Enhanced resection of primary high-grade gliomas using a combination of intraoperative magnetic resonance imaging and intraoperative fluorescence (5-aminolevulinic acid): A single-centre experience.

BACKGROUND: The extent of resection (EOR) of a tumor is a proven prognostic factor in patients undergoing surgery for suspected high grade glioma. A few recent publications have shown the importance of intraoperative magnetic resonance imaging (iMRI) with 5-aminolevulinic acid (5-ALA) fluorescence-guidance in order to maximally increase the EOR. AIM: The objective of our study was to calculate the effect on survival of patients with high grade gliomas of resection using both iMRI and 5-ALA fluorescence-guidance as intraoperative adjuncts. METHODS: Thirty-seven patients with gadolinum-enhancing high gliomas on preoperative MRI undergoing surgical excision were included in a prospective study. Surgeries began under white-light conditions. Intermittently, a blue light filter was switched on to search for remaining tumor tissue not visible to the naked eye. When gross total resection (GTR) was thought to have been achieved, iMRI was done to check for any contrast-enhancing part left behind. Surgery was concluded or resumed based on the iMRI findings. Histopathological examination of the tumor tissue was done. All patients underwent immediate postoperative MRI at the end of the surgery to calculate the EOR. RESULTS: Our results showed that out of the total of 37 patients, 17 patients died during the follow up period and 11 patients were still alive. The mean survival was 587.1 days and median survival was 491 days with a range of 342 to 943 days. When we compared these figures with the average survival in patients with a high grade glioma, i.e., 9 to 14 months, it showed that both the above mentioned modalities were very helpful in increasing the EOR, and in turn, the overall survival. CONCLUSIONS: The use of iMRI as well as fluorescence-guidance are appropriate methods to improve the extent of resection in surgery of contrast-enhancing gliomas. Best results can be achieved by the complementary use of both modalities.

Survival trends in glioma: Experience at a tertiary care centre.

BACKGROUND: Even after decades of research in the field of gliomas, the overall prognosis is still quite dismal. Several factors have been proposed that affect the outcome and survival length of patients with a glioma. Here, we present a series of 471 patients, who underwent surgical resection of their glioma at a tertiary level neurosurgical centre. MATERIALS AND METHODS: We noted retrospective data of patients' age, histological tumor grade, and whether or not intraoperative magnetic resonance imaging (MRI) was used, and assessed the survival length of these patients from the day of surgery. RESULTS: The overall survival in our series was approximately 14 months. Predictably, those with age less than 40 years and those with Karnofsky performance score (KPS) ≥80 had longer survival than those with a higher age and KPS <80; those with World Health Organisation (WHO) grade IV lesions had the shortest survival length compared to all the other grades. However, while comparing survival among other tumor grades, we did not find significant difference. Further, use of intraoperative MRI did not offer any statistically significant difference in survival. CONCLUSION: In addition to the conventional prognostic factors we need more definate ways to accurately predict survival in patients harbouring a glioma. Probably, assessing molecular characteristics of the individual tumors, such as presence of isocitrate dehydrogenase (IDH) mutation versus wild-type IDH, would help us in predicting survival more accurately.

Modulated Radiotherapy with Concurrent and Adjuvant Temozolomide for Anaplastic Gliomas: Indian Single-center Data.

OBJECTIVE: To evaluate early clinical outcome for anaplastic gliomas (AG) treated in the era of modulated radiotherapy (RT) and concurrent plus adjuvant temozolomide (TMZ) in an Indian setting. MATERIALS AND METHODS: Fifty-three patients with AGs treated with modulated RT and concurrent (95%) and adjuvant TMZ (90%) were analyzed. About 80% of patients had Karnofsky performance status (KPS) at least 90 with 30% seizure at presentation. Postoperative magnetic resonance imaging was available in 65% cases and RT dose was 60 Gy in 30 fractions. First posttreatment imaging was performed at 1 month and then at 3 and 6 months post-RT and then every 3 months. Kaplan-Meier analysis was used to estimate disease-free survival (DFS) and overall survival (OS), and analysis was done using SPSS version 18.0. RESULTS: With median follow-up of 25 months, 2-year DFS and OS were 75% and 88%. There were only 5% symptomatic central nerves system and 8% symptomatic hematological toxicities. At the 1st evaluation, 30.4% had complete response (CR), at 3 months 40%, and at 6 months 43%. At 6 months, only 4% had progressive disease. Forty-six patients were evaluable till the last follow-up with and 55% had stable to CR. On univariate analysis for DFS, KPS at presentation >90 (P = 0.001) and response at 6 months (P = 0.02) were significant and for OS KPS at presentation (P = 0.004) alone. CONCLUSION: Modulated RT with TMZ among Grade III glioma patients resulted in minimum treatment-related toxicities and encouraging survival. Molecular prognostic markers will determine most favorable groups in future.

A decade after International Subarachnoid Aneurysm Trial: Coiling as a first choice treatment in the management of intracranial aneurysms - Technical feasibility and early management outcomes.

PURPOSE: The technique of coiling has evolved in the last decade with evolution in both equipment and material. The preferable treatment of intracranial aneurysms at our center is endovascular coiling. We discuss the technical and management outcomes of consecutive patients treated with this approach and compare our results with a decade old International Subarachnoid Aneurysm Trial. MATERIALS AND METHODS: Between January 2006 and November 2011, a total of 324 aneurysms in 304 consecutive patients were treated. Endovascular treatment was done in 308 aneurysms (95.0%) in 288 patients while 16 patients (5%) underwent surgical clipping. Of the 308 aneurysms treated endovascularly, 269 (87.3%) were ruptured, and 39 (12.7%) were unruptured aneurysms. RESULTS: The endovascular coiling was feasible in all (99.6%) but 1 case. The immediate postoperative occlusion status was complete occlusion in 240 aneurysms (77.9%), neck remnant in 57 aneurysms (18.5%), and aneurysm remnant in 11 aneurysms (3.6%). Technical issues - with or without clinical effect-were encountered in 20 patients (6.9%). They included 18 thromboembolic events (6.2%) and intraprocedural aneurysmal rupture in 2 cases (0.7%). In "good grade" patients, H and H grade 1-3, a good outcome (modified Rankin score [mRS] 0-2) was in 87.6% patients while the bad outcome (mRS 3-5) was in 10.2% patients and mortality of 2.2%. In "bad grade" patients, H and H grade 3-5, a good outcome was in 29.2%, and bad outcome was in 41.7% patients with mortality was 29.1%. In the unruptured aneurysm group, the good outcome was seen in 97.7% and bad outcome in 2.3% with no mortality. CONCLUSIONS: In the current era, the favorable results of coiling demonstrated in previous studies may be applicable to the larger proportion of patients. In our series of consecutively treated patients using latest advances, such as three-dimensional imaging and the interventional material, endovascular management as first choice was feasible in 95% of patients with good technical and management outcomes.

Synchronous endometrial carcinoma and a macroprolactinoma: exploring a causal relationship.

BACKGROUND: While unopposed estrogen hormone secretion is most commonly implicated in the pathogenesis of endometrial carcinoma, the role of prolactin has only recently been highlighted. The authors present a case of a synchronous endometrial carcinoma in a patient with a prolactin-secreting macroadenoma. METHODS: A 29-year-old woman presented with a 4-year history of primary infertility, irregular periods and intermittent galactorrhea. Hormonal evaluation revealed elevated prolactin and subnormal luteinizing hormone and follicle-stimulating hormone (FSH) serum concentrations. An ultrasound of the pelvis revealed endometrial thickening. The MRI of the brain confirmed a pituitary macroadenoma. The patient underwent a resectoscopic polypectomy and dilation and curettage followed by transnasal transsphenoidal excision of the pituitary macroadenoma. RESULTS: The biopsy of the endometrium revealed a well-differentiated endometrioid carcinoma while that of the pituitary tumor confirmed a prolactinoma. CONCLUSION: An indirect causal mechanism can be postulated to explain this association. Hyperprolactinemia inhibits gonadotropin-releasing hormone leading to subnormal FSH and luteinizing hormone levels. Though the patient is hypoestrogenic, chronic anovulation with unopposed estrogen secretion can increase the risk of endometrial carcinoma. Patients with prolactinomas and irregular menstrual bleeding should undergo endometrial sampling to rule out this possibility.

Rosai-Dorfman disease mimicking a sphenoid wing meningioma.

A 40-year-old male presented with a single generalized tonic-clonic seizure. MRI revealed an enhancing, dural-based, left lateral sphenoid wing lesion suggestive of a meningioma. At microsurgical excision, the lesion was firm and relatively avascular. The histopathological report revealed S-100 positive histiocytic proliferation with lymphophagocytosis (emperipolesis) characteristic of the Rosai-Dorfman disease. The case and its management are discussed.