Diagnostic delay in primary central nervous system lymphoma.

This study investigates delay in diagnosing primary central nervous system lymphoma (PCNSL), which has a variable clinical and radiological presentation. Early diagnosis and treatment may improve survival and cause less sequela in PCNSL. Medical records of all new cases of PCNSL morphologically verified while alive or by autopsy in Norway in 1989-1998 were reviewed (n = 74). The time from initial symptom to final morphological diagnosis of PCNSL had a median (mean, range) of 70 (106, 22-330) days in 16 AIDS patients and 75 (157, 8-1285) days in 58 non-AIDS patients. Among non-AIDS patients, the time to diagnosis was longer in patients with no tumour in the first neuroimaging report after initial symptom (p = 0.001). Median (mean, range) time from initial symptom to neuroimaging was 14 (25, 1-60) days in AIDS patients and 21 (88, 1-1095) days in non-AIDS patients. In the non-AIDS group, those presenting with personality change or visual disturbance had more delayed imaging than the others. The time from first neuroimaging examination to final diagnosis in non-AIDS patients had a median (mean, range) of 28 (69, 1-845) days, and was longer when no tumour was indicated in the imaging report (p = 0.005) and if first biopsy did not confirm the diagnosis (p = 0.02). All AIDS patients had their diagnosis of PCNSL first established by autopsy. The time from first neuroimaging to autopsy had a median (mean, range) of 48 (81, 10-270) days. There is a considerable delay in the diagnosis of PCNSL and strategies for earlier diagnosis are thus needed. Physicians should consider early neuroimaging in patients with personality changes or visual disturbance, early renewed imaging in patients with persistent neurological symptoms but no tumour on initial imaging, and early/repeated biopsy of focal brain lesions in both AIDS patients and non-AIDS patients.

Incidence, clinical features, treatment and outcome of primary central nervous system lymphoma in Norway.

The incidence of primary central nervous system lymphoma (PCNSL) has been reported to increase in some parts of the world, while being stable in other regions. In an attempt to characterize the incidence rate, clinical features, treatment, outcome, and prognostic factors of PCNSL in Norway, we report our experience in a large unselected series of patients. Clinical features, histological diagnosis, radiological findings, treatment, and outcome of all patients diagnosed with PCNSL in Norway in the years 1989-1998 were registered. During the 10-year period 58 new cases of histologically verified PCNSL were registered in Norway. The annual incidence rate of PCNSL was on average 1.34 cases per million people with a non-significant increasing trend (p=0.069). For patients diagnosed before death (n=45) the estimated survival following histological diagnosis was 55%, 47%, and 23% at 1, 2, and 5 years, respectively. In Cox-regression analysis age, WHO performance status and treatment had independent prognostic impact on survival. In the studied decade, there was a non-significant trend towards increased incidence of PCNSL, perhaps due to increased availability of diagnostic imaging, especially magnetic resonance imaging.

Gamma-knife radiosurgery in pediatric cerebral and skull base tumors.

BACKGROUND: This retrospective study of 12 children with cerebral or skull base tumors was undertaken to evaluate morbidity and outcome after gamma-knife surgery. PROCEDURE: Twelve consecutive children treated with stereotactic radiosurgery in a curative intent were reviewed. There were five girls and seven boys. The mean age at diagnosis was 5.8 years and at radiosurgical treatment 8.4 years. There were four pilocytic astrocytomas, two craniopharyngeomas, two pineoblastomas, two ependymomas, and two other tumors of high malignancy. We used a 201-source Co60 Leksell gamma knife and all children were treated in general anesthesia. RESULTS: The mean tumor volume was 3.7 cm(3) and the mean tumor margin dose was 13.8 Gy. Seven patients remained stable after gamma-knife treatment with a mean follow- up of 78.6 months. One patient died during follow-up. The remaining four patients had progressive disease, two within and two outside the irradiated field, and have received further treatment. They are still alive with and without disease with a mean follow-up of 96.8 months. CONCLUSION: Gamma-knife surgery is an effective treatment in some non-resectable cerebral and skull base pediatric tumors. In most cases, it is used in combination with other therapeutic modalities. It is safe and well tolerated.

[Treatment of acoustic neuroma]. / Behandling av akustikusnevrinom.

BACKGROUND: Acoustic neuroma is the most common tumour in the cerebello-pontine angle. MATERIAL AND METHODS: We present the results after surgery in 99 cases, and the natural course of the disease in 82 patients followed for up to 20 years (mean 3 years). RESULTS: During the observation period, 43% of the tumours increased in size. 36% of patients suffered increasing hearing loss. Total removal was accomplished in 92 cases. In 12 cases hearing preservation was attempted; successfully in five cases. 72 patients had normal or near normal postoperative facial nerve function, whereas 19 patients got a facial nerve paralysis. Two patients died, one because of haemorrhagic infarction and cerebellar swelling, and one because of ventricular fibrillation. Five patients had to be reoperated for CSF leakage. INTERPRETATION: Acoustic neuroma treatment is still a challenge. We favour a team approach to treat this condition.

[Stereotactic radiosurgery of cerebral arteriovenous malformations]. / Stereotaktisk strålekirurgi av cerebrale arteriovenøse malformasjoner.

BACKGROUND: Different treatment modalities are being used for cerebral arteriovenous malformations. MATERIAL AND METHODS: We have evaluated the results of stereotactic radiosurgery on 85 patients (48 females) with median age 34.5 years (range 4-70 years) treated at Haukeland University Hospital in Norway in 1989-96. Median follow-up time was 7 years 3 months (range 51-144 months). Data were obtained retrospectively from patient files. RESULTS: Haemorrhage was the initial symptom in 72 patients. The majority of lesions were located deep within the brain parenchyma or near critical structures. The minimum dose to the periphery of the malformation was 15 to 33.3 Gy in 30-70% isodose line according to the volume and location of the malformation. Complete obliteration was obtained in 65 of 85 malformations (77%) and in two of five patients who were retreated. 85% of the malformations smaller than 4 cm3; 50% of those larger than 4 cm3 were obliterated after the treatment. The majority of the malformations were obliterated between two and three years after radiation. Radiation-related side effects were observed in six patients. Five patients experienced new bleeding during follow-up. INTERPRETATION: Small and medium-sized arteriovenous malformations are successfully treated with stereotactic radiosurgery with an acceptable rate of radiation-related side effects and latency bleeding.