Publications by authors named "Giampietro Pinna"

30 Publications

  • Page 1 of 1

Cauda equina ependymomas: surgical treatment and long-term outcomes in a series of 125 patients.

J Neurosurg Spine 2021 Oct 15:1-12. Epub 2021 Oct 15.

1Department of Neurosurgery, University Hospital Borgo Trento, Verona, Italy; and.

Objective: Cauda equina ependymoma (CEE) is a rare tumor for which little information is available on the oncological and clinical outcomes of patients. In this study the authors aimed to address functional, oncological, and quality-of-life (QOL) outcomes in a large series of consecutive patients operated on at their institution during the past 20 years.

Methods: The records of 125 patients who underwent surgery between January 1998 and September 2018 were reviewed. Analyzed variables included demographic, clinical, radiological, surgical, and histopathological features. Neurological outcomes were graded according to the McCormick and Kesselring scales. The QOL at follow-up was evaluated by administering the EQ-5DL questionnaire.

Results: On admission, 84% of patients had a McCormick grade of I and 76.8% had a Kesselring score of 0. At follow-up (clinical 8.13 years; radiological 5.87 years) most scores were unchanged. Sacral level involvement (p = 0.029) and tumor size (p = 0.002) were predictors of poor functional outcome at discharge. Tumor size (p = 0.019) and repeated surgery (p < 0.001) were predictors of poor outcome. A preoperative McCormick grade ≥ III and Kesselring grade ≥ 2 were associated with worse outcomes (p = 0.035 and p = 0.002, respectively). Myxopapillary ependymoma (MPE) was more frequent than grade II ependymoma (EII). The overall rate of gross-total resection (GTR) was 91.2% and rates were significantly higher for patients with EII (98%) than for those with MPE (84%) (p = 0.0074). On multivariate analysis, the only factor associated with GTR was the presence of a capsule (p = 0.011). Seventeen patients (13.7%) had recurrences (13 MPE, 4 EII; 76.4% vs 23.6%; p = 0.032). The extent of resection was the only factor associated with recurrence (p = 0.0023) and number of surgeries (p = 0.006). Differences in progression-free survival (PFS) were seen depending on the extent of resection at first operation (p < 0.001), subarachnoid seeding (p = 0.041), piecemeal resection (p = 0.004), and number of spine levels involved (3 [p = 0.016], 4 [p = 0.011], or ≥ 5 [p = 0.013]). At follow-up a higher proportion of EII than MPE patients were disease free (94.7% vs 77.7%; p = 0.007). The QOL results were inferior in almost all areas compared to a control group of subjects from the Italian general population. A McCormick grade ≥ 3 and repeated surgeries were associated with a worse QOL (p = 0.006 and p = 0.017).

Conclusions: An early diagnosis of CEE is important because larger tumors are associated with recurrences and worse functional neurological outcomes. Surgery should be performed with the aim of achieving an en bloc GTR. The histological subtype was not directly associated with recurrences, but some of the features more commonly encountered in MPEs were. The outcomes are in most cases favorable, but the mean QOL perception is inferior to that of the general population.
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http://dx.doi.org/10.3171/2021.5.SPINE202049DOI Listing
October 2021

H3K27me3 immunostaining is diagnostic and prognostic in diffuse gliomas with oligodendroglial or mixed oligoastrocytic morphology.

Virchows Arch 2021 Nov 24;479(5):987-996. Epub 2021 Jun 24.

Department of Diagnostics and Public Health, Section of Anatomic Pathology, University of Verona, Policlinico G.B. Rossi. P.le L.A. Scuro 10, 37134, Verona, Italy.

Oligodendroglioma is defined by IDH mutation and 1p/19q codeletion. The latter is mutually exclusive to ATRX immunohistochemical loss and has been recently associated with the loss of H3K27me3 immunostaining. We aimed to assess the diagnostic and prognostic value of H3K27me3 immuno-expression in diffuse gliomas with oligodendroglial or mixed oligoastrocytic morphology. H3K27me3 immunostaining was performed in 69 diffuse gliomas with oligodendroglial (n = 62) or oligoastrocytic (n = 7) morphology. The integration with routinely assessed IDH mutations, ATRX immunostaining, and 1p/19q codeletion classified these cases as 60 oligodendroglial and 9 astrocytic. H3K27me3 was lost in 58/60 oligodendrogliomas with retained (n = 47) or non-conclusive (n = 11) ATRX staining, 3/6 IDH-mutant astrocytomas with ATRX loss, and 3/3 IDH-wt astrocytomas. H3K27me3 was retained in 2/60 oligodendrogliomas with retained ATRX, and in 3/6 IDH-mutant astrocytomas, two of which had lost and one retained ATRX. The combination of H3K27me3 and ATRX immunostainings with IDH mutational status correctly classified 55/69 (80%) cases. In IDH-mutant gliomas, ATRX loss indicates astrocytic phenotype, while ATRX retention and H3K27me3 loss identify oligodendroglial phenotype. Only 14 (20%) IDH-mutant cases with retained ATRX and H3K27me3 or inconclusive ATRX immunostaining would have requested 1p/19q codeletion testing to be classified. Furthermore, H3K27me3 retention was associated with significantly shorter relapse-free survival (P < 0.0001), independently from IDH mutation or 1p/19q codeletion (P < 0.005). Our data suggest that adding H3K27me3 immunostaining to the diagnostic workflow of diffuse gliomas with oligodendroglial or mixed morphology is useful for drastically reducing the number of cases requiring 1p/19q codeletion testing and providing relevant prognostic information.
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http://dx.doi.org/10.1007/s00428-021-03134-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8572829PMC
November 2021

Sporadic cauda equina hemangioblastoma: surgical management in a pregnant woman.

Br J Neurosurg 2021 Apr 20:1-5. Epub 2021 Apr 20.

Department of Neurosurgery, Borgo Trento Hospital, AOUI Verona, Verona, Italy.

Hemangioblastoma is a rare benign vascular tumour of the central nervous system that occurs either sporadically or in association with Von Hippel-Lindau syndrome. Hemangioblastoma can be found throughout the central nervous system and usually present with late manifestations due to their slow growth rate. Cauda equina hemangioblastomas are extremely rare, and in the literature, no cases are reported on the surgical management of pregnant patients with this condition. We report the case of a young woman with back pain and sphincter dysfunctions in whom an L1-L2 hemangioblastoma was diagnosed. We describe the perioperative and surgical strategies we adopted to successfully treat the patient and preserve the fetus well-being.
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http://dx.doi.org/10.1080/02688697.2021.1914820DOI Listing
April 2021

Molecular Profiling of 22 Primary Atypical Meningiomas Shows the Prognostic Significance of 18q Heterozygous Loss and Homozygous Deletion on Recurrence-Free Survival.

Cancers (Basel) 2021 Feb 21;13(4). Epub 2021 Feb 21.

Department of Diagnostics and Public Health, Section of Pathology, University of Verona, 37134 Verona, Italy.

The use of adjuvant therapy is controversial in atypical meningiomas with gross total resection. Predictors of recurrence risk could be useful in selecting patients for additional treatments. The aim of this study was to investigate whether molecular features are associated with recurrence risk of atypical meningiomas. According to WHO classification, the diagnosis of atypical meningioma was based on the presence of one major criteria (mitotic activity, brain invasion) or three or more minor criteria. The molecular profile of 22 cases (eight mitotically active, eight brain-invasive, and six with minor criteria) was assessed exploring the mutational status and copy number variation of 409 genes using next generation sequencing. Of the 22 patients with a median follow up of 53.5 months, 13 had recurrence of disease within 68 months. mutation was the only recurrent alteration (11/22) and was unrelated to clinical-pathological features. Recurring meningiomas featured a significantly higher proportion of copy number losses than non-recurring ones ( = 0.027). Chromosome 18q heterozygous loss or homozygous deletion was significantly associated with shorter recurrence-free survival ( = 0.008; hazard ratio: 5.3). Atypical meningiomas could be tested routinely for these genetic alterations to identify cases for adjuvant treatment.
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http://dx.doi.org/10.3390/cancers13040903DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7927130PMC
February 2021

Long-term motor deficit in brain tumour surgery with preserved intra-operative motor-evoked potentials.

Brain Commun 2021 23;3(1):fcaa226. Epub 2021 Jan 23.

Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy.

Muscle motor-evoked potentials are commonly monitored during brain tumour surgery in motor areas, as these are assumed to reflect the integrity of descending motor pathways, including the corticospinal tract. However, while the loss of muscle motor-evoked potentials at the end of surgery is associated with long-term motor deficits (muscle motor-evoked potential-related deficits), there is increasing evidence that motor deficit can occur despite no change in muscle motor-evoked potentials (muscle motor-evoked potential-unrelated deficits), particularly after surgery of non-primary regions involved in motor control. In this study, we aimed to investigate the incidence of muscle motor-evoked potential-unrelated deficits and to identify the associated brain regions. We retrospectively reviewed 125 consecutive patients who underwent surgery for peri-Rolandic lesions using intra-operative neurophysiological monitoring. Intraoperative changes in muscle motor-evoked potentials were correlated with motor outcome, assessed by the Medical Research Council scale. We performed voxel-lesion-symptom mapping to identify which resected regions were associated with short- and long-term muscle motor-evoked potential-associated motor deficits. Muscle motor-evoked potentials reductions significantly predicted long-term motor deficits. However, in more than half of the patients who experienced long-term deficits (12/22 patients), no muscle motor-evoked potential reduction was reported during surgery. Lesion analysis showed that muscle motor-evoked potential-related long-term motor deficits were associated with direct or ischaemic damage to the corticospinal tract, whereas muscle motor-evoked potential-unrelated deficits occurred when supplementary motor areas were resected in conjunction with dorsal premotor regions and the anterior cingulate. Our results indicate that long-term motor deficits unrelated to the corticospinal tract can occur more often than currently reported. As these deficits cannot be predicted by muscle motor-evoked potentials, a combination of awake and/or novel asleep techniques other than muscle motor-evoked potentials monitoring should be implemented.
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http://dx.doi.org/10.1093/braincomms/fcaa226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884605PMC
January 2021

Holmes tremor: a delayed complication after resection of brainstem cavernomas.

J Neurosurg 2020 Dec 11:1-11. Epub 2020 Dec 11.

1Neurosurgery, Great Metropolitan Hospital Niguarda, Milan.

Objective: In this paper, the authors aimed to illustrate how Holmes tremor (HT) can occur as a delayed complication after brainstem cavernoma resection despite strict adherence to the safe entry zones (SEZs).

Methods: After operating on 2 patients with brainstem cavernoma at the Great Metropolitan Hospital Niguarda in Milan and noticing a similar pathological pattern postoperatively, the authors asked 10 different neurosurgery centers around the world to identify similar cases, and a total of 20 were gathered from among 1274 cases of brainstem cavernomas. They evaluated the tremor, cavernoma location, surgical approach, and SEZ for every case. For the 2 cases at their center, they also performed electromyographic and accelerometric recordings of the tremor and evaluated the post-operative tractographic representation of the neuronal pathways involved in the tremorigenesis. After gathering data on all 1274 brainstem cavernomas, they performed a statistical analysis to determine if the location of the cavernoma is a potential predicting factor for the onset of HT.

Results: From the analysis of all 20 cases with HT, it emerged that this highly debilitating tremor can occur as a delayed complication in patients whose postoperative clinical course has been excellent and in whom surgical access has strictly adhered to the SEZs. Three of the patients were subsequently effectively treated with deep brain stimulation (DBS), which resulted in complete or almost complete tremor regression. From the statistical analysis of all 1274 brainstem cavernomas, it was determined that a cavernoma location in the midbrain was significantly associated with the onset of HT (p < 0.0005).

Conclusions: Despite strict adherence to SEZs, the use of intraoperative neurophysiological monitoring, and the immediate success of a resective surgery, HT, a severe neurological disorder, can occur as a delayed complication after resection of brainstem cavernomas. A cavernoma location in the midbrain is a significant predictive factor for the onset of HT. Further anatomical and neurophysiological studies will be necessary to find clues to prevent this complication.
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http://dx.doi.org/10.3171/2020.7.JNS201352DOI Listing
December 2020

Neurosurgery in times of a pandemic: a survey of neurosurgical services during the COVID-19 outbreak in the Veneto region in Italy.

Neurosurg Focus 2020 12;49(6):E9

1Azienda ULSS 8 Berica, Ospedale San Botolo, Vicenza.

Objective: The purpose of this study was to analyze the effect of the coronavirus disease 2019 (COVID-19) outbreak and of the subsequent lockdown on the neurosurgical services of the Veneto region in Italy compared to the previous 4 years.

Methods: A survey was conducted in all 6 neurosurgical departments in the Veneto region to collect data about surgical, inpatient care and endovascular procedures during the month of March for each year from 2016 to 2020. Safety measures to avoid infection from SARS-CoV-2 and any COVID-19 cases reported among neurosurgical patients or staff members were considered.

Results: The mean number of neurosurgical admissions for the month of March over the 2016-2019 period was 663, whereas in March 2020 admissions decreased by 42%. Emergency admissions decreased by 23%. The average number of neurosurgical procedures was 697, and declined by 30% (range -10% to -51% in individual centers). Emergency procedures decreased in the same period by 23%. Subarachnoid hemorrhage and spontaneous intracerebral hemorrhage both decreased in Veneto-by 25% and 22%, respectively. Coiling for unruptured aneurysm, coiling for ruptured aneurysm, and surgery for ruptured aneurysm or arteriovenous malformation diminished by 49%, 27%, and 78%, respectively. Endovascular procedures for acute ischemic stroke (AIS) increased by 33% in 2020 (28 procedures in total). There was a slight decrease (8%) in brain tumor surgeries. Neurosurgical admissions decreased by 25% and 35% for head trauma and spinal trauma, respectively, while surgical procedures for head trauma diminished by 19% and procedures for spinal trauma declined by 26%. Admissions and surgical treatments for degenerative spine were halved. Eleven healthcare workers and 8 patients were infected in the acute phase of the pandemic.

Conclusions: This multicenter study describes the effects of a COVID-19 outbreak on neurosurgical activities in a vast region in Italy. Remodulation of neurosurgical activities has resulted in a significant reduction of elective and emergency surgeries compared to previous years. Most likely this is a combined result of cancellation of elective and postponable surgeries, increase of conservative management, increase in social restrictions, and in patients' fear of accessing hospitals. Curiously, only endovascular procedures for AIS have increased, possibly due to reduced physical activity or increased thrombosis in SARS-CoV-2. The confounding effect of thrombectomy increase over time cannot be excluded. No conclusion can be drawn on AIS incidence. Active monitoring with nasopharyngeal swabs, wearing face masks, and using separate pathways for infected patients reduce the risk of infection.
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http://dx.doi.org/10.3171/2020.9.FOCUS20691DOI Listing
December 2020

Atypical fibroxanthoma/pleomorphic dermal sarcoma of the scalp with aberrant expression of HMB-45: a pitfall in dermatopathology.

Pathologica 2020 Jun;112(2):105-109

Department of Medical Sciences and Public Health, Unit of Pathology, University of Cagliari, Italy.

Atypical fibroxanthoma (AFX) has been considered as the non-infiltrating precursor lesion of pleomorphic dermal sarcoma (PDS), which shows an aggressive clinical behavior, because of its extensive invasion of the deeper skin layers. Although these two tumors may represent two stages of the same disease, it can be difficult to differentiate between them, because of their similar clinical and histological features . Furthermore, they must be distinguished from a spindled variant of squamous carcinoma, melanoma and leiomyosarcoma . AFX/PDS still remains a diagnosis of exclusion, that needs to combine immunohistochemical markers for a definitive diagnosis. Usually AFX/PDS shows positivity for CD10, CD99, CD68, vimentin and lysozyme, while S100, HMB45, MART-1, cytokeratins, CD34, CD31, desmin and h-caldesmon are absent.

We report a case of 89-year-old male, with a history of squamous cell carcinoma removed from the right ear, presented to our department with a recently growing, ulcerated and bleeding 2 cm nodule on the scalp. After surgery the tumor recurred with infiltration to the cranial theca. The final histological diagnosis was "pleomorphic dermal sarcoma" (PDS), which showed an unexpected positivity for HMB45. We present, to the best of our knowledge, the first case of AFX/PDS with an aberrant diffuse expression of HMB45 and an aggressive biological behavior, that leads us to a difficult exclusion diagnosis.
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http://dx.doi.org/10.32074/1591-951X-39-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931565PMC
June 2020

Trans-thoracic versus retropleural approach for symptomatic thoracic disc herniations: comparative analysis of 94 consecutive cases.

Br J Neurosurg 2021 Apr 19;35(2):195-202. Epub 2020 Jun 19.

Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool, UK.

Purpose: The authors illustrate their results in the surgical treatment of symptomatic thoracic disc herniations (TDHs) by comparing the traditional open to the less invasive retropleural lateral approaches.

Methods: Retrospective review of 94 consecutive cases treated at a single Institution between 1988 and 2014. Fifty-two patients were males, 42 females, mean age was 53.9 years. Mean follow-up was 46.9 months (12-79 months). 33 patients were diagnosed with a giant thoracic disc herniation (GTDH). Upon admission, the most common symptoms were: motor impairment (91.4%,  = 86), neuropathic radicular pain with VAS > 4 (50%), bladder and bowel dysfunction (57.4% and 41.4% respectively) and sensory disturbances (29.7%). The surgical approach was based upon level, laterality and presence or absence of calcified lesions.

Results: Decompression was performed in 7 cases via a thoraco-laparo-phrenotomy and in 87 cases via an antero-lateral thoracotomy. Out of the latter cases, 49 (56%) were trans-thoracic trans-pleural approaches (TTA) and 38 (44%) were less invasive retropleural approaches (MIRA). At follow-up, there were 59.5% neurologically intact patients according to the McCormick Scale, while 64.8% and 67% had no bladder or bowel dysfunction respectively. Complications occurred in 24 patients (25.5%). Pulmonary complications were the commonest (12.7%) with pleural effusion being significantly more common in patients treated with TTA compared to MIRA (20% vs 5.2%: X 4.13 P:0.042). Severe post-operative neuralgia (VAS 7-10) was also significantly more frequent in the TTA group (22.4% vs 2.6% X 7.07 p 0.0078).

Conclusions: MIRA is a safe and effective technique to obtain adequate TDH decompression and is associated with lower morbidity compared to TTA.
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http://dx.doi.org/10.1080/02688697.2020.1779660DOI Listing
April 2021

Childhood erythrodermic lichen planus pemphigoides after nonavalent human papillomavirus vaccination.

JAAD Case Rep 2020 May 30;6(5):431-433. Epub 2020 Apr 30.

Section of Dermatology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.

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http://dx.doi.org/10.1016/j.jdcr.2020.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7200189PMC
May 2020

A Risk Score Based on 5 Clinico-Pathological Variables Predicts Recurrence of Atypical Meningiomas.

J Neuropathol Exp Neurol 2020 May;79(5):500-507

From the Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Italy.

The use of adjuvant radiotherapy is controversial in patients with atypical meningiomas treated with gross total resection (GTR). This study aimed to determine whether clinico-pathological features could be helpful to predict the recurrence risk in this group of patients and to identify high-risk ones who could benefit from adjuvant treatment. We collected 200 patients with primary atypical meningiomas treated with GTR but with no adjuvant radiotherapy from 5 different centers. A risk score, formulated by assigning 1 point for the presence and 0 points for the absence of 5 high-risk parameters (male sex, parasagittal site, Simpson grade 3, mitotic index ≥ 6/10 HPF, and sheeting), was the most significant predictor of recurrence. A score ≥2 was associated with 4.7 risk of shorter disease-free survival (p < 0.0001). Our findings indicate that the presence of at least 2 clinico-pathological high-risk factors predicts recurrence of totally resected primary atypical meningiomas and could be helpful for identifying patients who could benefit from adjuvant radiotherapy.
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http://dx.doi.org/10.1093/jnen/nlaa018DOI Listing
May 2020

A metabolomic data fusion approach to support gliomas grading.

NMR Biomed 2020 03 11;33(3):e4234. Epub 2019 Dec 11.

Dipartimento di Scienze Chimiche Geologiche, Università di Modena e Reggio Emilia, via G. Campi 103, Modena, Italy.

Magnetic resonance imaging (MRI) is the current gold standard for the diagnosis of brain tumors. However, despite the development of MRI techniques, the differential diagnosis of central nervous system (CNS) primary pathologies, such as lymphoma and glioblastoma or tumor-like brain lesions and glioma, is often challenging. MRI can be supported by in vivo magnetic resonance spectroscopy (MRS) to enhance its diagnostic power and multiproject-multicenter evaluations of classification of brain tumors have shown that an accuracy around 90% can be achieved for most of the pairwise discrimination problems. However, the survival rate for patients affected by gliomas is still low. The High-Resolution Magic-Angle-Spinning Nuclear Magnetic Resonance (HR-MAS NMR) metabolomics studies may be helpful for the discrimination of gliomas grades and the development of new strategies for clinical intervention. Here, we propose to use T -filtered, diffusion-filtered and conventional water-presaturated spectra to try to extract as much information as possible, fusing the data gathered by these different NMR experiments and applying a chemometric approach based on Multivariate Curve Resolution (MCR). Biomarkers important for glioma's discrimination were found. In particular, we focused our attention on cystathionine (Cyst) that shows promise as a biomarker for the better prognosis of glioma tumors.
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http://dx.doi.org/10.1002/nbm.4234DOI Listing
March 2020

Diffuse gliomas in patients aged 55 years or over: A suggestion for IDH mutation testing.

Neuropathology 2020 Feb 22;40(1):68-74. Epub 2019 Nov 22.

Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy.

Diffuse gliomas are defined on the isocitrate dehydrogenase (IDH) gene (IDH) mutational mutational status. The most frequent IDH mutation is IDH1 R132H, which is detectable by immunohistochemistry; other IDH mutations are rare (10%). IDH mutant gliomas have better prognosis. Further, IDH wild-type low-grade (II/III) gliomas have clinical behaviors similar to those of glioblastoma (GBM) and it was suggested that they are submitted to similar post-surgical treatment. The incidence of IDH mutant gliomas (2%) and that of GBMs with non-canonical IDH mutations (< 1%) are very low in patients ≥ 55 years. For this reason, it was suggested that immunohistochemistry against IDH1 R132H is sufficient to classify GBM as IDH wild-type in this age group. However, no indication was provided for IDH mutational testing in low-grade diffuse gliomas. To address this issue, 273 diffuse gliomas were tested for IDH1 R132H immunohistochemistry. 2/4 diffuse astrocytomas (DAs), 4/9 anaplastic astrocytomas (AAs), 2/256 GBMs, and 4/4 oligodendrogliomas had positive staining. No other IDH mutations were found in immuno-negative low-grade cases by DNA sequencing. To validate our findings, we considered 311 diffuse gliomas in patients ≥ 55 years in The Cancer Genome Atlas database. Fifty-five out of 311 gliomas had IDH R132H mutations (9/16 DAs; 8/48 AAs; 3/211 GBMs; 35/36 oligodendrogliomas), one DA, and one oligodendroglioma had other IDH mutations. IDH mutant gliomas had significantly higher frequency of O-6-methylguanine-DNA methyltransferase promoter methylation (P = 0.0008) and longer overall survival (P < 0.0001). In conclusion, low-grade gliomas are a minor part of gliomas (117/584) in patients ≥ 55 years, albeit they represent most IDH mutant gliomas in this age group (64/69 cases). IDH non-canonical mutations can be found in immunonegative low-grade gliomas (2/54). In view of its significance for prognosis and therapeutic management, our results suggest that IDH mutational status is assessed in all diffuse gliomas in patients ≥ 55 years by immunohistochemistry, followed by IDH sequencing in low-grade immunonegative cases.
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http://dx.doi.org/10.1111/neup.12608DOI Listing
February 2020

Glioblastoma with tumor-to-tumor metastasis from lung adenocarcinoma.

Neuropathology 2019 Dec 15;39(6):474-478. Epub 2019 Sep 15.

Department of Diagnostics and Public Health, Section of Anatomical Pathology, University and Hospital Trust of Verona, Verona, Italy.

Glioblastoma is a tumor with widely variable morphology. It may rarely show pseudoepithelial components or true epithelial differentiation. Metastasis to glioblastomas have been previously reported, but were unsupported by immunohistochemical or molecular analyses. Herein we describe a glioblastoma with carcinomatous foci in a patient with no past clinical history of tumors outside the central nervous system. The carcinomatous foci expressed epithelial, but not glial markers. Therefore, whole-body imaging was carried out to verify the presence of carcinoma. A lung mass was biopsied and it resulted as primary lung adenocarcinoma. Carcinomatous foci of glioblastoma and lung adenocarcinoma had the same KRAS mutation which was absent in glial areas of the glioblastoma. Thus, glioblastoma with tumor-to-tumor metastasis was diagnosed. This case demonstrates that, albeit rare, metastases to glioblastoma may occur, and they should be considered in the differential diagnosis of glioblastoma with carcinomatous foci. Even when the past clinical history is negative, the presence of carcinoma should be investigated to rule out glioblastoma with tumor-to-tumor metastasis.
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http://dx.doi.org/10.1111/neup.12601DOI Listing
December 2019

Giant intradural extramedullary spinal ependymoma, a rare arachnoiditis-mimicking condition: case report and literature review.

Br J Neurosurg 2019 Jun 19:1-6. Epub 2019 Jun 19.

f Department of Neurosurgery , Walton Centre NHS Foudation Trust , Liverpool , UK.

Ependymomas are tumours arising from the ependymal cells lining the ventricles and the central canal of the spinal cord. They represent the most common intramedullary spinal cord tumour in adults and are very rarely encountered in an extramedullary location. Only 40 cases of intradural extramedullary (IDEM) ependymomas have been reported, all of which were diagnosed pre-operatively as IDEM ependymomas on contrast-enhanced MRI. We report a 23-year old male presenting with rapidly worsening signs and symptoms of spinal cord disease. A spinal MRI demonstrated a posterior multi-cystic dilatation extended between T1 and T12. Post-contrast sequences showed peri-medullar leptomeningeal enhancement and the diagnosis of spinal arachnoiditis was made. The patient underwent surgery and the spinal cord appeared circumferentially wrapped by an irregular soft tissue. The tissue was sub-totally removed and the pathological diagnosis was ependymoma WHO grade II. The patient experienced an excellent neurological recovery and no further treatments were administered. A small residue is now stable at 2.5 years follow-up. Giant IDEM ependymomas are rare entities and pre-operative diagnosis can be challenging in some cases. Surgery represents the main treatment option being resolutive in most cases.
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http://dx.doi.org/10.1080/02688697.2019.1630551DOI Listing
June 2019

Magnetic resonance diffusion-tensor imaging metrics in High Grade Gliomas: Correlation with IDH1 gene status in WHO 2016 era.

Eur J Radiol 2019 Jul 7;116:174-179. Epub 2019 May 7.

Neuroradiology Departments, Azienda Ospedaliera Universitaria Integrata Verona, Ospedale Civile Maggiore, Borgo Trento, Verona, Italy.

Purpose: To evaluate any possible correlation between the presence of Isocitrate DeHydrogenase 1 mutation (IDH1m) and specific DTI (Diffusion Tensor Imaging) metrics, such as Fractional Anisotropy (FA), Mean Diffusivity (MD), Radial Diffusivity (RD) and Axial Diffusivity (AD).

Methods: We retrospectively analyzed 47 patients who underwent an advanced-MR study with DTI followed by surgical intervention with a subsequent histologic diagnosis of High-Grade Glioma (HGG) and immunohistochemical evaluation of IDH1 (Isocitrate DeHydrogenase) mutation status. For each DTI metrics we measured the ratio between tumor and normal tissue and we evaluated the correlation with IDH1 mutation.

Results: We observed a positive correlation with IDH1 status and RD and MD data. No correlation was demonstrated between IDH1 status and FA and AD.

Discussion: Our results support the hypothesis that the number of residual axonal fibers, extracellular matrix composition and the presence of colliquated tissue, may together contribute to a global RD increase in HGG, with a relatively higher increase in IDH1m tumors.

Conclusions: Our data are in favor of a need for multimodal advance evaluation of HGG. DTI metrics help to analyze IDH1 mutation status, in order to better characterize the lesions and to tailor treatment and follow up.
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http://dx.doi.org/10.1016/j.ejrad.2019.04.020DOI Listing
July 2019

Expanded Endoscopic Approach for Anterior Skull Base Tumors: Experience of a Multidisciplinary Skull Base Team.

J Craniofac Surg 2019 Sep;30(6):1730-1733

Otolaryngology Department.

The aim of this study is to describe the experience of a multidisciplinary skull base team with transnasal endoscopic surgery for anterior cranial base tumors.A retrospective chart review was conducted on patients who underwent an exclusive expanded transnasal approach to the anterior skull base in the period from December 2014 to November 2015. Data on patient demographics, tumor characteristics, surgical information, imaging, and postoperative complications were collected and analyzed.From a total of 120 patients with skull base diseases managed by the skull base team, 36 were admitted to this study. The overall complication rate in this series was 16.7%, gross total resection was achieved in 32 cases (88.9%) and postoperative CSF leakage occurred in 5 cases (13.9%).Our preliminary results confirm that an exclusive endoscopic transnasal approach to the anterior cranial base is a reliable technique with acceptable perioperative morbidity.
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http://dx.doi.org/10.1097/SCS.0000000000005562DOI Listing
September 2019

Is endoscopic inspection necessary to detect residual disease in acoustic neuroma surgery?

Eur Arch Otorhinolaryngol 2019 Aug 26;276(8):2155-2163. Epub 2019 Apr 26.

Otolaryngology-Head and Neck Surgery Department, University Hospital of Verona, piazzale Aristide Stefani, 1, 37126, Verona, Italy.

Main Goals: To analyze how and when the endoscope is used in vestibular schwannoma surgery and identify the benefits of using endoscopy in this type of surgery.

Background: It is currently unclear if there is any benefit from using an endoscope in vestibular schwannoma surgery so this retrospective analysis set out to study this.

Methods: All the patients who underwent vestibular schwannoma surgery at our clinic were included for all the vestibular schwannoma approaches taken. We studied when endoscopy was used during surgery and the goal of using endoscopy. Several pre- and postoperative factors were assessed such as complications, facial function, and hearing function in the case of techniques that allow hearing preservation.

Results: From January 2015 to September 2018, 280 patients underwent lateral skull base surgery. Of these, 112 were included in this study. The endoscope was used in all 112 patients, and in eight cases it was possible to identify residual disease using the endoscope to check the surgical field, and then to remove the disease under endoscopic view. Moreover, in two other cases, the endoscope was used to resolve a vasculoneural conflict between the anterior inferior cerebellar artery (AICA) loop and facial nerve in one case, and for deafferentation of the superior and inferior vestibular nerves in the second case. No major intraoperative complications occurred in our series. There was no statistically significant difference in postoperative facial nerve function between patients in whom the endoscope was used as a diagnostic tool and patients in whom it was used as an operative tool (p = 0.3152).

Conclusions: The endoscope may be useful, especially in surgical techniques where there is poor control of the internal auditory canal (IAC). An endoscopic support technique is strongly recommended to avoid residual disease, particularly in retrosigmoid and retrolabyrinthine approaches. Moreover, the recent introduction of the transcanal transpromontorial approach allows the endoscope to be used during all the procedures in patients affected by a vestibular schwannoma limited to the IAC or to support surgical procedures during an enlarged microscopic approach.
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http://dx.doi.org/10.1007/s00405-019-05442-4DOI Listing
August 2019

Intraoperative Measurement of Arterial Blood Flow in Aneurysm Surgery.

Acta Neurochir Suppl 2018;129:43-52

Division of Neurosurgery, Padua City Hospital, Padova, Italy.

Intraoperative flowmetry (IF) has been recently introduced during cerebral aneurysm surgery in order to obtain a safer surgical exclusion of the aneurysm. This study evaluates the usefulness of IF during surgery for cerebral aneurysms and compares the results obtained in the joined surgical series of Verona and Padua to the more recent results obtained at the neurosurgical department of Verona.In the first surgical series, between 2001 and 2010, a total of 312 patients were submitted to IF during surgery for cerebral aneurysm at the neurosurgical departments of Verona and Padua: 162 patients presented with subarachnoid hemorrhage (SAH) whereas 150 patients harbored unruptured aneurysms. In the second series, between 2011 and 2016, 112 patients were submitted to IF during surgery for cerebral aneurysm at the neurosurgical department of Verona; 24 patients were admitted for SAH, whereas 88 patients were operated on for unruptured aneurysms.Comparison of the baseline values in the two surgical series and the baseline values between unruptured and ruptured aneurysms showed no statistical differences between the two clinical series. Analysis of flowmetry measurements showed three types of loco-regional flow derangements: hyperemia after temporary arterial occlusion, redistribution of flow in efferent vessels after clipping, and low flow in patients with SAH-related vasospasm.IF provides real-time data about flow derangements caused by surgical clipping of cerebral aneurysm, thus enabling the surgeon to obtain a safer exclusion; furthermore, it permits the evaluation of other effects of clipping on the loco-regional blood flow. It is suggested that-in contribution with intraoperative neurophysiological monitoring-IF may now constitute the most reliable tool for increasing safety in aneurysm surgery.
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http://dx.doi.org/10.1007/978-3-319-73739-3_7DOI Listing
January 2019

Language in individuals with left hemisphere tumors: Is spontaneous speech analysis comparable to formal testing?

J Clin Exp Neuropsychol 2018 09 31;40(7):722-732. Epub 2018 Jan 31.

g Center for Mind/Brain Sciences (CIMeC) , University of Trento , Trento , Italy.

Background: The relationship between spontaneous speech and formal language testing in people with brain tumors (gliomas) has been rarely studied. In clinical practice, formal testing is typically used, while spontaneous speech is less often evaluated quantitatively. However, spontaneous speech is quicker to sample and may be less prone to test/retest effects, making it a potential candidate for assessing language impairments when there is restricted time or when the patient is unable to undertake prolonged testing.

Aim: To assess whether quantitative spontaneous speech analysis and formal testing detect comparable language impairments in people with gliomas. Specifically, we addressed (a) whether both measures detected comparable language impairments in our patient sample; and (b) which language levels, assessment times, and spontaneous speech variables were more often impaired in this subject group.

Method: Five people with left perisylvian gliomas performed a spontaneous speech task and a formal language assessment. Tests were administered before surgery, within a week after surgery, and seven months after surgery. Performance on spontaneous speech was compared with that of 15 healthy speakers.

Results: Language impairments were detected more often with both measures than with either measure independently. Lexical-semantic impairments were more common than phonological and grammatical impairments, and performance was equally impaired across assessment time points. Incomplete sentences and phonological paraphasias were the most common error types.

Conclusions: In our sample both spontaneous speech analysis and formal testing detected comparable language impairments. Currently, we suggest that formal testing remains overall the better option, except for cases in which there are restrictions on testing time or the patient is too tired to undergo formal testing. In these cases, spontaneous speech may provide a viable alternative, particularly if automated analysis of spontaneous speech becomes more readily available in the future. These results await replication in a bigger sample and/or other populations.
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http://dx.doi.org/10.1080/13803395.2018.1426734DOI Listing
September 2018

12 Years delayed postoperative spinal recurrence of craniopharyngioma. Case report and literature review.

Br J Neurosurg 2019 Dec 4;33(6):687-689. Epub 2017 Dec 4.

Neurosurgery Department, University of Verona, Borgo Trento Hospital, Verona, Italy.

A case of delayed spinal adamantinomatous craniopharyngioma recurrence is presented. A 54-year-old male patient was admitted in our Emergency Department complaining of urinary disorders and leg pains. He underwent surgical removal of intraventricular craniopharyngioma 12 years previously. On MR imaging a well-circumscribed intradural cistyc mass at the T12 level was reavealed. A T11 and T12 laminotomy was performed and total removal of the tumour was achieved. Histology examination showed adamantinous craniopharyngioma. The authors believe that this represents the third case described of spinal craniofaryngioma recurrence and the first involving the dorsal spine.
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http://dx.doi.org/10.1080/02688697.2017.1406454DOI Listing
December 2019

A microRNA signature from serum exosomes of patients with glioma as complementary diagnostic biomarker.

J Neurooncol 2018 Jan 26;136(1):51-62. Epub 2017 Oct 26.

Laboratory of Molecular Pathology, Department of Pathology and Diagnostics, University Hospital of Verona, Verona, Italy.

Malignant gliomas, the most frequent primary brain tumors, are characterized by a dismal prognosis. Reliable biomarkers complementary to neuroradiology in the differential diagnosis of gliomas and monitoring for post-surgical progression are unmet needs. Altered expression of several microRNAs in tumour tissues from patients with gliomas compared to normal brain tissue have been described, thus supporting the rationale of using microRNA-based biomarkers. Although different circulating microRNAs were proposed in association with gliomas, they have not been introduced into clinical practice so far. Blood samples were collected from patients with high and low grade gliomas, both before and after surgical resection, and the expression of miR-21, miR-222 and miR-124-3p was measured in exosomes isolated from serum. The expression levels of miR-21, miR-222 and miR-124-3p in serum exosomes of patients with high grade gliomas were significantly higher than those of low grade gliomas and healthy controls and were sharply decreased in samples obtained after surgery. The analysis of miR-21, miR-222 and miR-124-3p in serum exosomes of patients affected by gliomas can provide a minimally invasive and innovative tool to help the differential diagnosis of gliomas at their onset in the brain and predict glioma grading and non glial metastases before surgery.
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http://dx.doi.org/10.1007/s11060-017-2639-xDOI Listing
January 2018

Next-generation repeat-free FISH probes for DNA amplification in glioblastoma in vivo: Improving patient selection to MDM2-targeted inhibitors.

Cancer Genet 2017 01 1;210:28-33. Epub 2016 Dec 1.

Department of Diagnostics and Public Health, Anatomic Pathology, AOUI Hospital Trust of Verona, Italy.

A next-generation FISH probe mapping to the MDM2 locus-specific region has recently been designed. The level of MDM2 gene amplification (high versus low) may allow selection of patients for cancer treatment with MDM2 inhibitors and may predict their responsiveness. We investigated the spectrum of MDM2 gene alterations using the new probes in vivo after visualizing single neoplastic cells in situ from a series of glioblastomas. Signals from next-generation repeat-free FISH interphase probes were identified in tissue microarrays that included 3 spots for each of the 48 cases. The murine double minutes (MDM2)-specific DNA probe and the satellite enumeration probe for chromosome 12 were used. Three cases (6%) showed more than 25 signals (high gene amplification), and 7 (15%) showed 3-10 signals (gains); among these, 4 cases (8%) had an equal number of MDM2 and centromeric signals on chromosome 12 (polyploidy). Genomic heterogeneity was observed only in 3 cases with low gene amplification. In our series, 6% of glioblastomas exhibited high MDM2 amplification (in vivo) with a pattern related to the known double minutes/chromothripsis phenomenon (in situ), and only cases with low amplification showed genomic heterogeneity. We concluded that the rate of MDM2 gene amplification can be a useful predictive biomarker to improve patient selection.
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http://dx.doi.org/10.1016/j.cancergen.2016.11.004DOI Listing
January 2017

Neurophysiology of complex spinal cord untethering.

J Clin Neurophysiol 2014 Aug;31(4):326-36

*Section of Neurosurgery, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy; and Divisions of †Neurology and ‡Neurosurgery Department of Neurosciences, University Hospital, Verona, Italy.

Surgery of complex spinal dysraphisms can be challenging. A number of surgical maneuvers can place the conus and the cauda equina at risk for neurological injury during cord untethering, and the identification of functional neural structures within the lumbosacral region is often not possible solely on the basis of anatomy. Therefore, the assistance of intraoperative neurophysiological monitoring can be invaluable during these procedures. We describe the intraoperative neurophysiological monitoring strategy developed at our institution over the past 12 years when dealing with tethered cord surgery. Monitoring and mapping techniques are described, with a focus on the invaluable role played by neurophysiological mapping. This latter, for a neurosurgeon, impacts tethered cord surgery at least as strongly as neurophysiological monitoring. Our results suggest that the combination of monitoring and mapping techniques increases the safety of these procedures, minimizing long-term morbidity and improving the degree of cord untethering.
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http://dx.doi.org/10.1097/WNP.0000000000000115DOI Listing
August 2014

Pleomorphic xanthoastrocytoma: long-term results of surgical treatment and analysis of prognostic factors.

Br J Neurosurg 2013 Dec 20;27(6):759-64. Epub 2013 Mar 20.

Department of Neurosurgery, University Hospital , Verona , Italy.

Background: Pleomorphic Xanthoastrocytoma (PXA) is a rare brain tumour, most commonly affecting children and young adults. To date, only few data regarding the long-term follow-up of these patients after surgery are available. The aim of this study is to describe our single-institution experience in the surgical management of this particular glioma over a period of over 18 years.

Methods: We performed a retrospective review of all cases of PXA (40 patients) operated upon at the Department of Neurosurgery of Verona, Italy, between 1990 and 2008. The impact of clinical, radiological, surgical and histological factors on overall survival (OS) and progression-free survival (PFS) was analysed by means of univariate and multivariate models.

Findings: We achieved a gross total resection (GTR) in 65% of patients. Histological diagnosis was of grade II in 80%; anaplastic features were present in the remaining 20%. Adjuvant treatment, radiotherapy or chemo-radiotherapy, was administered in 40% of the cases. Median follow-up was 74 months. OS at 5- and 10 years was 76.32% and 68.24%, respectively. PFS at 5- and 10 years was 71% and 58%, respectively. In the multivariate model, histological grade, extent of resection and age at diagnosis (≤ 30 years vs > 30 years) were the only independent prognostic factors for both OS and PFS.

Conclusions: Our retrospective long-term study confirms the relatively favourable prognosis associated with PXA. Young patients with a low-grade tumour (WHO grade II) who underwent GTR carry the longest OS and PFS.
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http://dx.doi.org/10.3109/02688697.2013.776666DOI Listing
December 2013

Long-term results after posterior fossa decompression in syringomyelia with adult Chiari Type I malformation.

J Neurosurg Spine 2012 Nov 31;17(5):381-7. Epub 2012 Aug 31.

Department of Neurosurgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.

Object: There is little information about the long-term effectiveness and complications following decompressive surgery for syringomyelia related to Chiari malformation Type I (CM-I).

Methods: Examining long-term clinical and radiological follow-up, the authors studied a mixed retrospective and prospective single-institution cohort of 109 consecutive surgically treated adult patients with syringomyelia and CM-I. All patients underwent a standardized surgical protocol: decompression of the craniocervical junction, arachnoid exploration, and shrinkage of the cerebellar tonsils. Factors predicting outcome were investigated.

Results: The retrospective arm consisted of 41 cases treated between 1990 and 1994, and the prospective arm comprised 68 patients treated between 1994 and 2001. The mean overall age was 45.9 years, and 58.8% of the population was female. The median follow-up period was 12.7 years. The most frequent initial symptoms were pain and sensory and gait disturbances. There was no perioperative death or neurological deterioration. The comprehensive perioperative complication rate was approximately 11%, with 3 cases (2.7%) of CSF leakage. Regression analysis showed that the best combination of clinical and radiological outcome predictors was age and duration of symptoms. Clinical follow-up confirmed surgical result stability with clinical improvement of greater than 90% of the spinal and cranial manifestations over a long-term period. Two patients had radiological recurrences of syringomyelia without clinical signs 85 and 124 months after surgery.

Conclusions: Certain clinical predictors of poor clinical and radiological prognosis were identified-namely, age at time of surgery and symptom duration. The results of the study provide additional long-term data that support the effectiveness and safety of relieving CSF block at the craniocervical junction in CM-I-related syringomyelia.
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http://dx.doi.org/10.3171/2012.7.SPINE12272DOI Listing
November 2012

Conservative treatment of an atlantoaxial degenerative articular cyst: case report.

Spine J 2008 Jul-Aug;8(4):687-90. Epub 2007 Mar 20.

Unitá Operativa di Neurochirurgia, Ospedale Generale Regionale, Via Bohler 5, 39100 Bolzano, Italy.

Background: Atlantoaxial degenerative articular cysts are rare lesions that can cause extradural compression of the cervicomedullary junction. When symptomatic, they usually require surgical treatment. We report an unusual case of spontaneous regression of an atlantoaxial degenerative articular cyst after conservative treatment with an external cervical brace along with a systemic therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids. We also discuss the potential pathogenetic mechanisms involved.

Purpose: To describe a case of significant volume reduction of an atlantoaxial articular degenerative cyst in a patient treated with a Philadelphia collar and anti-inflammatory drugs.

Study Design: Case report with analysis of the literature.

Methods: A 80-year-old patient was admitted to our institution with a history of progressive tetraparesis, ataxic gait, and cervical pain. A cervical spine magnetic resonance imaging (MRI) scan showed an extradural mass lesion behind the dens of C2 causing significant compression of the cervicomedullary junction, suggesting the diagnosis of atlantoaxial degenerative articular cyst. The patient refused surgery in favour of a conservative treatment with a Philadelphia collar and a short-term course of NSAIDs and corticosteroids.

Results: After 6 weeks, the patient's neurological condition improved, and a 6-month follow-up cervical spine MRI scan revealed an almost complete regression of the atlantoaxial cystic lesion. At a 1-year follow-up, his clinical condition was further improved.

Conclusions: Atlantoaxial articular degenerative cysts are rare lesions that should be included in the differential diagnosis of those extradural lesions that can cause a ventral or ventrolateral compression of the cervicomedullary junction. They most commonly occur in elderly female patients affected by diffuse arthrosic degeneration of the cervical spine, with or without clear radiological signs of atlantoaxial instability, and have a typical appearance on MRI imaging. Surgery, with direct excision of the cyst and/or a C1-C2 fusion, is the first treatment of choice. Nevertheless, our report points out the possibility of a significant spontaneous regression of these lesions following a simple conservative strategy based on the use of an external cervical brace together with a systemic anti-inflammatory therapy.
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http://dx.doi.org/10.1016/j.spinee.2007.01.006DOI Listing
September 2008

Adenosine extracellular levels in human brain gliomas: an intraoperative microdialysis study.

Neurosci Lett 2003 Jul;346(1-2):93-6

Department of Preclinical and Clinical Pharmacology, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy.

Adenosine present in human brain glioma extracellular spaces is a marker of astrocyte purine metabolism. In this study, we evaluated adenosine levels in the extracellular fluid of 21 human gliomas of high-grade malignancy using brain microdialysis techniques coupled to high-performance liquid chromatography. The adenosine concentration (mean+/-SEM) within the control tissue was 2.99+/-0.37 microM and in the tumour tissue 1.56+/-0.46 microM. The reduction was statistically significant. It is concluded that the adenosine concentrations reached in the tumour tissue are sufficient to stimulate all adenosine receptor subtypes, suppress local anti-tumour immune responses and affect glial and endothelial cell proliferation.
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http://dx.doi.org/10.1016/s0304-3940(03)00596-2DOI Listing
July 2003

A prospective study on glioblastoma in the elderly.

Cancer 2003 Feb;97(3):657-62

Department of Medical Oncology, Azienda Ospedale-Università, Padova, Italy.

Background: Elderly patients (age > 65 years) with glioblastoma multiforme frequently are excluded from clinical studies, and prospective trials for patients with this age group do not exist to date.

Methods: The authors conducted a prospective trial in 79 consecutive elderly patients with glioblastoma who underwent surgery and received radiotherapy (59.44 grays in 33 fractions; Group A; n = 24 patients) or received the same radiotherapy plus adjuvant chemotherapy with procarbizine, lomustine, and vincristine (PCV; lomustine 110 mg/m(2) on Day 1, procarbazine 60 mg/m(2) on Days 8-21, and vincristine 1.4 mg/m(2) on Days 8 and 29 every 42 days; Group B; n = 32 patients), or received the same radiotherapy plus adjuvant temozolomide (150 mg/m(2) for 5 days every 28 days; Group C; n = 22 patients).

Results: The median time to disease progression (TTP) and median survival MST were 7.2 months (95% confidence interval [95%CI], 6.34-8.64) and 12.5 months (95%CI, 11.6-14.8), respectively. The TTP was significantly better for Group C compared with Groups A and B (10.7 months vs. 5.3 months and 6.9 months, respectively; P = 0.0002). Karnofsky performance status (KPS) (P < 0.001) and temozolomide (P < 0.001) were the only independent prognostic factors. Overall survival was better in Group C compared with Group A (14.9 months vs. 11.2 months; P = 0.002), but there were no statistical differences found between Groups A and B or between Groups B and C. Only KPS (P < 0.001) was predictive of overall survival, even if temozolomide chemotherapy was very close to the significance level (P = 0.058). Hematologic Grade 3-4 toxicity was higher with the PCV chemotherapy regimen compared with the temozolomide chemotherapy regimen.

Conclusions: Age alone should not preclude appropriate treatment in elderly patients with good performance status, for whom definitive radiation therapy and adjuvant chemotherapy with temozolomide is advised.
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http://dx.doi.org/10.1002/cncr.11097DOI Listing
February 2003

Temporary arterial occlusion in the repair of ruptured intracranial aneurysms: an analysis of risk factors for stroke.

J Neurosurg 2002 Oct;97(4):836-42

Department of Neurosurgery, University and City Hospital, Verona, Italy.

Object: This study was performed to further elucidate technical and patient-specific risk factors for perioperative stroke in patients undergoing temporary arterial occlusion during the surgical repair of their aneurysms.

Methods: One hundred twelve consecutive patients in whom temporary arterial occlusion was performed during surgical repair of an aneurysm were retrospectively analyzed. Confounding factors (inadvertent permanent vessel occlusion and retraction injury) were identified in six cases (5%) and these were excluded from further analysis. The demographics for the remaining 106 patients were analyzed with respect to age, neurological status, aneurysm characteristics, intraoperative rupture, duration of temporary occlusion, and number of occlusive episodes; end points considered were outcome at 3-month follow up and symptomatic and radiological stroke.

Conclusions: Overall 17% of patients experienced symptomatic stroke and 26% had radiological evidence of stroke attributable to temporary arterial occlusion. A longer duration of clip placement, older patient age, a poor clinical grade (Hunt and Hess Grades IV-V), early surgery, and the use of single prolonged clip placement rather than repeated shorter episodes were associated with a higher risk of stroke based on univariate analysis. Intraoperative aneurysm rupture did not affect stroke risk. On multivariate analysis, only poorer clinical grade (p = 0.001) and increasing age (p = 0.04) were significantly associated with symptomatic stroke risk.
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http://dx.doi.org/10.3171/jns.2002.97.4.0836DOI Listing
October 2002
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