Atypical and Malignant Meningiomas: Neurooncologic Management in a Brazilian cohort.

OBJECTIVE: To analyze the surgical and oncologic treatment of a Brazilian cohort of patients with grade II and III meningioma at a follow-up time of 15 years to get an overview of these patients' outcomes. METHODS: Cross-sectional study of 43 patients (26 women, 17 men; age range 20 to 83 years; average 57.72 ± 14.54) operated on from 2000 to 2014 at a single institution, with the neuropathologic diagnosis of meningioma grade II (39 patients) and grade III (4 patients). RESULTS: Radiotherapy: 24 patients (55.81%) underwent radiotherapy; the time between the surgical procedure and the beginning of radiotherapy was 5 months; 7 patients with a diagnosis of AM underwent a new surgical procedure, albeit of adjuvant therapy, because of tumor recurrence, and only 3 of them underwent radiotherapy after the first resection. Mortality: in total, 19 deaths (44.18%) were identified in this sample: 15 (38.46%) with GII and 4 (100%) with GIII. The 10-year survival was expected in 35% of GII patients and 0% of GIII patients. CONCLUSION: Surgery is still the main form of treatment and the mainstay for prolonging survival. Radiotherapy is still controversial; however, we observed its positive impact on recurrence and progression-free survival.

Clinical Outcome, Tumor Recurrence, and Causes of Death: A Long-Term Follow-Up of Surgically Treated Meningiomas.

OBJECTIVE: The medical literature still lacks information about the impact of surgery and adjuvant treatment on the life of patients with meningioma. The clinical outcome, timing of tumor recurrence, and causes of death are often overlooked. This study evaluates these data taking into account tumor localization and histologic grade. METHODS: The article is a cross-sectional study of patients operated on between 2000 and 2014 in a single institution. The series has 593 adult patients (442 females and 151 males) and follow-up of 68.8 ± 48.9 months. Imaging of 434 patients was reviewed and 379 patients/families interviewed. RESULTS: Sixty-eight deaths were related to tumor treatment/progression and 36 to other causes. After 2 years of surgery, deaths not related to tumor were 7 times more frequent than were tumor-related deaths (odds ratio, 7.1; 95% confidence interval, 2.8-19.5; P < 0.0001). Ten-year survival was expected in 85% of patients with grade I (GI) meningioma, 35% of patients with atypic (GII) meningioma, and 0% of patients with anaplastic (GIII) meningioma. Convexity tumors had about half the risk of recurrence compared with other localizations (odds ratio, 0.4; 95% confidence interval, 0.27-0.67; P = 0.0002). In GI meningioma, recurrence was neither related to death nor to impairment of independent life. All patients with GII and GIII meningioma who had recurrence died. 96.3% of interviewees reported neurologic improvement or stability after the surgery. CONCLUSIONS: Histologic grade is the most important factor for long-term survival. Complete resection has to be pursued in GII and GIII meningioma but must be carefully weighed against morbidities in GI meningioma.

Metástases encefálicas: considerações sobre diagnóstico e tratamento / Brain metastasis: a critical review about diagnosis and treatment

O câncer sistêmico é a segunda maior causa de mortalidade na população adulta. Destes pacientes, 20% desenvolvem sintomas neurológicos em algum momento de sua doença. A incidência do câncer sistêmico vem crescendo com a evolução dos exames diagnósticos, melhora das terapias e ao aumento da sobrevida da população geral. Isto reflete, conseqüentemente, no aumento da incidência das metástases intracranianas o que representa, por sua vez, uma considerável fonte de morbimortalidade. Neste artigo os autores revisam os princípios de diagnóstico e conduta a cerca das metástases encefálicas.

Low-grade astrocytoma: surgical outcomes in eloquent versus non-eloquent brain areas.

A retrospective study of 81 patients with low-grade astrocytoma (LGA) comparing the efficacy of aggressive versus less aggressive surgery in eloquent and non-eloquent brain areas was conducted. Extent of surgical resection was analyzed to assess overall survival (OS) and progression- free survival (PFS). Degree of tumor resection was classified as gross total resection (GTR), subtotal resection (STR) or biopsy. GTR, STR and biopsy in patients with tumors in non-eloquent areas were performed in 31, 48 and 21% subjects, whereas in patients with tumors in eloquent areas resections were 22.5, 35 and 42.5%. Overall survival was 4.7 and 1.9 years in patients with tumors in non-eloquent brain areas submitted to GTR/STR and biopsy (p=0.013), whereas overall survival among patients with tumors in eloquent area was 4.5 and 2.1 years (p=0.33). Improved outcome for adult patients with LGA is predicted by more aggressive surgery in both eloquent and non-eloquent brain areas.

Low-grade astrocytoma: surgical outcomes in eloquent versus non-eloquent brain areas / Astrocitoma de baixo grau: resultado cirúrgico em área eloquente versus não eloquente

A retrospective study of 81 patients with low-grade astrocytoma (LGA) comparing the efficacy of aggressive versus less aggressive surgery in eloquent and non-eloquent brain areas was conducted. Extent of surgical resection was analyzed to assess overall survival (OS) and progression- free survival (PFS). Degree of tumor resection was classified as gross total resection (GTR), subtotal resection (STR) or biopsy. GTR, STR and biopsy in patients with tumors in non-eloquent areas were performed in 31, 48 and 21% subjects, whereas in patients with tumors in eloquent areas resections were 22.5, 35 and 42.5%. Overall survival was 4.7 and 1.9 years in patients with tumors in non-eloquent brain areas submitted to GTR/STR and biopsy (p=0.013), whereas overall survival among patients with tumors in eloquent area was 4.5 and 2.1 years (p=0.33). Improved outcome for adult patients with LGA is predicted by more aggressive surgery in both eloquent and non-eloquent brain areas.

Foi realizado estudo retrospectivo em 81 pacientes com astrocitoma de baixo grau (LGA) comparando a eficácia da ressecção cirúrgica com cirurgia menos agressiva em relação à área eloquente e não eloquente do cérebro. A extensão da ressecção cirúrgica foi analisada para avaliar a sobrevida geral (OS) e o tempo livre de doença (PFS). O grau da ressecção cirúrgica foi classificado como ressecção total (GTR), subtotal (STR) e biópsia. Nos pacientes com lesão em área não eloquente foram realizadas GTR, STR e biópsia em 31, 48 e 21% dos casos, enquanto, naqueles com lesão em área eloquente, em 22,5, 35 e 42,5%, respectivamente. A sobrevida geral foi de 4,7 e 1,9 anos em pacientes com lesões em área não eloquente submetidos à GTR/STR e biópsia (p=0,013). Nos pacientes com lesão em áreas eloquentes, a sobrevida geral foi de 4,5 e 2,1 anos (p=0,33), respectivamente. A extensão da ressecção é fator preditivo de sobrevida tanto nas lesões em áreas eloquentes quanto nas não eloquentes.

Meningiomas múltiplos: relato de caso e revisão da literatura / Multiple meningiomas: report of a case and review of literature

O termo meningiomas múltiplos se refere a uma condição em que ocorre a presença de dois ou mais meningiomas em diferentes localizações intracranianas, simultâneos ou cronologicamente distintos, excluindo-se os casos de neurofibromatose. Relatamos o caso de um paciente de 56 anos de idade apresentando múltiplas lesões intracranianas. Os meningiomas múltiplos não apresentam comportamento clínico, patológico ou cirúrgico diferente dos meningiomas solitários, entretanto apresentam um mecanismo de formação próprio. As diferentes teorias de patogênese propostas na literatura são discutidas.

Use of intraoperative MRI for resection of gliomas / Uso de ressonância magnética intraoperatória para ressecção de gliomas

Literature has shown that extent of tumor resection has an impact on quality of life and survival of patients with gliomas. Intraoperative MRI has been used to increase resection while preserving procedure's safety. METHOD: The first five patients with gliomas operated on at the University of São Paulo using intraoperative MRI are reported. All but one patient had Karnofsky Performance Status of 100 percent before surgery. Presentation symptoms were progressive headache, seizures, behavior disturbance, one instance of hemianopsia, and another of hemiparesis. RESULTS: Gross total removal was achieved in two patients. Surgical resection was limited by tumor invasion of critical areas like the internal capsule or the mesencephalon in the remaining patients. CONCLUSION: Intra-operative MRI is an important tool that helps surgeons to remove glial tumors, however, knowledge of physiology and functional anatomy is still fundamental to avoid morbidity.

A literatura demonstra que extensão da ressecção do tumor tem impacto na qualidade de vida e sobrevida dos pacientes com gliomas. RM intraoperatória tem sido utilizada para aumentar a área de ressecção, preservando a segurança do procedimento. MÉTODO: Os cinco primeiros pacientes com gliomas operados na Universidade de São Paulo utilizando RM intraoperatória são relatados. Quatro pacientes tinham índice de Karnofsky de 100 por cento antes da cirurgia. Primeiros sintomas foram cefaléia progressiva, convulsões, distúrbios de comportamento, um caso de hemianopsia, e outro de hemiparesia. RESULTADOS: A remoção macroscópica total foi obtida em dois pacientes. A ressecção cirúrgica foi limitada pela invasão tumoral de áreas críticas como a cápsula interna ou o mesencéfalo no restante dos pacientes. CONCLUSÃO: A RM intra-operatório é uma importante ferramenta que auxilia o cirurgião para remover os tumores gliais, porém, o conhecimento da fisiologia e anatomia funcional ainda é fundamental para evitar a morbidade.

Cognitive impairments in patients with low grade gliomas and high grade gliomas.

OBJECTIVE: The relationship between brain tumors and cognitive deficits is well established in the literature. However, studies investigating the cognitive status in low and high-grade gliomas patients are scarce, particularly in patients with average or lower educational level. This study aimed at investigating the cognitive functioning in a sample of patients with low and high-grade gliomas before surgical intervention. METHOD: The low-grade (G1, n=19) and high-grade glioma (G2, n=8) patients underwent a detailed neuropsychological assessment of memory, executive functions, visuo-perceptive and visuo-spatial abilities, intellectual level and language. RESULTS: There was a significant impairment on verbal and visual episodic memory, executive functions including mental flexibility, nominal and categorical verbal fluency and speed of information processing in G2. G1 showed only specific deficits on verbal and visual memory recall, mental flexibility and processing speed. CONCLUSION: These findings demonstrated different levels of impairments in the executive and memory domains in patients with low and high grade gliomas.

Cognitive impairments in patients with low grade gliomas and high grade gliomas / Comprometimentos cognitivos em pacientes com gliomas de baixo grau e gliomas de alto grau

OBJECTIVE: The relationship between brain tumors and cognitive deficits is well established in the literature. However, studies investigating the cognitive status in low and high-grade gliomas patients are scarce, particularly in patients with average or lower educational level. This study aimed at investigating the cognitive functioning in a sample of patients with low and high-grade gliomas before surgical intervention. METHOD: The low-grade (G1, n=19) and high-grade glioma (G2, n=8) patients underwent a detailed neuropsychological assessment of memory, executive functions, visuo-perceptive and visuo-spatial abilities, intellectual level and language. RESULTS: There was a significant impairment on verbal and visual episodic memory, executive functions including mental flexibility, nominal and categorical verbal fluency and speed of information processing in G2. G1 showed only specific deficits on verbal and visual memory recall, mental flexibility and processing speed. CONCLUSION: These findings demonstrated different levels of impairments in the executive and memory domains in patients with low and high grade gliomas.

OBJETIVO: A associação entre tumores cerebrais e déficits cognitivos é bem estabelecida na literatura. No entanto, estudos sobre a cognição de pacientes com gliomas de baixo e alto grau são escassos, especialmente, em sujeitos com baixa escolaridade. Este estudo investigou o funcionamento cognitivo de uma amostra de pacientes com gliomas de baixo e alto grau antes da intervenção cirúrgica. MÉTODO: Os pacientes com glioma de baixo grau (G1, n=19) e alto grau (G2, n=8) foram avaliados quanto à memória, funções executivas, habilidades visuo-perceptivas e visuo-espaciais, nível intelectual e linguagem. RESULTADOS: Houve prejuízo significativo em G2 na memória episódica verbal e visual, funções executivas incluindo flexibilidade mental, fluência verbal nominal e categórica e velocidade de processamento de informações. G1 demonstrou apenas déficits específicos de evocação verbal e visual, flexibilidade mental e velocidade de processamento. CONCLUSÃO: Estes achados demonstraram níveis diferenciados de comprometimento nos domínios executivos e mnésticos de pacientes com gliomas de baixo e alto grau.

Use of intraoperative MRI for resection of gliomas.

UNLABELLED: Literature has shown that extent of tumor resection has an impact on quality of life and survival of patients with gliomas. Intraoperative MRI has been used to increase resection while preserving procedure's safety. METHOD: The first five patients with gliomas operated on at the University of São Paulo using intraoperative MRI are reported. All but one patient had Karnofsky Performance Status of 100% before surgery. Presentation symptoms were progressive headache, seizures, behavior disturbance, one instance of hemianopsia, and another of hemiparesis. RESULTS: Gross total removal was achieved in two patients. Surgical resection was limited by tumor invasion of critical areas like the internal capsule or the mesencephalon in the remaining patients. CONCLUSION: Intra-operative MRI is an important tool that helps surgeons to remove glial tumors, however, knowledge of physiology and functional anatomy is still fundamental to avoid morbidity.

Edema peritumoral em meningiomas: o que há de novo? / Peritumoral brain edema in meningiomas: what's new?

Objetivos: Edema peritumoral (EP) está presente em 60% dos meningiomas intracranianos. Ao contrário dos tumores intra-axiais, cuja fisiopatologia do edema é creditada a uma desordem da barreira hêmato-encefálica, o real mecanismo de formação do edema perilesional nos meningiomas ainda é desconhecida. Revisar as teorias de formação do EP, assim como suas diversas características são os objetivos deste artigo. Métodos: Os autores discutem, através de revisão de literatura, a associação do EP em meningiomas com fatores clínicos, radiológicos, cirúrgicos, histopatológicos e com recorrência tumoral. Resultados: Vários fatores causais têm sido discutido nos diversos artigos, como a quebra da barreira hêmato-encefálica, compressão mecânica e vascular; a secreção de fontes produtores de edema, relacionado a hipoplasia de veias de drenagem e ao padrão de vascularização pial. Conclusão: A causa da formação de edema peritumoral em meningiomas é provavelmente multifatorial e pode estar associada a um maior potencial invasivo do tumor. O seu estudo aprofundado poderá trazer dados adicionais para o esclarecimento dos mecanismos de formação dos meningiomas e de seu comportamento biológico levando ao melhor manejo clínico dos pacientes.

Objective: Approximately 60% of meningiomas are associated with peritumoral edema. Unlike intraxial tumors whose edema is credited to a blood brain barrier breakage, meningiomas’ peritumoral edema pathogenesis still remains unknown. The article reviews the edema´s formation theories and different edema characteristics. Methods: The authors discuss the association of peritumoralbrain edema with clinical, radiological, histopathological and surgical aspects, and recurrence in meningiomas. Results: Different theories have being proposed to explain their formation. Mechanical factors such as tumoral compression of the adjacent parenchyma causing cerebral ischemia or the compression of large veins or sinus are considered to cause edema. The production of edemagenic substances, the breakage of the blood brain barrier, edema related to the tumor drainage veins hypoplasia as well as pial blood supply are studied hypothesis. Conclusion: Peritumoral brain edema pathogenesis is probably related to several factors and may be associated to meningioma’s greater invading potentiality. As a consequence, it’s reasonable to consider edema’s presence as an additional factor to be taken into account when arranging layout of strategies for meningiomas treatment.