The transfrontal isthmus approach for insular glioma surgery.

OBJECTIVE: The classic transopercular or transsylvian approach to insular gliomas removes the tumor laterally through the insular cortex. This study describes a new anteroposterior approach through the frontal isthmus for insular glioma surgery. METHODS: The authors detailed the surgical techniques for resection of insular gliomas through the transfrontal isthmus approach. Fifty-nine insular gliomas with at least Berger-Sanai zone I involvement were removed with the new approach, and extent of resection and postoperative neurological outcomes were assessed. RESULTS: Fifty-nine patients were enrolled in the study, including 35 men and 24 women, with a mean (range) age 44.3 (19-75) years. According to the Berger-Sanai classification system, the most common tumor was a giant glioma (67.8%), followed by involvement of zones I and IV (18.6%). Twenty-two cases were Yasargil type 3A/B, and 37 cases were Yasargil type 5A/B. The average angle between the lateral plane of the putamen and sagittal line was 33.53°, and the average width of the isthmus near the anterior insular point was 33.33 mm. The average angle between the lateral plane of the putamen and the sagittal line was positively correlated with the width of the isthmus near the anterior insular point (r = 0.935, p < 0.0001). The median (interquartile range [IQR]) preoperative tumor volume was 67.82 (57.64-92.19) cm3. Of 39 low-grade gliomas, 26 (66.67%) were totally resected; of 20 high-grade gliomas, 19 (95%) were totally resected. The median (IQR) extent of resection of the whole group was 100% (73.7%-100%). Intraoperative diffusion-weighted imaging showed no cases of middle cerebral artery- or lenticulostriate artery-related stroke. Extent of insular tumor resection was positively correlated with the angle of the lateral plane of the putamen and sagittal line (r = -0.329, p = 0.011) and the width of the isthmus near the anterior insular point (r = -0.267, p = 0.041). At 3 months postoperatively, muscle strength grade exceeded 4 in all cases, and all patients exhibited essentially normal speech. The median (IQR) Karnofsky performance score at 3 months after surgery was 90 (80-90). CONCLUSIONS: The transfrontal isthmus approach changes the working angle from lateral-medial to anterior-posterior, allowing for maximal safe removal of insular gliomas.

Surgical treatment of diffuse and multi-lobes involved glioma with the assistance of a multimodal technique.

Diffuse and multi-lobes involved glioma (DMG) is a rare disease, and the aim of this study was to assess the role of multimodal-assisted surgical resection of tumours combined with chemoradiotherapy and identify prognosis. Clinical data were collected from 38 patients with a diagnosis of DMG. Nineteen patients received multimodal-assisted surgical resection of tumours combined with chemoradiotherapy, and another 19 patients underwent chemoradiotherapy alone after stereotactic puncture biopsy. The clinical characteristics, magnetic resonance imaging (MRI) findings, histopathological diagnosis, progression-free survival, and overall survival of DMG patients were retrospectively analysed. Twenty-six males and 12 females were included, and the age of the participants ranged from 10 to 80 years (46.34 ± 15.61). The median overall survival in our study was 25 months, and the progression-free survival was 17 months. The extent of resection was 50.10-73.60% (62.54% ± 7.92%). The preoperative and the postoperative KPS score of the patients in the operation group showed no statistically significant difference. The results of logistic regression demonstrated that overall survival was positively associated with operative treatment + chemoradiotherapy (p = 0.003) but negatively associated with age and corpus callosal involvement (p = 0.028 and 0.022, respectively). Kaplan-Meier analyses showed that those who underwent surgical treatment had a significant progression-free and overall survival benefit compared to those who did not undergo surgical treatment (log-rank test; p = 0.011 and 0.008, respectively). Older age and involvement of the corpus callosum represent a poor prognosis in DMG patients. Multimodal-assisted surgical resection of tumours combined with chemoradiotherapy might be a treatment option for DMG. Further research is needed to obtain the clear evidence of the effect of surgical treatment.

Exploring the efficacy of tumor electric field therapy against glioblastoma: An in vivo and in vitro study.

AIMS: Tumor electric fields therapy (TTFields) is emerging as a novel anti-cancer physiotherapy. Despite recent breakthroughs of TTFields in glioma treatment, the average survival time for glioblastoma patients with TTFields is <2 years, even when used in conjugation with traditional anti-cancer therapies. To optimize TTFields-afforded efficacy against glioblastoma, we investigated the cancer cell-killing effects of various TTFields paradigms using in vitro and in vivo models of glioblastoma. METHODS: For in vitro studies, the U251 glioma cell line or primary cell cultures prepared from 20 glioblastoma patients were treated with the tumor electric field treatment (TEFT) system. Cell number, volume, and proliferation were measured after TEFT at different frequencies (100, 150, 180, 200, or 220 kHz), durations (24, 48, or 72 h), field strengths (1.0, 1.5, or 2.2V/cm), and output modes (fixed or random sequence output). A transwell system was used to evaluate the influence of TEFT on the invasiveness of primary glioblastoma cells. For in vivo studies, the therapeutic effect and safety profiles of random sequence electric field therapy in glioblastoma-transplanted rats were assessed by calculating tumor size and survival time and evaluating peripheral immunobiological and blood parameters, respectively. RESULTS: In the in vitro settings, TEFT was robustly effective in suppressing cell proliferation of both the U251 glioma cell line and primary glioblastoma cell cultures. The anti-proliferation effects of TEFT were frequency- and "dose" (field strength and duration)-dependent, and contingent on the field sequence output mode, with the random sequence mode (TEFT-R) being more effective than the fixed sequence mode (TEFT-F). Genetic tests were performed in 11 of 20 primary glioblastoma cultures, and 6 different genetic traits were identified them. However, TEFT exhibited comparable anti-proliferation effects in all primary cultures regardless of their genetic traits. TEFT also inhibited the invasiveness of primary glioblastoma cells in transwell experiments. In the in vivo rat model of glioblastoma brain transplantation, treatment with TEFT-F or TEFT-R at frequency of 200 kHz and field strength of 2.2V/cm for 14 days significantly reduced tumor volume by 42.63% (TEFT-F vs. control, p = 0.0002) and 63.60% (TEFT-R vs. control, p < 0.0001), and prolonged animal survival time by 30.15% (TEFT-F vs. control, p = 0.0415) and 69.85% (TEFT-R vs. control, p = 0.0064), respectively. The tumor-bearing rats appeared to be well tolerable to TEFT therapies, showing only moderate increases in blood levels of creatine and red blood cells. Adverse skin reactions were common for TEFT-treated rats; however, skin reactions were curable by local treatment. CONCLUSION: Tumor electric field treatment at optimal frequency, strength, and output mode markedly inhibits the cell viability, proliferation, and invasiveness of primary glioblastoma cells in vitro independent of different genetic traits of the cells. Moreover, a random sequence electric field output confers considerable anti-cancer effects against glioblastoma in vivo. Thus, TTFields are a promising physiotherapy for glioblastoma and warrants further investigation.

Correlation of p16 and nm23-H1 expression levels with incidence and prognosis of soft tissue sarcoma.

The expression levels of p16 and nm23-H1 genes in soft tissue sarcoma (STS) were evaluated to investigate correlation of the expression levels with the incidence and prognosis of STS. Tumor tissues and para-carcinoma normal tissues were collected from 64 STS patients. The messenger ribonucleic acid (mRNA) expression levels of p16 and nm23-H1 in the tissues were detected via reverse transcription-quantitative polymerase chain reaction (RT-qPCR), and the protein expression levels of p16 and nm23-H1 in tissues were detected using immunohistochemistry. Spearman's correlation analysis was used for the correlation between expression levels of p16 and nm23-H1 in STS tissues and the correlation between p16 and nm23-H1 mRNA and protein expression. Moreover, the correlation of p16 and nm23-H1 expression levels in tumor tissues with pathological parameters and prognosis of STS patients were analyzed combined with clinical data. Results of RT-qPCR showed that mRNA expression levels of p16 and nm23-H1 in tumor tissues of STS patients were significantly lower than those in para-carcinoma normal tissues (P<0.01). Results of immunohistochemistry showed that the positive expression rates of p16 and nm23-H1 in tumor tissues of STS patients (43.75 and 39.06% respectively) were significantly lower than those in para-carcinoma normal tissues (85.93 and 89.06% respectively). The expression of p16 and nm23-H1 mRNA was positively correlated with protein expression levels. There was a positive correlation between the expression levels of p16 and nm23-H1 in tumor tissues of STS patients. The negative expression of p16 in tumor tissues of STS patients correlated with tumor size, tumor metastasis and clinical staging, and the negative expression of nm23-H1 correlated with tumor metastasis and clinical staging. The overall 5-year survival rate of patients was 54.68%, and the prognosis of patients with positive expression levels of p16 and nm23-H1 was better. Univariate survival analyses revealed that p16 and nm23-H1 were influencing factors of the overall survival rate of STS patients. p16 and nm23-H1 expression in STS is low, and their expression levels are closely related to the pathological parameters and prognosis of STS patients, so they can serve as reference indexes for prognosis estimation of STS.

Reconstruction using massive allografts after resection of extremity osteosarcomas the study design: A retrospective cohort study.

PURPOSE: Allografts have been shown useful in the reconstruction of bone defects after tumor resection. This study aimed to investigate the feasibility of using massive allografts to reconstruct bone defects after resection of extremity osteosarcomas. METHODS: The clinical data of 15 patients treated with massive allograft reconstruction after resection of extremity osteosarcomas from January 2005 to January 2008 were retrospectively reviewed. Neoadjuvant and postoperative chemotherapy was used in all patients. The postoperative functions of the salvaged limbs were evaluated using the scoring system proposed by the Musculoskeletal Tumor Society (MSTS). RESULTS: All patients were followed up for a mean of 61 months (range, 14-99 months). No nonunion occurred during follow-up. The mean time to union was 9 months (range, 3-21 months). No immune rejection, allograft infection, allograft fracture, and limb length disparity occurred. However, 2 patients had broken implants. The mean MSTS score at the last follow-up was 26 points. Four patients died and 2 patients had tumor recurrence. The 5-year disease free survival rate was 73.3%. CONCLUSION: Massive allograft reconstruction is safe and effective for bone defects caused by resection of extremity osteosarcomas.