Surgical outcomes of endoscopic transsphenoidal pituitary adenoma resection in elderly versus younger patients

Introduction Pituitary adenomas (PAs) are one of the most common type of intracranial neoplasm with increased incidence in elderly patients. The outcomes of endoscopic transsphenoidal surgery (ETS) specifically on elderly patients remains unclear. Methods We performed a retrospective cohort study to compare elderly patients (age 65 years) with non-elderly patients (age <65 years) who underwent ETS for PA from January 2005 to December 2021. Surgical outcomes, including extent of resection, complication profile, length of stay, and endocrinopathy rates, were compared between elderly and non-elderly patients. Results A total of 690 patients were included with 197 (29%) being elderly. Elderly patients showed higher rates of hypertension (p<0.05), myocardial infarction (p<0.01), and atrial fibrillation (p=0.01) but not other comorbidities. Elderly patients also had more frequent optic nerve involvement (72% of cases vs. 61%, p=0.01). Tumor characteristics and other patient variables were otherwise similar between younger and elderly patients. Postoperative CSF leaks (2% vs. 2%, p=0.8), 30-day readmission, reoperation, postoperative complications, and postoperative endocrinopathies were similar between younger and older patients. Subdividing patients into age <65, 65-79, and >80 also did not demonstrate a worsening of surgical outcomes with age. Conclusion For well selected elderly patients in experienced endoscopic skull base centers, good surgical outcomes similarly to younger patients may be achieved.

Immunohistochemical expression of HGF and cMET in meningiomas

Background Meningiomas are the most common intracranial neoplasm together with gliomas; but unlike gliomas they are still graded according to their histopathological picture. Many growth factors and tyrosine kinase receptors have been studied in meningiomas in an attempt for prognostic stratification of patients, also to find a suitable targeted therapy for meningiomas. Aim of the study To correlate the immunohistochemical expression of HGF and cMET with the different WHO grades of meningioma in addition to brain invasion. Materials and methods This study included 60 cases of meningiomas (WHO grade I, n = 30 and WHO grade II & III, n = 30), brain invasion was present in 14 cases. Results HGF, cMET & HGF/cMET co-expression were positive in 60.0%, 65.0% and 58.3% respectively of the cases; WHO grade I meningioma showed positivity in 30.0%, 33.3% and 30.0% of the cases respectively in contrast with 90.0%, 96.7% and 86.7% of the cases of WHO grades II & III meningiomas respectively. The relation was statistically highly significant (p- value: &lt;0.001). As regards cases with brain invasion the expression of HGF, cMET and HGF/cMET co-expression was found in 92.9%, 100.0% and 92.9% respectively in comparison with 50.0%, 54.3% and 47.8% in the rest of the cases of meningiomas respectively; the relation was statistically significant (p- value: 0.004). Conclusion The results suggest that HGF/cMET pathway may play a role in the progression of meningiomas from WHO grade I to higher grades II & III.

Trends in physician reimbursements and procedural volumes for radiosurgery versus open surgery in brain tumor care: an analysis of Medicare data from 2009 to 2018

OBJECTIVE Given its minimally invasive nature and effectiveness, stereotactic radiosurgery (SRS) has become a mainstay for the multimodal treatment of intracranial neoplasm. However, no studies have evaluated recent trends in the use of SRS versus those of open resection for the management of brain tumor or trends in the involvement of neurosurgeons in SRS (which is primarily delivered by radiation oncologists). Here, the authors used publicly available Medicare data from 2009 to 2018 to elucidate trends in the treatment of intracranial neoplasm and to compare reimbursements between these approaches. METHODS By using CPT Professional 2019, the authors identified 10 open resection and 9 SRS codes (4 for neurosurgery and 5 for radiation oncology) for the treatment of intracranial neoplasm. Medicare payments (inflation adjusted) and allowed services (number of reimbursed procedures) for each code were abstracted from the Centers for Medicare and Medicaid Services Part B National Summary Data File (2009–2018). Payments per procedure and procedures per 100,000 Medicare enrollees were analyzed with linear regression and compared with tests for equality of slopes (α = 0.05). The average payment per procedure over the study period was compared by using the 2-tailed Welsh unequal variances t-test, and more granular comparisons were conducted by using ANOVA with post hoc Tukey honestly significant difference (HSD) tests. RESULTS From 2009 to 2018, the number of SRS treatments per 100,000 Medicare enrollees for intracranial neoplasm increased by 3.97 cases/year (R2 = 0.99, p < 0.001), while comparable open resections decreased by 0.34 cases/year (R2 = 0.85, p < 0.001) (t16 = 7.5, p < 0.001). By 2018, 2.6 times more SRS treatments were performed per 100,000 enrollees than open resections (74.9 vs 28.7 procedures). However, neurosurgeon involvement in SRS treatment declined over the study period, from 23.4% to 11.5% of SRS treatments; simultaneously, the number of lesions treated per session increased from 1.46 to 1.84 (R2 = 0.98, p < 0.001). Overall, physician payments from 2013 to 2018 averaged $1816.08 (95% CI $1788.71–$1843.44) per SRS treatment and $1565.59 (95% CI $1535.83–$1595.34) per open resection (t10 = 15.9, p < 0.001). For neurosurgeons specifically, reimbursements averaged $1566 per open resection, but this decreased to $1031–$1198 per SRS session; comparatively, radiation oncologists were reimbursed even less (average $359–$898) per SRS session (p < 0.05 according to the Tukey HSD test for all comparisons). CONCLUSIONS Over a decade, the number of open resections for intracranial neoplasm in Medicare enrollees declined slightly, while the number of SRS procedures increased greatly. This latter expansion is largely attributable to radiation oncologists; meanwhile, neurosurgeons have shifted their involvement in SRS toward sessions for the management of multiple lesions.

COT-18 Prognosis and problems about secondary intracranial neoplasm in childhood cancer survivors: a single-institution retrospective cohort study

Objective: As childhood cancer survivors gradually increased, late complications of treatment have been at issue and risk of secondary neoplasm is increasing cumulatively. We retrospectively analyzed clinical outcome and problems of treatment for secondary intracranial neoplasm. Patients and Methods: 497 patients (children, adolescents and young adults) with malignant central nervous system neoplasm were treated in our institution from 1971 to 2015. 188 cases (37.8%) were enrolled in this follow-up study. Diagnosis of primary neoplasm included low grade glioma (29%), embryonal tumor (23.5%), germ cell tumor (24.5%), ependymoma (8%), other (15%). Results: Fourteen cases of them were diagnosed as secondary intracranial neoplasm. Twelve cases were operated and histopathological diagnosis included 6 glioblastomas, 1 anaplastic astrocytoma, 1 anaplastic ependymoma, 4 meningiomas. In all cases, histopathological finding and molecular profile of secondary intracranial neoplasm differed from that of primary malignant brain tumors. Duration from the first operation of primary tumors to diagnosis of secondary intracranial neoplasm ranged from 5 to 36 years (average: 29.3). In malignant glioma cases except meningioma cases, origin of them was contained in high irradiation field (&gt;40Gy). In malignant glioma cases, Chemotherapies using temozolomide and bevacizumab were selected after tumor removal. In 3 cases of them, reirradiation was performed. Response for treatment was poor or transient in most cases, median survival time was 12 months. Of late complications, such as endocrinological problem needed replacement (55%), cerebrovascular event (15.9%), secondary neoplasm (7.4%), secondary neoplasm was importantly related with prognosis. Conclusion: It is difficult to plan therapeutic strategies against second malignant neoplasm because of lack of information in case of long-term survivors and restriction for first radiation. Clinical outcome of them is poor and new treatment targets should be developed. It is important to plan clinical trials to reduce treatment intensity and usable long-term follow-up system.

Management dilemmas in pineoblastoma recurrence diagnosed during pregnancy

Pineoblastoma is an extremely rare intracranial neoplasm, with increased risk of craniospinal metastasis. There is only one case reported in the literature who presented during pregnancy. Described here is a woman who presented at five months of gestation with recurrence of pineoblastoma, who had previously defaulted adjuvant therapy following surgical decompression. The challenges in the diagnosis and treatment of pineoblastoma and its effects on pregnancy are also discussed.

Headache related to an intracranial neoplasm

Patients presenting for headache often worry about having a brain tumour. Specific tumours may induce headache by varied mechanisms, producing different phenotypes. Virtually all headache and facial pain phenotypes can be secondary to a brain tumour, but clinical clues to a secondary aetiology are often present. Headaches may also be related to the treatment of intracranial neoplasms such as intrathecal chemotherapy, radiotherapy, and craniotomy. The ICHD-3 therefore includes several codes related to brain tumours, illustrating this diversity. Although not specifically represented in the classification, the association of trigeminal autonomic cephalalgias with pituitary tumours is now supported by the literature and is discussed in a specific section.