Publications by authors named "Giacoma Maria Floriana Brunetto"

6 Publications

  • Page 1 of 1

Outcome Features Analysis in Intramedullary Tumors of the Cervicomedullary Junction: A Surgical Series.

J Neurol Surg A Cent Eur Neurosurg 2021 May 4;82(3):225-231. Epub 2021 Feb 4.

Department of Neurology and Psychiatry, Endovascular Neurosurgery/Interventional Neuroradiology, "Sapienza" University of Rome, Rome, Italy.

Object:  The aim of this study is to investigate the impact of surgery for different cervicomedullary lesions on symptomatic pattern expression and postoperative outcome. We focused on specific outcome features of the early and late postoperative assessments. The former relies on surgery-related transient and permanent morbidity and feasibility of radicality in eloquent areas, whereas the latter on long-term course in lower grade tumors and benign tumorlike lesions (cavernomas, etc.).

Material And Methods:  We retrospectively analyzed 28 cases of intramedullary tumors of the cervicomedullary junction surgically treated at our institution between 1990 and 2018. All cases were stratified for gender, histology, macroscopic appearance, location, surgical approach, and presence of a plane of dissection (POD). Mean follow-up was 5.6 years and it was performed via periodic magnetic resonance imaging (MRI) and functional assessments (Karnofsky Performance Scale [KPS] and modified McCormick [MC] grading system).

Results:  In all, 78.5% were low-grade tumors (or benign lesions) and 21.5% were high-grade tumors. Sixty-one percent underwent median suboccipital approach, 18% a posterolateral approach, and 21% a posterior cervical approach. Gross total resection was achieved in 54% of cases, near-total resection (>90%) in 14%, and subtotal resection (50-90%) in 32% of cases. Early postoperative morbidity was 25%, but late functional evaluation in 79% of the patients showed KPS > 70 and MC grade I; only 21% of cases showed KPS < 70 and MC grades II and III at late follow-up. Mean overall survival was 7 years in low-grade tumors or cavernomas and 11.7 months in high-grade tumors. Progression-free survival at the end of follow-up was 71% (evaluated mainly on low-grade tumors).

Conclusions:  The surgical goal should be to achieve maximal cytoreduction and minimal postoperative neurologic damage. Functional outcome is influenced by the presence of a POD, radicality, histology, preoperative status, and employment of advanced neuroimaging planning and intraoperative monitoring.
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May 2021

Transoral Endoscopic Approach to Repair Early Pharyngeal Perforations After Anterior Cervical Spine Surgery without Failure of Instrumentation: Our Experience and Review of Literature.

World Neurosurg 2020 09 17;141:219-225. Epub 2020 Jun 17.

IRCCS Neuromed, Pozzilli, Italy.

Background: Pharyngoesophageal injury during anterior cervical spine surgery is a rare and potentially life-threatening complication; generally it is the result of intraoperative manipulation or hardware erosion and sometimes may be due to weakness of the pharyngoesophageal wall from pre-existing pathologic conditions, such as diabetes, gastritis, or obesity.

Case Description: We describe the management strategies in patients with an early postoperative hypopharyngeal perforation that occurred after anterior cervical spine surgery without failure of instrumentation, and we present a case treated endoscopically at our institution.

Conclusions: Appropriate treatment for pharyngoesophageal perforations is controversial and not investigated in detail. There is a lack of prospective studies comparing initial conservative versus surgical approaches to treatment. In addition, endoscopic management is growing as a therapeutic option, but no consensus concerning the indications for an endoscopic approach in the treatment of pharyngoesophageal injury in anterior cervical spine surgery is currently reached. A common theme proposed in the literature is that early recognition and aggressive investigation and treatment are essential to ensure a good outcome. A customized interdisciplinary surgical approach is essential for successful treatment. Use of the transoral endoscopic approach is a useful noninvasive method to treat this rare but potentially devastating complication.
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September 2020

The Role and Real Effect of an Iterative Surgical Approach for the Management of Recurrent High-Grade Glioma: An Observational Analytic Cohort Study.

World Neurosurg 2019 Jan 3. Epub 2019 Jan 3.

Department of Neurosurgery, Neuromed, IRCCS, Sapienza University of Rome, Pozzilli, Italy.

Background: The benefits of multiple interventions on the recurrence of high-grade gliomas are renowned. However, the real effect of repeated operations on the survival parameters does not seem to have been assessed. The aim of the present study was to determine whether reoperation for selected patients is safe and feasible.

Methods: A total of 78 patients with high-grade glioma had undergone surgery from 2004 to 2014. All the patients had met the following inclusion criteria: American Society of Anesthesiologists score 1-3, Karnofsky performance scale score >60, and reintervention ≥4 months after the first surgery. The following parameters were evaluated: overall survival (OS) after diagnosis and reintervention, progression-free survival (PFS) after reintervention, number of surgical procedures, and OS of patients who had undergone surgery >2 times. The results were compared with those of 78 patients with high-grade glioma who had undergone adjuvant chemotherapy.

Results: OS at 1 year was 100%. At 2 years, OS was 39.4% for those with glioblastoma and 58.3% for those with anaplastic astrocytoma. PFS after 6 months was 53.03% for glioblastoma and 75.0% for anaplastic astrocytoma. Of the 78 patients, 55 had undergone reoperation, with 15 requiring a third intervention and 8 requiring 4. Major complications developed in only 2 patients. Statistical analysis revealed no significant differences in complications or worsening neurological status.

Conclusions: These data showed excellent outcomes in terms of OS and PFS and clinical conditions after multiple surgical procedures. Therefore, reintervention appears to be a feasible and safe solution for selected patients.
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January 2019

Extent of tumor removal and molecular markers in cerebral glioblastoma: a combined prognostic factors study in a surgical series of 105 patients.

J Neurosurg 2012 Aug 1;117(2):204-11. Epub 2012 Jun 1.

Department of Neurosurgery INM-IRCCS Neuromed, Pozzilli (Isernia), University of Rome "Sapienza;" Italy.

Object: In this paper, the authors' goal was to evaluate the prognostic value of YKL-40 expression as a prognostic factor for glioblastomas and to compare its validity to the already known MGMT.

Methods: Between January 2002 and January 2007, 105 patients were treated for cerebral glioblastoma. The extent of removal was classified in 4 groups. YKL-40 expression was evaluated by a semiquantitative immunohistochemical staining scale (0, no staining; 1, mild expression; and 2, strong expression). MGMT promoter methylation status was analyzed with methylation-specific polymerase chain reaction. All patients received adjuvant radiotherapy and chemotherapy. Kaplan-Meier curves were used to analyze progression-free survival (PFS) and overall survival (OS), and to compare these parameters between the subgroups stratified by extent of surgical removal, MGMT methylation, and YKL-40 expression. The log-rank test was used to determine statistical significance. A multivariate regression analysis was applied to extent of removal, YKL-40 expression, and MGMT status to check their specific statistical power and to test the independence of the variables.

Results: There were 55 men and 50 women with a mean age of 58 years. Extent of surgical removal is reported. The MGMT promoter was methylated in 48 patients and nonmethylated in 57. Analysis of YKL-40 expression is reported. The median PFS was 10.7 months (14.9 months in the gross-total removal subgroup) (p < 0.0001), and the median OS was 12.5 months (17.4 months in the gross-total removal group) (p < 0.0001). In the univariate analysis, OS was significantly correlated to the extent of resection (p < 0.0001), MGMT status (p < 0.0001), and YKL-40 (p < 0.0001). Multivariate analysis showed that all 3 factors reached statistical significance with respect to patient survival. In particular, surgical removal contributed more than the 2 other factors to the survival prediction (β = -0.6254). Interestingly, YKL-40 (β = -0.3867) contributed more than MGMT (β = -0.1705) to the predicted survival.

Conclusions: The extent of removal is the most important factor influencing the OS of patients harboring glioblastomas. When biological aggressiveness is taken into account, YKL-40 expression was found to be an independent prognostic factor that predicts OS better than MGMT status.
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August 2012

Extra central nervous system metastases from cerebral glioblastoma multiforme in elderly patients. Clinico-pathological remarks on our series of seven cases and critical review of the literature.

Tumori 2008 Jan-Feb;94(1):40-51

Department of Neurological Sciences-Neurosurgery, University of Rome Sapienza, Rome, Italy.

Aims And Background: The aim of the study was to evaluate the treatment of the extracranial metastases from glioblastoma multiforme in the elderly, discussing their uncommon occurrence and their pathogenesis.

Methods: The authors report seven cases of elderly patients (mean age, 69 years), with an initial diagnosis of cerebral glioblastoma multiforme, treated by a grossly total surgical removal and followed by adjuvant radiotherapy (64 Gy in 6 weeks, using Linac) and adjuvant chemotherapy (temozolomide both concomitant and sequential to radiotherapy).

Results: All patients presented a postoperative course characterized by good functional and clinical conditions (Karnofsky performance scale > or =70), which remained unchanged for a mean period of about 21 months (range, 16-23), with no neuroradiological signs of lesion regrowth. After this interval, new clinical signs occurred, and their clinical and radiological investigation showed metastatic repetitions in different sites: lung, liver, humerus and lymph nodes. All the metastases were surgically treated, but regrowth of the brain tumor and progression to deep important neural structures caused the patients' exitus after a mean interval of about 10 months (range, 8-12) from the diagnosis of metastasis.

Conclusions: We found 128 cases of extra CNS metastases in the English literature. The main features of the patients of the previous reports and of those of the present series were analyzed. The main modalities of glioblastoma multiforme spread, the few theories about the rarity of metastasis, and the probable biological, histological and immunogenetic mechanisms involved in the pathogenesis are described. Although several studies have reported a poor outcome in elderly patients, they affirm that the treatment of those with a Karnofsky performance status >60 should be just as aggressive as in younger patients. This allows them to obtain a longer survival time and to also treat metastases, which are uncommon particularly in the elderly.
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June 2008

Intramedullary cavernous angioma of the spinal cord in a pediatric patient, with multiple cavernomas, familial occurrence and partial spontaneous regression: case report and review of the literature.

Childs Nerv Syst 2007 Nov 21;23(11):1319-26. Epub 2007 Jul 21.

Department of Neurological Sciences-Neurosurgery, University of Rome La Sapienza, Neurochirurgia1, Viale del Policlinico, 155, 00185 Rome, Italy.

Object: The authors present their experience with the 17th pediatric intramedullary cavernoma reported in English literature.

Methods: The patient firstly underwent surgery for a left frontal cavernoma when he was 2 years old. Also the child's mother was operated for a C2-C3 intramedullary cavernoma. He grew up normally and the radiological follow-up was negative for other brainstem cavernous malformations. When he was 11 years old he complained a worsening tetraparesis. A cerebral and spinal magnetic resonance (MR) imaging revealed the presence of a C1 intramedullary cavernoma and a pontine cavernoma. He underwent surgery for the cervical lesion, which was completely removed. The postoperative course was regular with a total recovery from the neurological deficit. The boy underwent a radiological follow-up, monitoring the pontine lesion, which spontaneously regressed when he was 19 years old.

Conclusion: The rarity of the pediatric intramedullary cavernoma, the familial occurrence, and the spontaneous regression of the pontine cavernoma make this case very peculiar.
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November 2007