Descriptive Epidemiology of Brain and Central Nervous System Tumours: Results from Iran National Cancer Registry, 2010-2014.

BACKGROUND: Central nervous system (CNS) tumours account for only 1-2% of cancer incidence but are a major reason for mortality and morbidity due to malignancies. Recent studies show an increase in the rate of CNS tumours worldwide, especially in developing countries. Moreover, there is significant heterogeneity in epidemiological patterns worldwide. This study is aimed at representing nationwide epidemiology of CNS tumours in Iran. METHODS: Iran National Cancer Registry 2010-2014 data were reviewed for CNS tumours. The epidemiological rates were calculated for both genders and all age groups using the 2011 census information. RESULTS: Out of 17345 cases, 58.5% were men and 41.5% were women. The mean age was 45.55 years ranging from less than 1 month to 100 years old. Average total age-standardized incidence rate (ASR) was 5.19 for primary tumours. The annual percent change (APC) was 14.23% during the study period. The most frequent site and histology recorded were brain, NOS and diffuse astrocytic, respectively. Geographical distribution showed about five-fold difference in ASRs between different provinces. CONCLUSION: The overall ASR calculated was higher than the global rate in 2012 but lower than that of most developed countries, showing an increasing trend which may be due to either advances in diagnosing or risk factor augmentation. The mean age and incident rates were higher than those of previous reports in Iran.

The role of tranexamic acid in prevention of hemorrhage in major spinal surgeries.

BACKGROUND: Blood loss that necessitates blood transfusion is one of the most frequent complications of major spinal surgeries. This study has been designed to evaluate the efficacy and safety of prophylactic tranexamic acid (TA) in decreasing perioperative blood loss. MATERIALS AND METHODS: From January to August 2011, all the patients who needed major spinal surgeries and aged between 18 and 60-year-old were divided into two groups randomly, the experimental group received 10 mg/kg of TA 20 min after inducing the anesthesia as loading dose followed by 0.5 mg/kg/h until skin closure and the control group received equal amounts of normal saline as placebo. Intraoperative blood loss was recorded by estimating blood with the suction tube plus the number of bloody gasses. The amounts compared between the 2 groups and analyzed. RESULTS: Forty patients were enrolled in this study in the first group intraoperative, the 1st and 2nd postoperative days, the mean blood loss were 574 ml, 80.5 ml, and 669.5 ml while in the second group were 797 ml, 124 ml, and 921.5 ml. CONCLUSION: TA seems to be safe and can be considered in spinal surgeries with significant excepted blood loss especially in female patients and instrumental procedures. We suggest further studies on TAs efficacy and safety in larger scales.

Psychological consideration in patients with cerebral gliomas candidates for intra-operative radiation therapy based on tumor location.

OBJECTIVE: Intra-operative Radiation Therapy (IORT) is gaining popularity as an adjuvant option to surgical resection, in treatment of glioblastoma multiforme (GBM) for increasing survival rate, which a highly aggressive cerebral tumor with poor prognosis. Τhe authors plan to investigate the effects of IORT combined with surgical resection on the psychological status of these patients based on tumor location. SUBJECT AND METHODS: From December 2013 to February 2017, we have enrolled 109 patients with high grade cerebral gliomas, documented by Magnetic Resonance Spectroscopy (MRS). Patients with previous history of brain surgery or radiation, altered mental status and psychological content and patients diagnosed with metastases were excluded. Demographic data, tumor volume based on pre-operative Magnetic Resonance Imaging (MRI) and psychological status were recorded based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. The remaining 56 patients, were equally randomized into conventional (surgical resection-group A), and trial (surgical resection with IORT-group B) who underwent IORT using the 50kV INTRABEAM® system (Carl Zeiss Meditec AG, Germany). Psychological profiles of both groups were re-evaluated in the 3rd post-operative month. RESULTS: Group A consisted of 18 males and 10 females with mean age of 54.4 years, while group B consisted of 16 males and 12 females with mean age of 57.8 years. Tumor volumetry revealed mean 81.52cc and 82.8cc for group A and B respectively. (P value 0.14) Patients were classified based on glioma location on pre-operative MRI: a) left parietal lobe (6 in group A, 5 in group B); b) left temporal lobe (7 in group A, 5 in group B); c) right parietal lobe (5 in group A, 6 in group B); d) left fronto-temporal lobe (4 in group A, 6 in group B); e) left parieto-temporal lobe (4 in group A, 5 in group B); and, f) right frontal lobe (2 in group A, 1 in group B). Group B received mean 8.05 Gy radiation for mean 11.2 minutes. Post-operative psychological in the 3rd month evaluation revealed the following in each class: a) Group A: 1 mild depression, Group B: 1 mild depression and 2 major depression; b) Group A: no disorder, Group B: 1 mild depression; c) no disorders in both groups; d) Group A: no disorder, Group B: 1 mild depression, 1 major depression and 1 Obsessive-Compulsive Disorder (OCD); Conclusion: Utilization of IORT is shown to improve survival rate of patients suffering from GBM. However, the psychological status is a major determinating factor for the quality of life of these patients. Our study showed that IORT increased psychological disorders in patients with gliomas located in left parietal, left fronto-temporal and left parieto-temporal lobes and should be considered in pre-operative strategy selection.

Deep brain nucleus targeting in Parkinson's disease and essential tremor by image guided surgery using neuronavigation system with tractography and volume of tissue of activated assessment.

OBJECTIVE: Deep Brain Stimulation (DBS) is an effective surgical approach for treatment of Parkinson's disease (PD), dystonia and essential tremor (ET). Traditionally, DBS is performed using frame-based stereotactic technique. Recently, image guided surgery (IGS) using neuronavigation has gained popularity in neurosurgical procedures. We aim to investigate whether DBS using neuronavigation is capable of improving patient's outcome and minimize its complications. SUBJECT AND METHODS: From February 2011 to October 2016, 20 patients with PD and 6 patients with ET were enrolled in the study. Patients aged between 18 to 70 years, were included and they underwent Magnetic Resonance Imaging (MRI) for deep brain nucleus volumetry. Among PD patients, 14 cases underwent subthalamic nucleus (STN) implantation, while other 6 cases underwent globus pallidus internus (GPi) implantation. Furthermore, ventral intermediate nucleus (VIN) implantation was performed for ET patients, all with IGS using neuronavigation system. Patients were assessed by unified Parkinson's disease rating scale (UPDRS) for PD and tremor scores for ET in their follow ups. Authors utilized Butson model for volume of tissue activated (VTA) assessment. In addition, detailed tractography was performed to evaluate white matter circuits radiating from deep nucleuses. RESULTS: PD patients with GPi volume of more than 600mm3 and less than 400mm3 were excluded from the study. Mean right and left GPi volume was 519±94.2mm3 and 480±80.3mm3, respectively. Calculated VTA based on Butson model revealed that 70% of cases who exhibited improved UPDRS of more than 50% in the 7th month of follow-up, had their VTA outside their defined GPi and STN boundaries with outer layer overlap. In contrast, 60% of cases who showed UPDRS improvement of less than 50% in same follow-up month, have their VTA inside defined GPi and STN boundaries. Moreover, ET patients experienced mean 55% and 79% improvement in tremor scores at mean 6.7 and 9.9 follow up month respectively. No surgery related complications were observed. Furthermore, tractography analysis revealed increased superior frontal gyrus and thalamus connection in patients with improved UPDRS. CONCLUSION: IGS using neuronavigation allowed more accurate deep nucleus targeting, minimized intra- and post-operative complications and improved clinical outcome in DBS candidate patients. Our study revealed that increased white matter connections with remote parts of the brain would suggest that isolated deep nucleus stimulation could not explain symptom recovery and that patients' specific white matter stimulation by tractography coupled with IGS should be in priority.

Psychological aspects in brain tumor patients: A prospective study.

OBJECTIVE: Very few studies have utilized specific criteria to assess mental disorders in brain tumor patients, and from them, they are mainly descriptive. The purpose of this study is to examine mental disorders in relation to tumor characteristics and patients' psychosocial factors using DSM-IV (depression, sleep and mood) criteria, among brain tumor patients. MATERIALS AND METHODS: From March 2009 to July 2011, 98 patients who surgically treated with intracranial neoplasm were included in this prospective study. The mean age of the patient group was 42.2 years with a range of 18-60 years with a male to female ratio of 1.2. The most common tumor type was glioblastoma multiform (30.3%), followed by meningioma (16.8%) and anaplastic glioma (12.3%). RESULTS: In our study, the prevalence of mild depression was about 30% for males and 38% for females before surgery; however at 3 months after surgery, this amount decreased to the amount of 25.6% and 26% for male and female patients respectively. Before tumor operation, the prevalence of major depression was 10.4% for males and 19.7% for females. At 3 months after operation the prevalence of major depression was 12.8% for males, and 6.7% for females. Aggression or suicide attempts were not seen related to depression. Before operative intervention, severe anxiousness as well as severe Obsessive Compulsive Disorder (OCD) symptoms was present in 14.7% of males while at 3 months after operation, prevalence of severe anxiousness and severe OCD symptoms decreased to 4% and 9.3% respectively. In females, 28.7% of the subjects had reported to have severe anxiousness and 25.6% severe OCD symptoms. Three months after surgery, these amounts were 17.6% and 38.7% respectively. CONCLUSION: Depressive symptoms as well as anxious and OCD psychopathology were shown to be prevalent signs among patients with brain tumor. Diagnosis of the previous mentioned symptoms were totally based on DSM-IV criteria and these disorders and the percentiles don't seem to be related to each other. Due to high variability of tumor stages, statistical analysis of whether the mentioned psychiatric symptoms get worsen at the later stages of the tumor genesis was not feasible. Although not measured directly, mentioned psychiatric symptoms seem to get worsen at the later stages of the brain tumor. The associated factors are tumor location, patient's premorbid psychiatric status, cognitive symptoms and adaptive or maladaptive response to stress.

Radioguided surgery using gamma detection probe technology for resection of cerebral glioma.

OBJECTIVE: Using microsurgical procedures without intraoperative imaging, Gross Total Resection (GTR) has so far only been achieved in less than 30% of all cases. Radio-guided surgery was introduced in the clinical setting in 1985 in an attempt to facilitate intraoperative tumor detection. Because of few studies in literature about this subject, we decided to use gamma probe with the hypothesis that we could increase extent of tumor resection. MATERIALS AND METHODS: From January 2013 till February 2014, 22 patients with cerebral glioma were randomized equally into two groups and evaluated. In the first group, 370MBq of Technetiumc-99m was injected. The microsurgical resection of the tumor was performed as much as possible, and then the tumoral bed was examined, if the signal was more than 2 times of the background signal, more tissue resection performed if feasible until the signal was diminished. In the control group, conventional resection of the tumor was performed. The extent of tumor resection was assessed by contrast magnetic resonance imaging (MRI) study. RESULTS: Before surgery the patients in the first group had average tumor volume of 81.68±9.78. In the second group the average tumor volume before surgery was 82.63±10.06cc. There is no significant difference between preoperative tumor volumes in two groups. In the first group, in the post-operative MRI, the tumor volume was 5.04±2.69cc and in the second group it was 9.5±4.8cc. Eight patients (72.7%) in the radioguided group experienced radical resection (more than 95%), but in the control group radical resection was achieved in just 3 patients (27.2%), radical resection was significantly higher in radioguided group (P<0.001). Due to the usage of the gamma detection probe, time of finding the tumor in the radioguided group was significantly less than control group (P=0.02). However total operation time in the radioguided group, was not significantly more than the control group (P=0.88). CONCLUSIONS: Neuronavigation system increases the percentage of gross total resection, but it is expensive, increases duration of surgery is not considered a real-time assessment, and is not accurate in determining the borders of glioma due to brain shift. In contrast, radio-guided surgery is easy to use, real time, not expensive, and increases the extent of tumor resection.