analyzed long-term complications, steroid dependency, or results relating to specific brain locations. It is important to understand the radiobiologic effects of a well-demarcated high dose of radiation on the brain lesion, controlling the tumor growth and not causing significant alteration of the related brain region, especially in an area controlling eloquent function.