Abstract Objective The typical recurrence of a glioblastoma occurs locally, usually within 2 cm from the original lesion. With the improvement of surgery techniques, more aggressive surgical ...strategies have become feasible, resulting in a significantly increased rate of complete resection. Therefore, we were interested, if these improvements are also reflected by the tumor recurrence pattern. Patients and methods Inclusion criteria were: first diagnosis of glioblastoma, followed by standard adjuvant radio-chemotherapy and histologically proven tumor recurrence. Patients were divided according to the recurrence pattern: patients with a local vs. distant recurrence vs. both recurrence patterns. Data were correlated with extend of resection, molecular tumor configuration, clinical status and survival data. Results Between 2007 and 2014 we could include 97 GBM patients in this single center, retrospective study. Local, distant or combined tumor recurrence was observed in 77 (79.3%), 10 (10.3%) and 10 patients (10.3%), respectively. Median PFS of all patients was 8 months (m), median OS 20m. Median PFS for patients with local recurrence was 7m versus 13m for patients with distant recurrence vs. 9m for patients with both recurrences (p=0.646). Median OS was 21m vs. 20m (vs. 14m (p=0.098)), respectively. Regarding MGMT methylation status no correlation regarding recurrence pattern could be observed. Conclusions Despite complete resection of the contrast-enhancing tumor, the majority of recurrences occurred locally. Patients with distant tumor recurrence presented an increased PFS. Therefore, to gain a local control maybe we have to shift toward an even more aggressive “supramarginal” resection, using extensive intraoperative monitoring to avoid permanent deficits.
Pathophysiological processes following subarachnoid hemorrhage (SAH) present survivors of the initial bleeding with a high risk of morbidity and mortality during the course of the disease. As ...angiographic vasospasm is strongly associated with delayed cerebral ischemia (DCI) and clinical outcome, clinical trials in the last few decades focused on prevention of these angiographic spasms. Despite all efforts, no new pharmacological agents have shown to improve patient outcome. As such, it has become clear that our understanding of the pathophysiology of SAH is incomplete and we need to reevaluate our concepts on the complex pathophysiological process following SAH. Angiographic vasospasm is probably important. However, a unifying theory for the pathophysiological changes following SAH has yet not been described. Some of these changes may be causally connected or present themselves as an epiphenomenon of an associated process. A causal connection between DCI and early brain injury (EBI) would mean that future therapies should address EBI more specifically. If the mechanisms following SAH display no causal pathophysiological connection but are rather evoked by the subarachnoid blood and its degradation production, multiple treatment strategies addressing the different pathophysiological mechanisms are required. The discrepancy between experimental and clinical SAH could be one reason for unsuccessful translational results.
Introduction
Osteoporotic vertebral fractures are a major healthcare problem. Vertebral cement augmentation (VCA) is frequently used as a minimally invasive surgical approach to manage symptomatic ...fractures. However, there is a potential risk of adjacent segment fracture (ASF), which may require second surgery. The addition of transcutaneous screw-fixation with cement augmentation superior and inferior to the fracture Hybrid transcutaneous screw fixation (HTSF) might represent an alternative treatment option to reduce the incidence of ASF.
Materials and methods
We retrospectively compared surgery time, hospital stay, intraoperative complication rate and the occurrence of ASF with the need for a surgical treatment in a cohort of 165 consecutive patients receiving either VCA or HTSF in our academic neurosurgical department from 2012 to 2020. The median follow-up was 52.3 weeks in the VCA-group and 51.9 in the HTSF-group.
Results
During the study period, 93 patients underwent VCA, and 72 had HTSF. Of all patients, 113 were females (64 VCA; 49 HTSF) and 52 were males (29 VCA; 23 HTSF). The median age was 77 years in both groups. Median surgery time was 32 min in the VCA-group and 81 min in the HTSF-group (
p
< 0.0001). No surgery-related complications occurred in the VCA-group with two in the HTSF-group (
p
= 0.19). ASF was significantly higher in the VCA-group compared to HTSF (24 26% vs. 8 11% patients;
p
< 0.02). The proportion of patients requiring additional surgery due to ASF was higher in the VCA-group (13 vs. 6%), but this difference was not statistically significant (
p
= 0.18). Median hospital stay was 9 days in the VCA-group and 11.5 days in the HTSF-group (
p
= 0.0001).
Conclusions
Based on this single-center cohort study, HTSF appears to be a safe and effective option for the treatment of osteoporotic vertebral compression fractures. Surgical time and duration of hospital stay were longer in the HTSF-group, but the rate of ASF was significantly reduced with this approach. Further studies are required to ascertain whether HTSF results in superior long-term outcomes or improved quality of life.
Aneurysmal subarachnoid hemorrhage (SAH) is associated with a mortality of more than 30%. Only about 30% of patients with SAB recover sufficiently to return to independent living.
This article is ...based on a selective review of pertinent literature retrieved by a PubMed search.
Acute, severe headache, typically described as the worst headache of the patient's life, and meningismus are the characteristic manifestations of SAH. Computed tomog raphy (CT) reveals blood in the basal cisterns in the first 12 hours after SAH with approximately 95% sensitivity and specificity. If no blood is seen on CT, a lumbar puncture must be performed to confirm or rule out the diagnosis of SAH. All patients need intensive care so that rebleeding can be avoided and the sequelae of the initial bleed can be minimized. The immediate transfer of patients with acute SAH to a specialized center is crucially important for their outcome. In such centers, cerebral aneurysms can be excluded from the circulation either with an interventional endovascular procedure (coiling) or by microneurosurgery (clipping).
SAH is a life-threatening condition that requires immediate diagnosis, transfer to a neurovascular center, and treatment without delay.
The molecular pathways underlying the pathogenesis after subarachnoid haemorrhage (SAH) are poorly understood and continue to be a matter of debate. A valid murine SAH injection model is not yet ...available but would be the prerequisite for further transgenic studies assessing the mechanisms following SAH. Using the murine single injection model, we examined the effects of SAH on regional cerebral blood flow (rCBF) in the somatosensory (S1) and cerebellar cortex, neuro-behavioural and morphological integrity and changes in quantitative electrocorticographic and electrocardiographic parameters. Micro CT imaging verified successful blood delivery into the cisterna magna. An acute impairment of rCBF was observed immediately after injection in the SAH and after 6, 12 and 24 hours in the S1 and 6 and 12 hours after SAH in the cerebellum. Injection of blood into the foramen magnum reduced telemetric recorded total ECoG power by an average of 65%. Spectral analysis of ECoGs revealed significantly increased absolute delta power, i.e., slowing, cortical depolarisations and changes in ripples and fast ripple oscillations 12 hours and 24 hours after SAH. Therefore, murine single-blood-injection SAH model is suitable for pathophysiological and further molecular analysis following SAH.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Aim of the present study was to analyze the oncological impact of 5-ALA fluorescence of cerebral metastases. A retrospective analysis was performed for 84 patients who underwent 5-ALA ...fluorescence-guided surgery of a cerebral metastasis. Dichotomized fluorescence behavior was correlated to the histopathological subtype and primary site of the metastases, the degree of surgical resection on an early postoperative MRI within 72 hours after surgery, the local in-brain-progression rate and the overall survival. 34/84 metastases (40.5%) showed either strong or faint and 50 metastases (59.5%) no 5-ALA derived fluorescence. Neither the primary site of the cerebral metastases nor their subtype correlated with fluorescence behavior. The dichotomized 5-ALA fluorescence (yes vs. no) had no statistical influence on the degree of surgical resection. Local in-brain progression within or at the border of the resection cavity was observed in 26 patients (30.9%). A significant correlation between 5-ALA fluorescence and local in-brain-progression rate was observed and patients with 5-ALA-negative metastases had a significant higher risk of local recurrence compared to patients with 5-ALA positive metastases. After exclusion of the 20 patients without any form of adjuvant radiation therapy, there was a trend towards a relation of the 5-ALA behavior on the local recurrence rate and the time to local recurrence, although results did not reach significance anymore. Absence of 5-ALA-induced fluorescence may be a risk factor for local in-brain-progression but did not influence the mean overall survival. Therefore, the dichotomized 5-ALA fluorescence pattern might be an indicator for a more aggressive tumor.
Purpose
The new Medical Licensing Regulations 2025 (
Ärztliche Approbationsordnung
, ÄApprO) require the development of competence-oriented teaching formats. In addition, there is a great need for ...high-quality teaching in the field of radiation oncology, which manifests itself already during medical school. For this reason, we developed a simulation-based, hands-on medical education format to teach competency in performing accelerated partial breast irradiation (APBI) with interstitial multicatheter brachytherapy for early breast cancer. In addition, we designed realistic breast models suitable for teaching both palpation of the female breast and implantation of brachytherapy catheters.
Methods
From June 2021 to July 2022, 70 medical students took part in the hands-on brachytherapy workshop. After a propaedeutic introduction, the participants simulated the implantation of single-lead catheters under supervision using the silicone-based breast models. Correct catheter placement was subsequently assessed by CT scans. Participants rated their skills before and after the workshop on a six-point Likert scale in a standardized questionnaire.
Results
Participants significantly improved their knowledge-based and practical skills on APBI in all items as assessed by a standardized questionnaire (mean sum score 42.4 before and 16.0 after the course,
p
< 0.001). The majority of respondents fully agreed that the workshop increased their interest in brachytherapy (mean 1.15, standard deviation SD 0.40 on the six-point Likert scale). The silicone-based breast model was found to be suitable for achieving the previously defined learning objectives (1.19, SD 0.47). The learning atmosphere and didactic quality were rated particularly well (mean 1.07, SD 0.26 and 1.13, SD 0.3 on the six-point Likert scale).
Conclusion
The simulation-based medical education course for multicatheter brachytherapy can improve self-assessed technical competence. Residency programs should provide resources for this essential component of radiation oncology. This course is exemplary for the development of innovative practical and competence-based teaching formats to meet the current reforms in medical education.
Prognostication of glioblastoma survival has become more refined due to the molecular reclassification of these tumors into isocitrate dehydrogenase (IDH) wild-type and IDH mutant. Since this ...molecular stratification, however, robust clinical prediction models relevant to the entire IDH wild-type glioblastoma patient population are lacking. This study aimed to provide an updated model that predicts individual survival prognosis in patients with IDH wild-type glioblastoma.
Databases from Germany and the Netherlands provided data on 1036 newly diagnosed glioblastoma patients treated between 2012 and 2018. A clinical prediction model for all-cause mortality was developed with Cox proportional hazards regression. This model included recent glioblastoma-associated molecular markers in addition to well-known classic prognostic variables, which were updated and refined with additional categories. Model performance was evaluated according to calibration (using calibration plots and calibration slope) and discrimination (using a C-statistic) in a cross-validation procedure by country to assess external validity.
The German and Dutch patient cohorts consisted of 710 and 326 patients, respectively, of whom 511 (72%) and 308 (95%) had died. Three models were developed, each with increasing complexity. The final model considering age, sex, preoperative Karnofsky Performance Status, extent of resection, O6-methylguanine DNA methyltransferase (MGMT) promoter methylation status, and adjuvant therapeutic regimen showed an optimism-corrected C-statistic of 0.73 (95% confidence interval 0.71-0.75). Cross-validation between the national cohorts yielded comparable results.
This prediction model reliably predicts individual survival prognosis in patients with newly diagnosed IDH wild-type glioblastoma, although additional validation, especially for long-term survival, may be desired. The nomogram and web application of this model may support shared decision-making if used properly.
There is still controversy surrounding the role of cytoreductive surgery in the management of malignant gliomas because randomized studies have been missing. Here we review recent data from ...prospective studies that provide novel arguments in support of surgery.
Presently available studies not only demonstrate a benefit of surgical resection of malignant gliomas compared with biopsy. Data from a randomized surgical study on a technique for identifying residual tumour intraoperatively also substantiate the beneficial role of maximal cytoreduction in patients treated by resection. Potential mechanisms appear to be linked to the removal of the therapy-resistant, hypoxic, and highly-proliferative tumour core.
Clinical data currently available support the use of surgery for the management of malignant glioma. Surgery improves survival and may enhance the efficacy of adjunct and adjuvant therapies.
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