Spinal ependymomas: Benefits of extent of resection for different histological grades

Although the World Health Organization (WHO) categorizes spinal ependymomas into three histological grades, difference in surgical outcomes between WHO grades I and II tumors are unclear. For these benign tumors, prognosis may be best determined by factors other than tumor grade alone, such as extent of resection. To analyze the effects of the extent of resection on different grades of spinal ependymomas, we performed a comprehensive literature review to identify adult spinal ependymoma patients who received surgical resection with a clearly identifiable WHO grade. A total of 175 patients were identified. While grade III tumors carried the worst prognosis as expected (p < 0.001), grade I and II tumors did not differ significantly in outcomes following surgery. Overall, gross total resection (GTR, 68.7%, 114/166) provided significantly improved progression-free survival (PFS, p < 0.001) and overall survival (OS, p = 0.022) compared to the subtotal resection group. Surprisingly, the highest GTR rate was achieved for grade II tumors (78.8%, 78/99; p < 0.001) followed by grade I (58.9%, 33/56) and grade III tumors (27.3%, 3/11). Interestingly, PFS was significantly improved by GTR for grade II tumors (p < 0.001), but not for grade I (p = 0.705). Similar trends, although not statistically significant, were found for OS. Our results show that while GTR provides the best overall outcomes, GTR is most effective for classic grade II ependymomas, but not for grade I ependymomas. Despite having a lower WHO grade, myxopapillary ependymomas have a lower GTR rate, and benefit less from GTR.     

Operative management of brainstem hemangioblastomas

Brainstem hemangioblastomas are technically challenging lesions. The authors retrospectively analyzed their experience in 24 patients with brainstem hemangioblastomas to evaluate the management strategies used over time and the results of microsurgical treatment. All patients were operated on between 2007 and 2012. The patients received postoperative follow-up by neuroradiological and neurological examinations. The maximum diameter of the tumors ranged from 2.0 to 4.5 cm (mean 3.6 cm). Gross total resection was achieved in 24 patients (100%). Two patients (8%) had new neurological deficits or worsening of pre-existing deficits. One patient (4%) died because of brain stem dysfunction after the operation. Radical en bloc surgical resection of brainstem hemangioblastomas in symptomatic patients is a safe and effective primary treatment. Preoperative embolization is not necessary. It is very important and necessary to differentiate and dissect precisely at the interface of the tumor surface and the brainstem with a meticulous microsurgical technique until the tumor is removed en bloc. The preoperative neurological status of the patient predicts the postoperative functional outcome. Asymptomatic patients with hemangioblastoma may be followed clinically with MRI surveillance at regular intervals.     

Sulforhodamine 101 selectively labels human astrocytoma cells in an animal model of glioblastoma

Sulforhodamine 101 (SR101) is a useful tool for immediate staining of astrocytes. We hypothesized that if the selectivity of SR101was maintained in astrocytoma cells, it could prove useful for glioma research. Cultured astrocytoma cells and acute slices from orthotopic human glioma (n = 9) and lymphoma (n = 6) xenografts were incubated with SR101 and imaged with confocal microscopy. A subset of slices (n = 18) were counter-immunostained with glial fibrillary acidic protein and CD20 for stereological assessment of SR101 co-localization. SR101 differentiated astrocytic tumor cells from lymphoma cells. In acute slices, SR101 labeled 86.50% (±1.86; p < 0.0001) of astrocytoma cells and 2.19% (±0.47; p < 0.0001) of lymphoma cells. SR101-labeled astrocytoma cells had a distinct morphology when compared with in vivo astrocytes. Immediate imaging of human astrocytoma cells in vitro and in ex vivo rodent xenograft tissue labeled with SR101 can identify astrocytic tumor cells and help visualize the tumor margin. These features are useful in studying astrocytoma in the laboratory and may have clinical applications.     

Effectiveness of radiotherapy for elderly patients with anaplastic gliomas

Postoperative radiotherapy (RT) is utilized routinely in the management of anaplastic World Health Organization Grade III gliomas (AG), including anaplastic astrocytoma (AA) and anaplastic oligodendroglioma (AO). However, the optimal role of RT in elderly AG patients remains controversial. We evaluated the effectiveness of RT in elderly AG patients using a national cancer registry. The USA Surveillance, Epidemiology, and End Results database (1990–2008) was used to query patients over 70 years of age with AA or AO. Independent predictors of overall survival were determined using a multivariate Cox proportional hazards model. Among 390 elderly patients with AG, 333 (85%) had AA and 57 (15%) had AO. Approximately two-thirds of AA patients (64%) and AO patients (65%) received RT. Most AO patients (58%) and many AA patients (41%) underwent surgical resection; the remainder had biopsy. The median overall survival for all patients who underwent RT was 6 months (95% confidence interval [CI], 5–7 months) versus 2 months (95% CI 1–6) in patients who did not have RT. Patients who had gross total resection (GTR) plus RT had a median overall survival of 11 months (95% CI 7–14). Multivariate analysis for all patients showed that undergoing RT was significantly associated with improved survival (hazard ratio [HR] 0.52, p < .0001). AA tumor type (HR 1.37, p = .03) was associated with worse survival than AO tumor type; female sex (HR 0.59, p < .0001) and being married (HR 0.66, p = .002) significantly improved survival. Patients that underwent GTR had a significant reduction in the hazards of mortality compared to biopsy (HR 0.72, p = .04). Elderly AG patients undergoing RT had better overall survival compared to patients who did not receive RT. Treatment strategies involving maximal safe resection plus RT should be considered in the optimal management of AG in elderly patients.     

Predictive value of electrocorticography for postoperative epilepsy in patients with supratentorial meningioma

This study examines electrocorticography (ECoG) signals in patients with supratentorial meningioma before and after tumor resection, and discusses its predictive value with regard to postoperative epilepsy. Ninety-one patients with supratentorial meningioma, who presented with seizures, were studied. Patients were followed-up for 2 to 5 years, and the occurrence rate of postoperative epilepsy in each group was compared. Depending on the frequency and amplitude variation in multiple spike waves on ECoG, patients were divided into those with an increase in epileptic discharge (Group A), those with no change (Group B), and those with a reduction in epileptic discharge (Group C). Postoperative seizures was classified as early postoperative seizures (within 1 week of surgery) or late postoperative seizures (> 1 week after surgery). After lesion resection and measurement of ECoG, the 91 patients were divided into Group A (12 patients, 13.19%), Group B (36 patients, 39.56%) and Group C (43 patients, 47.25%). Of these 91 patients, 29 (31.87%) had early postoperative seizures of which seven patients (58.33%) were from Group A, 13 (36.11%) were from Group B and nine (20.93%) were from Group C (χ² = 6.53, p < 0.05). Seventeen patients (18.68%) had late postoperative seizures, of which two patients (16.67%) were from Group A, seven were from Group B (19.44%) and eight were from Group C (18.60%) (χ² = 0.05, p > 0.05). Of the 29 patients with early postoperative seizures, seven (24.14%) also had late postoperative epilepsy. Of the 62 patients who did not experience early postoperative seizures, 10 (16.13%) also had late postoperative epilepsy (χ² = 0.83, p > 0.05). Thus, the change in ECoG before and after resection in patients with supratentorial meningioma has a predictive value for early postoperative seizures.     

Factors associated with survival for patients with glioblastoma with poor pre-operative functional status

Patients with glioblastoma (GB) are known to have poor prognoses, and among these patients, those with poor neurological function have an even poorer prognosis. Consequently, aggressive surgeries and adjuvant therapies are often withheld because of this dismal outlook. The effects of aggressive therapies in this small subset of patients remain unknown. The goal of this study was to evaluate outcomes and factors associated with survival for poor functioning patients who underwent aggressive resection of their GB. Adult patients who underwent surgical resection of an intracranial primary GB at an academic tertiary-care institution between 1997 and 2007 were retrospectively reviewed. Patients with a Karnofsky Performance Scale (KPS) score of ?60 were included. A total of 100 patients with primary GB met the inclusion criteria. The average age (±standard deviation) and KPS score of this cohort were 54 ± 15 years and 53 ± 12, respectively. No patient (0%) experienced perioperative mortality, and 0 (0%), 10 (10%), and 3 (3%) of patients incurred a new or increasing language, motor, and visual deficit, respectively. At last follow-up, 88 (88%) patients died with a median survival of 6.6 months. The factors associated with improved survival were age <65 year (p = 0.005), tumor size >2 cm (p = 0.01), radical tumor resection (p = 0.01), and temozolomide (p = 0.001). This study identifies a subset of patients with poor functional status who may benefit from aggressive surgical resection.     

Treatment and survival of patients harboring histological variants of glioblastoma

It is unclear whether the survival difference observed between glioblastoma (GBM), giant cell glioblastoma (gcGBM), and gliosarcoma (GSM) patients is due to differences in tumor histology, patient demographics, and/or treatment regimens. The USA National Cancer Database was utilized to evaluate patients diagnosed with GBM, gcGBM, and GSM between 1998 and 2011. Kaplan–Meier survival estimates and Cox proportional hazards models were utilized to estimate overall survival. A cohort of 69,935 patients was analyzed; 67,509 (96.5%) of these patients had GBM, 592 (0.9%) gcGBM, and 1834 (2.6%) GSM. The median age for GBM and GSM patients was 61 versus 56 years for gcGBM (p < 0.0001). Higher extent of resection (p < 0.0001) and radiation (p = 0.001) were observed in gcGBM patients compared to other histologies. Multivariate analysis showed that gcGBM patients had a 20% reduction in the hazards of mortality (hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.69–0.93) compared to GBM, while GSM patients trended towards higher hazards of mortality (HR 1.04, 95% CI 0.96–1.12) than the GBM cohort. Previous studies have suggested a disparity in the survival of patients with GBM tumors and their histological variants. Using a large cohort of patients treated at hospitals nationwide, this study found a 20% reduction in the hazards of mortality in gcGBM patients compared to GBM. Similarly, gcGBM patients had a 24% reduction in the hazards of mortality compared to the GSM cohort. GSM patients had a 3% increase in the hazards of mortality compared to GBM.     

Medullary hemangioblastoma: 34 patients at a single institution

This study aimed to elucidate the surgical experience of medullary hemangioblastoma (MH) at a single institution. We reviewed 34 consecutive patients with MH operated on between January 2005 and June 2012 in the neurosurgery department of the Beijing Tiantan Hospital. There were 14 men and 20 women. The patients were aged from 17 to 60 years with an average age of 38 years. Tumors were cystic in 12 patients (Type A), and solid in 22 patients. The solid tumors were of a small size in six patients (<3 cm, Type B), large in 12 (3.1–5 cm, Type C), and giant in four (>5 cm, Type D). Radical tumor removal was achieved in all patients. Tracheotomy was performed in 10 patients (one Type B patient, seven Type C, two Type D) postoperatively. Pneumonia secondary to lower cranial nerve palsy occurred in six patients (all Type C). Complications including intracranial infection (n = 5), gastrointestinal bleeding (n = 2), and intracranial hematoma (n = 1) also occurred in this group. Follow-up (range, 2–82 months; mean, 30 months) was available in all patients. At follow-up, 29 patients (85.3%) had a good outcome. Twenty-eight of these (82.4%) had an excellent outcome postoperatively (Karnofsky Performance Status ⩾80). Although transient surgical complications are possible especially for large solid tumors, total surgical resection can be performed with favorable long-term outcomes with meticulous microsurgical technique and understanding of the vascular pattern of the tumor. Postoperative management of MH is as important as the operation.     

Gamma Knife radiosurgery following subtotal resection of vestibular schwannoma

During treatment of large vestibular schwannomas, incomplete resection (IR) followed by Gamma Knife surgery (GKS; Elekta AB, Stockholm, Sweden) possibly offers tumor growth control and good clinical outcome, and is being discussed as an alternative to complete tumor removal with its inherent risks, especially for facial nerve function. However, available data for this concept are limited due to the small number of published studies. To analyze the effects of combined therapy in a larger cohort, we reviewed the currently available data. Six studies comprising 159 patients with a tumor diameter of at least 2 cm were included (median volume 19.95 cm³ in four studies, n = 137). GKS was performed on average 6 months postoperatively with a mean marginal dose of 11.88 Gy (mean target volume 4.42 cm³, mean diameter 18.45 mm). Preoperatively facial nerve function was serviceable (House and Brackmann Grades I+II) in 158 of 159 patients (99.4%) and in 125 of 151 patients (82.8%, 95% confidence interval [CI] 76–88%) postoperatively. Hearing was serviceable in 29 of 151 patients (19.2%) preoperatively and in 16 of 79 patients postoperatively (20.2%, 95%CI 12–31%). Within a mean follow-up time of 50 months (range 12–102 months), facial nerve function and hearing after IR remained serviceable in 142 of 151 (94.0%, 95%CI 89–97%) and 15 of 129 patients (11.6%, 95%CI 7–18%). Tumor growth control was achieved in 149 of 159 patients (93.8%). Six patients were subjected to repeated therapy. Minimal complications were reported for microsurgery and GKS. Combined therapy was shown to be beneficial regarding both tumor control and adverse side effects among all analyzed studies.     

Microvessel density and vascular endothelial growth factor expression as predictors of childrens’ survival from cerebellar medulloblastoma

Cerebellar medulloblastoma is the most common malignant brain tumor of childhood. This neoplasm is highly vascular and has a high growth rate. We aimed to determine whether high microvessel density (MVD) and expression of vascular endothelial growth factor (VEGF) in medulloblastoma tissue is correlated with survival time in children with this tumor. Tissue from 32 cerebellar medulloblastomas in 14 girls and 18 boys was studied. The standard-risk group comprised patients older than 3 years, without metastases of medulloblastoma and a residual post-operative tumor with a surface area less than 1.5 cm². The patients assigned to a high-risk group had at least one of the following indicators: younger than 3 years, metastases, or a residual post-operative tumor with a surface area larger than 1.5 cm². For each tumor, MVD was determined and the expression of VEGF was assessed using immunohistochemical techniques. The 5-year survival rate for the 32 patients was 56.2%. Five-year survival rates were 70.6% and 40.0% for patients in the standard-risk and high-risk groups, respectively. The mean (±standard deviation, SD) MVD for all patients was 22.0 ± 9.1 microvessels per 0.7 mm². There was no difference in the survival rate between the groups with above-average MVD and below-average MVD (66.7% and 50.0%, respectively). Testing revealed 7 tumors with VEGF expression and 25 without. The 5-year survival rates for these 2 groups were not significantly different (57.1% vs. 56.0%, respectively). The mean (±SD) MVD values for the VEGF-positive and VEGF-negative groups were not significantly different (19.1 ± 6.5 vs. 22.9 ± 9.7 microvessels per 0.7 mm², respectively, Mann–Whitney U-test = 78.5, Z = ?0.41, p = 0.68). There were no significant correlations between risk groups and expression of VEGF or MVD. These results indicate that neither high MVD nor the expression of VEGF in tumor tissue predicts poor prognosis in children with cerebellar medulloblastoma.     

Randomized trial for superiority of high field strength intra-operative magnetic resonance imaging guided resection in pituitary surgery

Till date there are no randomized trials to suggest the superiority of intra-operative magnetic resonance imaging (IOMRI) guided trans-sphenoidal pituitary resection over two dimensional fluoroscopic (2D-F) guided resections. We conducted this trial to establish the superiority of IOMRI in pituitary surgery. Primary objective was to compare extent of tumor resection between the two study arms. It was a prospective, randomized, outcome assessor and statistician blinded, two arm (A: IOMRI, n = 25 and B: 2D-F, n = 25), parallel group clinical trial. 4 patients from IOMRI group cross-over to 2D-F group and were consequently analyzed in latter group, based on modified intent to treat method. A total of 50 patients were enrolled till completion of trial (n = 25 in each study arm). Demographic profile and baseline parameters were comparable among the two arms (p > 0.05) except for higher number of endoscopic procedures and experienced neurosurgeons (>10 years) in arm B (p = 0.02, 0.002 respectively). Extent of resection was similar in both study arms (A, 94.9% vs B, 93.6%; p = 0.78), despite adjusting for experience of operating surgeon and use of microscope/endoscope for surgical resection. We observed that use of IOMRI helped optimize the extent of resection in 5/20 patients (25%) for pituitary tumor resection in-group A. Present study failed to observe superiorty of IOMRI over conventional 2D-F guided resection in pituitary macroadenoma surgery. By use of this technology, younger surgeons could validate their results intra-operatively and hence could increase EOR without causing any increase in complications.     

Learning curve for the endoscopic endonasal approach for suprasellar craniopharyngiomas

The endoscopic endonasal approach is considered an alternative minimally invasive approach for suprasellar craniopharyngiomas. However, the complicated surgical manipulations required by this approach have limited its application. We evaluate whether the approach features a learning curve. Thirty-three patients were retrospectively reviewed and grouped as early (17 patients) and late (16 patient) groups. The operation time, extent of removal, ophthalmology, endocrinology, reconstruction and modifications of standard technique were evaluated. Between the two groups, the operation time decreased from 201.1 ± 105.3 min in the early group to 107.6 ± 90.0 min in the late group (p < 0.05). Regarding clinical outcomes, non-significantly increasing trends toward the rate of gross total resection, visual improvement and (from 76.5% to 87.5%, 73.3% to 93.3%), significantly decreasing trends toward the rate of tumor recurrence (from 23.5% to 0% p < 0.05) and non-significantly decreasing trends toward the rate of hypopituitarism recovery (26.7% to 0%) were observed between the two groups. With respect to complications, non-statistically significant decreasing trends toward transient cranial nerve paralysis (from 5.9% to 0%) and non-statistically significant increasing trends toward rate of CSF leakage, meningitis and new hypothyroidism (from 11.8% to 25%, 11.8% to 31.3%, 0 to 3%) were observed. We identified a learning curve for the endoscopic endonasal approach for suprasellar craniopharyngiomas. The exact number of patients necessary to establish a significant improvement in the clinical outcomes and decrease in the complications warrants further investigation. The outcomes of tumor recurrence may be associated with duration of follow-up. The CSF leakage represented the most common complication.     

Prognosis by tumor location in adults with intracranial ependymomas

Intracranial ependymomas are rare tumors in adults. Thus, factors affecting prognosis are poorly understood. We performed a study to investigate whether tumor location is an important prognostic factor in adults who undergo surgery for intracranial ependymomas. PubMed was searched to identify studies that reported clinical outcomes in adult patients with intracranial ependymoma. Data were extracted for patient and tumor characteristics, extent of resection, progression-free survival (PFS), and overall survival (OS). Tumors were categorized as supratentorial or infratentorial and extraventricular or intraventricular. Presenting clinical features and tumor characteristics were tabulated. Kaplan–Meier and multivariate Cox regression survival analyses were performed to determine PFS and OS by tumor location. Extent of resection was also analyzed by tumor location. A total of 183 patients were included in the meta-analysis. Patients presented at a mean of 8.2 months with a myriad of clinical features. The mean tumor size was 3.38 cm, and 19.3% of tumors were cystic. Supratentorial tumors were most commonly located in the frontal and parietal lobes, and infratentorial tumors in the fourth ventricle. Supratentorial tumors demonstrated significantly poorer PFS (p < 0.001) and OS (p = 0.003) than infratentorial tumors, despite a higher rate of gross total resection (GTR) for the supratentorial tumors (72.6% versus 42.1%). Extraventricular ependymomas displayed significantly poorer PFS than intraventricular ependymomas (p = 0.009). In summary, supratentorial ependymomas have significantly poorer PFS and OS than their infratentorial counterparts, despite being more conducive to GTR, suggesting increased clinical aggressiveness. Extraventricular location is also associated with significantly poorer PFS than intraventricular location.     

Multiple resections and survival of recurrent glioblastoma patients in the temozolomide era

Glioblastoma (GBM) is the most prevalent and aggressive primary brain tumor in adults for which recurrence is inevitable and surgical resection is often recommended. We investigated the relationship between multiple tumor resections and overall survival (OS) in adult glioblastoma patients who received adjuvant radiotherapy and temozolomide following initial surgery. We retrospectively reviewed the records of all newly diagnosed adult GBM patients with tumor recurrence at our institution from March 2003 to October 2012. Kaplan–Meier survival estimates and multivariate analysis using Cox’s proportional hazards model were utilized to evaluate the impact of multiple resections on OS. A total of 202 GBM patients were analyzed; 83 (41.1%), 94 (46.5%), and 25 (12.4%) patients underwent one, two, and three or more total resections, respectively. Patients who underwent multiple resections were significantly younger (p < 0.0001) and had higher perioperative Karnofsky Performance Status scores (p < 0.0001) than single resection patients. The median OS in months was 21.1, 25.5, and 29.0 for patients who had one, two, and three or more resections, respectively (Wilcoxon p = 0.03). In a confounder-adjusted multivariate model, patients with multiple resections did not have significantly improved survival (p = 0.55). Older age was strongly associated with poorer OS (hazard ratio 1.34, p < 0.0001). Age at diagnosis was the only predictor of survival for recurrent GBM patients. After adjusting for age at diagnosis, multiple resections were not an independent predictor of OS in our glioblastoma cohort treated in the temozolomide era.     

Treatment and survival of supratentorial and posterior fossa ependymomas in adults

Ependymoma is a rare primary brain or spinal cord tumor that arises from the ependyma, a tissue of the central nervous system. This study analyzed a large cohort of adult supratentorial and posterior fossa ependymoma tumors in order to elucidate factors associated with overall survival. We utilized the USA National Cancer Database to study adult World Health Organization grade II/III supratentorial and posterior fossa ependymoma patients treated between 1998 and 2011. Overall survival was estimated by the Kaplan–Meier method and factors associated with survival were determined using a multivariate Cox proportional hazards model. Among 1318 patients, 1055 (80.0%) had grade II and 263 (20.0%) anaplastic tumors located in the posterior fossa (64.3%) and supratentorial region (35.7%). Overall average age was 44.3 years, 48.0% of patients were female, 86.5% were Caucasian, and 36.8% underwent near/gross total surgical resection. Radiotherapy was given to 662 patients (50.8%) and 75 (5.9%) received chemotherapy. Older age at diagnosis (hazard ratio [HR] 1.51, p < 0.0001), high tumor grade (HR 1.82, p = 0.005), and large tumor size (HR 1.66, p = 0.008) were associated with poor survival. Females compared to males (HR 0.67, p = 0.03) and patients with posterior fossa tumors versus supratentorial (HR 0.64, p = 0.04) had a survival advantage. Our study showed that older patients, with supratentorial tumors, and high histological grade had an increased risk of mortality. A survival benefit was captured in females and patients with posterior fossa tumors. Adjuvant radiotherapy and chemotherapy did not confer a survival benefit among all patients, even after stratification by tumor grade or anatomical location.     

Hearing preservation after stereotactic radiosurgery for vestibular schwannoma: A systematic review

Radiosurgery has evolved into an effective alternative to microsurgical resection in the treatment of patients with vestibular schwannoma. We performed a systematic analysis of the literature in English on the radiosurgical treatment of vestibular schwannoma patients. A total of 254 published studies reported assessable and quantifiable outcome data of patients undergoing radiosurgery for vestibular schwannomas. American Association of Otolaryngology-Head and Neck Surgery (AAO-HNS) class A or B and Gardner-Robertson (GR) classification I or II were defined as having preserved hearing. A total of 5825 patients (74 articles) met our inclusion criteria. Practitioners who delivered an average dose of ?12.5 Gy as the marginal dose reported having a higher hearing preservation rate (?12.5 Gy = 59% vs. >12.5 Gy = 53%, p = 0.0285). Age of the patient was not a significant prognostic factor for hearing preservation rates (<65 years = 58% vs. >65 years = 62%; p = 0.4317). The average overall follow-up was 41.2 months. Our data suggest that an overall hearing preservation rate of about 57% can be expected after radiosurgical treatment, and patients treated with ?12.5 Gy were more likely to have preserved hearing.     

Early adjuvant radiotherapy in the treatment of atypical meningioma

Atypical meningiomas have a greater propensity to recur than benign meningiomas and the benefits of early adjuvant radiotherapy are unclear. Existing studies report conflicting results. This retrospective cohort study evaluated the role of early adjuvant radiotherapy following surgical resection of atypical meningioma. A triple center case-note review of adults with newly-diagnosed atypical meningiomas between 2001 and 2010 was performed. Pathology diagnosis was made according to the World Health Organization classification in use at the time of surgery. Patients with multiple meningiomas, neurofibromatosis type 2 and radiation-induced meningiomas were excluded. Extent of resection was defined as gross total resection (GTR; Simpson Grade I–III) or subtotal resection (STR; Simpson Grade IV–V). Survival analysis was performed using the Kaplan–Meier method. One hundred thirty-three patients were identified with a median age of 62 years (range 22–86 years) and median follow-up of 57.4 months (range 0.1–152.2 months). Tumors were mostly located in the convexity (50.4%) or falcine/parasagittal regions (27.1%). GTR (achieved in 85%) was associated with longer progression free survival (PFS) (5 year PFS 81.2% versus 40.08%, log-rank = 11.117, p = 0.001) but not overall survival (OS) (5 year OS 76.6% versus 39.7%, log-rank = 3.652, p = 0.056). Following GTR, early adjuvant radiotherapy was administered to 28.3% of patients and did not influence OS (5 year OS 77.0% versus 75.7%, log-rank = 0.075, p = 0.784) or PFS (5 year PFS 82.0% versus 79.3%, log-rank = 0.059, p = 0.808). Although extent of resection emerged as an important prognostic variable, early adjuvant radiotherapy did not influence outcome following GTR of atypical meningiomas. Prospective randomized controlled trials are planned.     

Combined modality treatment of newly diagnosed glioblastoma multiforme in a regional neurosurgical centre

The “local experience” of the Stupp protocol was examined in the treatment of patients with newly diagnosed glioblastoma multiforme (GBM) with particular emphasis given to the extent of surgical resection and its effect on survival. Thirty-one patients with newly diagnosed GBM who underwent combined modality treatment according to the Stupp protocol were assessed retrospectively. Variables assessed were the extent of surgery, size and site of the tumour, age and performance status. Primary end points were overall survival (OS) and progression-free survival (PFS). Median OS was 33 months for macroscopic tumour resection (9 patients; 29%), 15 months for debulking (15; 48%) and 9 months for biopsy (7; 22%). Macroscopic tumour resection resulted in significantly improved OS and PFS compared to the two less radical surgical options (p < 0.001). Patients with GBM undergoing maximal resection of the tumour followed by adjuvant radiotherapy and chemotherapy have an improved survival compared to patients undergoing either subtotal resection or biopsy alone. This statistically significant survival benefit was achieved in a regional neurosurgical centre with minimal additional toxicity.     

Early postoperative emergency department presentation predicts poor long-term outcomes in patients surgically treated for meningioma

Previous authors have identified a number of factors that predict morbidity, mortality, and recurrence in patients undergoing resection of a meningioma. We sought to study a novel potential prognostic indicator: early postoperative visit to the emergency department (ED). We conducted a retrospective cohort study on 239 patients who underwent a meningioma resection at our institution between 2001 and 2013 with over 3 months of follow-up postoperatively. All postoperative entries in the medical record were reviewed to identify any ED visit with a neurologic or wound-related complaint within a 90 day postoperative period. The relationships between ED presentation, tumor grade, and extent of surgical resection with future risk of operative recurrence and mortality were analyzed using Fisher’s exact test. Variables associated with increased risks of mortality or operative recurrence in a univariate analysis were then included in the multivariate logistic regression model. Patients with a postoperative ED visit were found to be significantly more likely to die during the follow-up period (23.0% versus 4.85%, p < 0.0001) or develop an eventual operative recurrence (12.2% versus 3.0%, p = 0.0131). Postoperative ED presentation was found to be associated with a higher risk of mortality and operative recurrence independent of pathological tumor grade (p < 0.0001 and p = 0.0102, respectively). Presentation to the ED is associated with significantly higher rates of future operative recurrence and mortality in patients with recent meningioma resections. This poor prognostic relationship is independent of tumor pathological grade. Increased vigilance and follow-up may be warranted in such patients.