The extended pterional approach allows excellent results for removal of anterior cranial fossa meningiomas / O acesso pterional extendido permite excelente resultado para a ressecção dos meningiomas da fossa craniana anterior

ABSTRACT Objective To describe a unique operative strategy, instead the classical pterional approach, and to analyses it safety and effectiveness for removal of anterior cranial fossa meningiomas. Method We identify 38 patients with tuberculum sellae and olphactory groove meningiomas operated between 1986 and 2013. Medical charts, operative reports, imaging studies and clinical follow-up evaluations were reviewed and analyzed retrospectively. The pterional craniotomy is extended toward the frontal bone providing access through the subfrontal route, besides the usual anterolateral view provided by the classical pterional approach. Results Surgical mortality occurred in one patient (2.6%). Gross total resection was achieved in 27 patients (86.8%). Median time of follow-up was 69.4 months. Conclusion The extended pterional approach allows excellent results. Total removal of meningiomas of the anterior cranial fossa was obtained in 86.8 % of patients, with low morbidity and mortality.

RESUMO Objetivo Descrever a craniotomia pterional estendida, ao invés da abordagem pterional clássica, e analisar sua segurança e eficácia para a remoção dos meningiomas da fossa anterior. Método Identificamos 38 pacientes com meningiomas do tubérculo da sela e da goteira olfatória operados entre 1986 e 2013. Os prontuários, relatórios cirúrgicos, exames de imagem e acompanhamento pós-operatório foram analisados retrospectivamente. A craniotomia pterional com extensão para o osso frontal permite acesso pela via subfrontal além da via anterolateral do acesso pterional clássico. Resultados A mortalidade cirúrgica foi de 2,6% (um paciente). A remoção total foi alcançada em 86,8% (27 pacientes) com um tempo médio de seguimento de 69,4 meses. Conclusão A abordagem pterional estendida permite excelentes resultados. A remoção total dos meningiomas da fossa craniana anterior foi obtida em 86,8% dos pacientes, com baixa morbi-mortalidade.

Atypical and anaplastic meningiomas in a public hospital in São Paulo State, Brazil / Meningiomas atípicos e anaplásicos em um hospital público de São Paulo, Brasil

Atypical/anaplastic (World Health Organization (WHO) grades II and III) are less common and have poorer outcomes than benign meningiomas. This study aimed to analyze the outcome of patients with these tumors.Method Overall/recurrence-free survivals (RFS) and the Karnofsky Performance Scale of 52 patients with grades II (42) and III (9) meningiomas surgically treated were analyzed (uni/multivariate analysis).Results Total/subtotal resections were 60.8%/35.3%. Patients <60 years-old and grade II tumors had longer survival. Grade II tumors, total resection andde novo meningioma had better RFS (univariate analysis). Patients >60 years-old, de novo meningioma and radiotherapy had longer survival and patients <60 years-old and with grade II tumors had longer RFS (multivariate analysis). Recurrence rate was 51% (39.2% Grade II and 66.7% Grade III). Operative mortality was 1.9%.Conclusion Age <60 years-old, grade II tumors and de novomeningiomas were the main predictors for better prognosis among patients with grades II and III meningiomas.

Meningiomas atipicos/anaplásticos (graus II e III da World Health Organization (WHO)) são menos comuns e tem prognóstico pior que os benignos. Este estudo visa analisar o prognóstico de pacientes com estes tumores.Método Sobrevida/sobrevida livre de doença (SLD) e índice de Karnofsky de 52 pacientes com meningiomas graus II (42) e III (9) tratados cirurgicamente foram avaliados (análises uni/multivariada).Resultados Pacientes <60 anos e com tumores grau II tiveram sobrevida mais longa. Tumores grau II , ressecção total e meningioma de novotiveram melhor SLD (análise univariada). Pacientes >60 anos, meningiomade novo e radioterapia tiveram sobrevida mais longa e, pacientes <60 anos e com tumores grau II tiveram SLD mais longa (análise multivariada). Recidiva ocorreu em 51% (39.2% Graus II e 66,7% Graus III). A mortalidade operatória foi 1,9%.Conclusão Idade <60 anos, meningiomas grau II e de novo foram preditores de melhor prognóstico entre pacientes com meningiomas graus II/ III.

Impact of Multimodality Approach for Patients with Leptomeningeal Metastases from Solid Tumors

The purpose of this study was to evaluate treatment patterns, outcome and prognosticators for patients with leptomeningeal metastases from solid tumor. Medical records of 80 patients from January 1, 2004 to May 31, 2011 were retrospectively reviewed. Most frequent site of origin was the lung (59%) followed by the breast (25%). Most patients were treated with intrathecal chemotherapy (90%) and/or whole brain radiotherapy (67.5%). Systemic therapy was offered to 27 patients (33.8%). Percentage of patients treated with single, dual, and triple modality were 32.5%, 43.8%, and 23.8%, respectively. Median survival was 2.7 months and 1 yr survival rate was 11.3%. Multivariate analysis showed that negative cerebrospinal fluid cytology, fewer chemotherapy regimen prior to leptomeningeal metastases, whole brain radiotherapy, systemic therapy, and combined modality treatment (median survival; single 1.4 vs. dual 2.8 vs. triple 8.3 months, P<0.001) had statistical significance on survival. Subgroup analysis of non-small cell lung cancer (NSCLC) patients showed that targeted therapy had significant independent impact on survival (median survival; 10.5 vs. 3.0 months, P=0.008). Unlike previous reports, survival of patients with NSCLC primary was comparable to breast primary. Furthermore, combined modality treatment for all patients and additionally targeted therapy for NSCLC patients should be considered in the treatment of leptomeningeal metastases from solid tumor.

Mortality is higher in patients with leptomeningeal metastasis in spinal cord tumors / Mortalidade é mais elevada na disseminação metastática leptomeníngea em tumores da medula espinhal

Spinal cord tumors are a rare neoplasm of the central nervous system (CNS). The occurrence of metastases is related to poor prognosis. The authors analyzed one series of metastasis cases and their associated mortality. METHODS: Clinical characteristics were studied in six patients with intramedullary tumors with metastases in a series of 71 surgical cases. RESULTS: Five patients had ependymomas of which two were WHO grade III. The patient with astrocytoma had a grade II histopathological classification. Two patients required shunts for hydrocephalus. The survival curve showed a higher mortality than the general group of patients with no metastases in the CNS (p<0.0001). CONCLUSION: Mortality is elevated in patients with metastasis and greater than in patients with only primary lesions. The ependymomas, regardless of their degree of anaplasia, are more likely to cause metastasis than spinal cord astrocytomas.

Tumores da medula espinhal são neoplasias raras do sistema nervoso central (SNC). A ocorrência de metástases é relacionada a pior prognóstico. Os autores analisaram uma série de casos de metástases e a mortalidade relacionada. MÉTODO: Foram estudadas as características clínicas em seis pacientes com metástases tumorais numa série de 71 casos operados. RESULTADOS: Cinco pacientes tinham ependimomas e dois dos quais foram grau III pela classificação da OMS. O paciente portador de astrocitoma tinha classificação histopatológica de grau II. Dois pacientes necessitaram de derivação devido à hidrocefalia. A curva de sobrevivência mostrou mortalidade mais elevada no grupo de pacientes com disseminação pelo SNC (p<0,0001). CONCLUSÃO: A mortalidade, além de elevada em pacientes com metástases, é maior do que em pacientes apenas com lesão primária. Os ependimomas, independentemente do seu grau de anaplasia, costumam causar mais metástases do que os astrocitomas medulares.

Olfactory groove meningiomas: surgical technique and follow-up review

BACKGROUND: Olfactory groove meningiomas comprise 4-10 percent of the intracranial meningiomas. Generally they give signs of brain compression due to great size they reach before diagnosis. In this study, the clinical outcome of patients with olfactory groove meningiomas surgically treated was analyzed. METHOD: 17 patients operated on from 1988-2006. Female: 16, Male: 1. Age: 19-76 years-old (mean=53.12± 13.11). Follow-up: 1-209 months (mean=51.07±12.73. Bifrontal/bifrontal-bi-orbital approaches were used. Outcome was analyzed using survival/recurrence-free Kaplan-Mayer curves. RESULTS:16 had WHO grade 1; one grade 2 meningiomas. Resection Simpson's grade 1 was in achieved in 64.7 percent, grade 2 in 29.4 percent and grade 3 in 5.9 percent. There was no recurrence during the follow-up. Global and operative mortality were 11.8 percent. Main postoperative complications were osteomielitis (11.8 percent) and pneumonia (5.9 percent). CONCLUSION: Extensive approaches allowed total resection of most olfactory groove meningiomas with no recurrence during the follow-up, but operative mortality and local complications were high.

INTRODUÇÃO: Os meningiomas da goteira olfatória constituem 4-10 por cento dos meningiomas intracranianos. Geralmente eles causam sinais de compressão do tronco cerebral porque atingem grandes tamanhos antes do diagnóstico. Neste estudo foram analisadas os resultados do tratamento cirúrgico de pacientes com meningiomas da goteira olfatória. MÉTODO: 17 pacientes operados de 1988-2006. Mulheres: 16. Homens: 1. Idade: 19-76 anos (média=53,12±13,11). Seguimento: 1-209 meses (média=51,07±12,73. Foram utilizados acessos bifrontal/bifrontal bi-orbital. A evolução clinica foi analisada usando curvas de sobrevida e de sobrevida livre de doença de Kaplan-Mayer. RESULTADOS: 16 pacientes tinham meningioma WHO grau 1; um tinha meningioma grau 2. Ressecção Simpson grau 1 foi obtida em 64.7 por cento, grau 2 em 29.4 por cento e grau 3 em 5.9 por cento. Não houve recidiva durante o seguimento. A mortalidade global e a pós-operatória foram 11.8 por cento. As principais complicações pós-operatórias foram osteomielite (11.8 por cento) e pneumonia (5.9 por cento). CONCLUSÃO: Abordagens extensas possibilitaram ressecção total da maioria dos meningiomas da goteira olfatória sem recidiva durante o seguimento, mas a mortalidade operatória e as complicações locais foram altas.

Meningiomas intracraneales / Intracranial meningiomas

The author excised an intracranial meningioma from 28 patients, 17 women and 11 men, between 7 and 78 years of age, from 1974 to 1992. The tumor was located in the olfactory groove in 4 patients, in the cerebral convexity in another 4, in the falx in 8 (3 in the frontal and 5 in the parietal region). In 6 patients, the meningioma was found in the inner one third and in 1 in the middle third of sphenoid; in 1, in the clivus, in 1 in the petrous bone; in 2 patients the tumor was located in the tubercle of the sella turcica and in another patient it was in the cerebello-pontine angle. Total resection of the meningioma was accomplished in 16 patients (57.1%) because the tumor was in an accessible area. The tumor recurred in one patient, who died 5 years post operatively. In 8 (28.5%) of 12 patients in whom subtotal resection was done, post operative radiation was used, and in 3 of them recurrence occurred in less than 5 years after completion of treatment and in one, in less than 10. In 3 of the remain 4 patients, in whom subtotal resection was done but were not followed by radiation therapy, recurrence also occurred before 5 years post surgery, and in 1 patient at the end of 5 years

Retinoblastoma: invasión al sistema nervioso central / Retinoblastoma: central nervous system invasion

Se presenta el caso de un paciente del sexo masculino de 2 años de edad, que cursó con retinoblastoma bilateral. El O.D. fue enucleado con persistencia de actividad neoplásica en el borde de sección quirúrgica, lo que propició carcinamatosis meníngea, diseminación al sistema ventricular, invasión al diencéfalo, corteza cerebral y cerebelosa. Se presentan los hallazgos de autopsia y la correlación clínico*patológica