Albert H. Kim

Erratum to stem nourished by branches: glioblastomas co-opt classic neurotrophic factor signaling to maintain stem-like cell pool

Background: Pituitary tumor apoplexy commonly causes cranial nerve palsies (CNPs). Based on visual acuity and visual field outcomes, some studies suggest maximum benefit of surgery occurs within 8 days of ictus. In practice, many patients present to neurosurgical attention later than this. The potential benefit of surgical intervention in these late-presenting patients has not yet been described. Methods: A retrospective chart review of patients presenting to Barnes Hospital who underwent transsphenoidal sellar decompression for pituitary tumor apoplexy (2001–2016) was conducted. Patients without pathologic evidence of pituitary ischemia or hemorrhage were excluded. Time from symptom onset to surgical intervention was determined. Serial cranial nerve and ophthalmologic exams were reviewed for evolution of visual and oculomotor function. Results: 45 patients fulfilled inclusion criteria. The cohort exhibited 68 total preoperative CNPs (33 CN II, 21 CN III, 1 CN IV, 1 CN V, 12 CN VI). Average time from symptom-onset-to surgery was 16.8 days (SD 20.3). Average follow-up time was 3.2 years (SD 3.7). Overall, 44% (95% CI 37–51%) of CNPs had resolved at one month, with 61% (95% CI 56–66%) demonstrating improvement. At one year 73% (95% CI 69–76%) had resolved, with 83% (95% CI 81–85%) demonstrating improvement. At 4, 8, and 14-day cutoffs for acuity of intervention, there were no significant differences between earlier and later treatment groups with respect to the proportion of CNPs that resolved by one month (≤ 4d 36%, >4d 45%, p = 0.70; ≤ 8d 32%, >8d 59%, p = 0.08; ≤ 14d 39%, > 14d 50%, p = 0.84) or by one year (≤ 4d 57%, >4d 77%, p = 0.49; ≤ 8d 59%, >8d 86%, p =.08; ≤ 14d 63%, >14d 83%, p = 0.60). There were no significant differences between earlier and later treatment groups in the proportion of CNPs that demonstrated improvement by one month (≤ 4d 48%, > 4d 64%, p = 0.41; ≤ 8d 51%, > 8d 73%, p = 0.24; ≤ 14d 56%, > 14d 67%, p = 0.99) or by one year (≤ 4d 69%, >4d 87%, p = 0.34; ≤ 8d 75%, > 8d 91%, p = 0.27; ≤ 14d 78%, >14d 89%, p = 0.96). There were trends toward superior rates of CNP resolution or improvement in the groups treated in delayed fashion. Conclusion: Patients with pituitary tumor apoplexy who undergo transsphenoidal sellar decompression greater than 8 days post-ictus experience non-inferior outcomes with respect to CNP resolution and improvement compared with those with earlier operations. The temporal correlation of rapid CNP resolution/improvement following surgery also suggests a benefit of surgical decompression regardless of timing in a substantial proportion of patients.

OBJECTIVE: The precision of laser probe insertion for interstitial thermal therapy of deep-seated lesions is limited by the method of stereotactic guidance. The objective of this study was to evaluate the feasibility of customized STarFix 3D-printed stereotactic platforms to guide laser probe insertion into mesiotemporal and posterior fossa targets. METHODS: The authors conducted a retrospective review of 5 patients (12–55 years of age) treated with laser interstitial thermal therapy (LITT) in which STarFix platforms were used for probe insertion. Bone fiducials were implanted in each patient's skull, and subsequent CT scans were used to guide the design of each platform and incorporate desired treatment trajectories. Once generated, the platforms were mounted on the patients' craniums and used to position the laser probe during surgery. Placement of the laser probe and the LITT procedure were monitored with intraoperative MRI. Perioperative and follow-up MRI were performed to identify and monitor changes in target lesions. RESULTS: Accurate placement of the laser probe was observed in all cases. For all patients, thermal ablation was accomplished without intraoperative complications. Of the 4 patients with symptomatic lesions, 2 experienced complete resolution of symptoms, and 1 reported improved symptoms compared with baseline. CONCLUSIONS: Customized stereotactic platforms were seamlessly incorporated into the authors' previously established LITT workflow and allowed for accurate treatment delivery.

BACKGROUND. Optimal use of stereotactic radiosurgery (SRS) vs external beam radiation therapy (EBRT) for treatment of residual/recurrent atypical mening

Glioblastoma stem-like cells (GSCs) play a critical role in glioblastoma progression and recurrence. We discuss recent results on the role of the mitotic ubiquitin ligase cell division cycle 20–anaphase-promoting complex (CDC20-APC) in the governance of cardinal GSC functions through a mechanism involving the transcription factor sex-determining region Y-box 2 (SOX2). These findings expand the non-mitotic roles of CDC20-APC with implications for stem cell biology.

Introduction: Neurofibromatosis type II (NF2) is a challenging inherited cancer condition, which predisposes patients to bilateral vestibular schwannomas, cranial and spinal meningiomas, spinal ependymomas and peripheral nerve schwannomas. A large contemporary cohort of patients with NF2 was reviewed to assess the impact of present-day therapies upon the natural history of this disease. Methods: A retrospective review of 54 patients with NF2 was performed using an IRB-approved brain tumor registry at Washington University in St. Louis over the last two decades. Data collection included demographics, age at diagnosis, burden of cranial and spinal disease, age at onset of deafness, treatments received (medical, surgical and radiation), and outcomes. Statistical analyses included a chi-square test used to compare early vs late age of diagnosis with respect to early vs late onset of unilateral deafness. Results: Median age at diagnosis was 17.5 years (range 3–65); average age at last follow-up was 31 years (range 3–69) for 25 males and 29 females. Of 48 patients who had spinal imaging done, tumors were found in the cervical spine (85.4%), thoracic spine (72.9%), lumbar spine (81.3%), and throughout the spine (60.4%). Median lifetime tumor burden during the time period tracked for this cohort of patient was 6 (range 2–25) intracranial tumors and 6.5 (range 0–32) spinal tumors. The number of spinal tumors likely represents a conservative estimate of small spinal tumors, as many were “too numerous to count.” The median number of lifetime medical and surgical interventions to date related to NF2 was 5 (range 0–17), surgical interventions 3 (range 0–17). The median number of surgical interventions per year was 0.1 (range 0–1.75). Fifteen individuals (27.8%) underwent radiosurgical treatment (9 for meningiomas, 8 for vestibular schwannomas, 3 for both, 2 for other cranial schwannomas, and 2 for spinal tumors). Eleven (20.4%) received bevacizumab (Avastin), an intravenous antibody to vascular endothelial growth factor (VEGF) therapy, two (3.4%) received everolimus (Afinitor), and one (1.9%) received panzopanib (Votrient). Median duration of medical therapy was 16.5 months (range 3–58, n = 12). Four (7.4%) died due to progressive disease or complications of treatment; median age at death was 26.5 years (range 4–38). Median age of onset of unilateral deafness, Gardener-Robertson class 3 or higher, was 21 years (range 7–56, n = 31); median age of bilateral deafness was 24 years (range 13–61, n = 15). Using a chi-square test (p < .001), it was determined that patients diagnosed with NF2 at an early age (<=20 years) had earlier onset of unilateral deafness (median age 15, range 7–20), compared with those diagnosed at a later age (unilateral deafness in latter group at median age 31, range 21–56) Conclusion: NF2 is a complex tumor predisposition disorder associated with bilateral vestibular schwannomas and numerous other tumors of the nervous system. NF2 patients typically undergo large numbers of surgical interventions and other treatments with an increasing number undergoing medical treatment such as bevacizumab in recent years. Patients diagnosed at a younger age are more likely to have an earlier age of onset of unilateral deafness.

BACKGROUND:. The efficacies of adjuvant stereotactic radiosurgery (SRS) and external beam radiation therapy (EBRT) for atypical meningiomas (AMs) after

BACKGROUND:. Indications for external beam radiation therapy (EBRT) for atypical meningiomas (AMs) remain unclear.OBJECTIVE:. To analyze features associ