Multidomain and long-term cognitive evaluation in malignant glioma patients.

Aim: We performed longitudinal evaluations of the neurocognitive status in glioma patients to describe possible variations over the course of illness. Materials and methods: Glioma patients underwent a complete battery of standardized neuropsychological tests pre-radiotherapy at 6, 12 and 24 months. Results: We enrolled 130 patients, 67.7% of whom had a deficit in at least one cognitive domain. The most affected domains included executive function (n = 68, 52.3%), long-term memory (n = 46, 35.3%) and short-term memory (n = 39, 30%). At follow-up, cognitive status worsened in 31.5%, remained unchanged in 38.4% and improved in 30.1% of patients. Conclusion: This is one of few studies investigating longitudinal neurocognitive status in a wide sample of patients to monitor neuropsychological changes due to tumor progression and treatment administration.

Malignant gliomas are brain tumors with dismal prognosis that can affect patients' neurocognitive status. We performed longitudinal neuropsychological assessments to describe variations due to illness progression and treatment administration. Patients underwent a battery of standardized neuropsychological tests tapping into different cognitive domains (memory, attention, abstract reasoning, executive functions, learning), pre-radiotherapy and at 6, 12 and 24 month follow-up. We enrolled 130 patients, and almost 70% of them had at least one cognitive deficit. The most affected domains were executive function and long- and short-term memory. At follow-up assessments, cognitive status worsened in one-third of patients, whereas it remained unchanged or improved in two-thirds of patients. This is one of few longitudinal studies investigating cognitive function in a large sample of patients to monitor changes along the illness course.

The role of surgical resection in patients with brain metastases.

PURPOSE OF REVIEW: Treatment of brain metastases represent a critical issue and different options have to be considered according to patients and tumour characteristics; in recent years, new therapeutic strategies have been proposed. In this review, we discuss the role of surgical resection on the basis of patient selection, new surgical techniques and the use of intraoperative adjuncts. The integration with postoperative whole brain radiotherapy will be also outlined because alternative treatment options are currently available. RECENT FINDINGS: Surgical removal has been considered the mainstay in the treatment of brain metastases, in selected patients, with limited number of intracranial lesions and controlled primary disease, mainly in combination with whole brain radiotherapy. In the last few years, the increasing role of stereotactic focal radiotherapy has deeply modified the indications to open surgical procedures and whole brain radiotherapy. SUMMARY: The appearance of brain metastases is considered a sign of bad prognosis. Treatment of these lesions is important for quality of life, providing local tumour control, preventing death from neurological causes and improving survival, although potentially only in a minority of patients. Careful patient selection, with adequate evaluation of clinical prognostic score, the use of appropriate surgical techniques and surgical adjuncts are major determinants of favourable outcome in patients undergoing resection of brain metastases.

Endoscopic Reconstruction of CSF Pathways in Ventricular Tumors.

Neuroendoscopy is now considered to be a minimally invasive surgical approach for expanding lesions bulging into the ventricle, and it is also considered to be a relevant tool for performing biopsy procedures, fenestration of cystic walls, or for performing tumor removal in selected cases. Furthermore, the use of neuroimaging and the accurate follow-up of brain tumor patients have allowed the documentation of tumoral and pseudotumoral cystic areas that cause the obstruction of cerebrospinal fluid (CSF) pathways. Neuroendoscopic procedures enable the fenestration of cystic lesions, in addition to enabling third ventriculostomy or septostomy to restore CSF pathways. We analyze our experience regarding 77 patients affected by brain tumors arising from the wall of the third or lateral ventricle. In all cases hydrocephalus or obstruction of CSF flow was present. With an endoscopic technique, septostomy, cystostomy, endoscopic third ventriculostomy (ETV), and tumor resection were performed to control intracranial hypertension.ETV was performed in 53 patients with noncommunicating hydrocephalus. In 4 patients with low-grade astrocytoma ETV was definitely the only surgical treatment. In 12 cystic tumors, cystostomy and marsupialization into the ventricle solved a relevant mass effect with clinical intracranial hypertension syndrome. In 10 patients, neuroendoscopic relief of CSF pathways was possible by performing septostomy with the implantation of an Ommaya reservoir or one-catheter shunt. In 5 colloid cysts and 2 cystic craniopharyngiomas, removal was possible by restoring CSF flow without other procedures. After intracranial hypertension control, in 13 malignant gliomas and 5 leptomeningeal metastases, the patients' quality of life improved sufficiently to provide for tumor adjuvant therapy.In this series, endoscopy, due to its minimally invasive characteristics and reduced complications, was found to be safe and effective, without any relevant postoperative morbidity, gained by avoiding major surgical approaches.Based on these results and on the increasing number of series described in the literature, we believe that endoscopic techniques should be considered a selected approach for treating CSF obstructions caused by para-intraventricular tumors. The result of using neuroendoscopy is the reconstruction of CSF pathways that bypass the tumor occlusion. This surgical procedure is not only limited to the relief of noncommunicating hydrocephalus, but it is also useful for tumor removal or biopsies and the evacuation of cystic lesions. In patients affected by malignant tumors, neuroendoscopy can be performed to control intracranial hypertension before the patients start adjuvant chemotherapy or radiotherapy.

Neuroendoscopic biopsy of ventricular tumors: a multicentric experience.

OBJECT: Although neuroendoscopic biopsy is routinely performed, the safety and validity of this procedure has been studied only in small numbers of patients in single-center reports. The Section of Neuroendoscopy of the Italian Neurosurgical Society invited some of its members to review their own experience, gathering a sufficient number of cases for a wide analysis. METHODS: Retrospective data were collected by 7 centers routinely performing neuroendoscopic biopsies over a period of 10 years. Sixty patients with newly diagnosed intraventricular and paraventricular tumors were included. No patient harboring a colloid cyst was included. Data regarding clinical presentation, neuroimaging findings, operative techniques, pathological diagnosis, postoperative complications, and subsequent therapy were analyzed. RESULTS: In all patients, a neuroendoscopic tumor biopsy was performed. In 38 patients (64%), obstructive hydrocephalus was present. In addition to the tumor biopsy, 32 patients (53%) underwent endoscopic third ventriculostomy (ETV), and 7 (12%) underwent septum pellucidotomy. Only 2 patients required a ventriculoperitoneal shunt shortly after the endoscopy procedure because ETV was not feasible. The major complication due to the endoscopy procedure was ventricular hemorrhage noted on the postoperative images in 8 cases (13%). Only 2 patients were symptomatic and required medical therapy. Infection occurred in only 1 case, and the other complications were all reversible. In no case did clinically significant sequelae affect the patient's outcome. Tumor types ranged across the spectrum and included glioma (low- and high-grade [27%]), pure germinoma (15%), pineal parenchymal tumor (12%), primary neuroectodermal tumor (4%), lymphoma (9%), metastasis (4%), craniopharyngioma (6%), and other tumor types (13%). In 10% of patients, the pathological findings were inconclusive. According to diagnosis, specific therapy was performed in 35% of patients: 17% underwent microsurgical removal, and 18% underwent chemotherapy or radiotherapy. CONCLUSIONS: This is one of the largest series confirming the safety and validity of the neuroendoscopic biopsy procedure. Complications were relatively low (about 13%), and they were all reversible. Neuroendoscopic biopsy provided meaningful pathological data in 90% of patients, making subsequent tumor therapy feasible. Cerebrospinal fluid pathways can be restored by ETV or septum pellucidotomy (65%) to control intracranial hypertension. In light of the results obtained, a neuroendoscopic biopsy should be considered a possible alternative to the stereotactic biopsy in the diagnosis and treatment of ventricular or paraventricular tumors. Furthermore, it could be the only surgical procedure necessary for the treatment of selected tumors.