Intratumoral Hemorrhage Research Articles

Stereotactic radiosurgery with and without checkpoint inhibition for patients with metastatic non-small cell lung cancer to the brain: a matched cohort study.

Immune checkpoint inhibitors (ICIs) improve survival in patients with advanced non-small cell lung cancer (NSCLC). Clinical trials examining the efficacy of ICIs in patients with NSCLC excluded patients with untreated brain metastases (BMs). As stereotactic radiosurgery (SRS) is commonly employed for NSCLC-BMs, the authors sought to define the safety and radiological and clinical outcomes for patients with NSCLC-BMs treated with concurrent ICI and SRS. A retrospective matched cohort study was performed on patients who had undergone SRS for one or more NSCLC-derived BMs. Two matched cohorts were identified: one that received ICI before or after SRS within a 3-month period (concurrent ICI) and one that did not (ICI naive). Locoregional tumor control, peritumoral edema, and central nervous system (CNS) adverse events were compared between the two cohorts. Seventeen patients (45 BMs) and 34 patients (92 BMs) composed the concurrent-ICI and ICI-naive cohorts, respectively. There was no statistically significant difference in overall survival (HR 0.99, 95% CI 0.39-2.52, p = 0.99) or CNS progression-free survival (HR 2.18, 95% CI 0.72-6.62, p = 0.11) between the two groups. Similarly, the 12-month local tumor control rate was 84.9% for tumors in the concurrent-ICI cohort versus 76.3% for tumors in the ICI-naive cohort (p = 0.94). Further analysis did reveal that patients receiving concurrent ICI had increased rates of CNS complete response for BMs treated with SRS (8/16 [50%] vs 5/32 [15.6%], p = 0.012) per the Response Assessment in Neuro-Oncology (RANO) criteria. There was also a shorter median time to BM regression in the concurrent-ICI cohort (2.5 vs 3.1 months, p < 0.0001). There was no increased rate of radiation necrosis or intratumoral hemorrhage in the patients receiving concurrent ICI (5.9% vs 2.9% in ICI-naive cohort, p = 0.99). There was no significant difference in the rate of peritumoral edema progression between the two groups (concurrent ICI: 11.1%, ICI naive: 21.7%, p = 0.162). The concurrent use of ICI and SRS to treat NSCLC-BM was well tolerated while providing more rapid BM regression. Concurrent ICI did not increase peritumoral edema or rates of radiation necrosis. Further studies are needed to evaluate whether combined ICI and SRS improves progression-free survival and overall survival for patients with metastatic NSCLC.

Amide proton transfer imaging of glioblastoma, neuroblastoma, and breast cancer cells on a 11.7 T magnetic resonance imaging system

PurposeThe purpose of this study was (i) to determine the optimal magnetization transfer (MT) pulse parameter for amide proton transfer (APT) chemical exchange saturation transfer (CEST) imaging on an ultra-high-field magnetic resonance imaging (MRI) system and (ii) to use APT CEST imaging to noninvasively assess brain orthotopic and ectopic tumor cells transplanted into the mouse brain. MethodsTo evaluate APT without the influence of other metabolites, we prepared egg white phantoms. Next, we used 7–11-week-old nude female mice and the following cell lines to establish tumors after injection into the left striatum of mice: C6 (rat glioma, n = 8) as primary tumors and Neuro-2A (mouse neuroblastoma, n = 11) and MDA-MB231 (human breast cancer, n = 8) as metastatic tumors. All MRI experiments were performed on an 11.7 T vertical-bore scanner. CEST imaging was performed at 1 week after injection of Neuro-2A cells and at 2 weeks after injection of C6 and MDA-MB231 cells. The MT pulse amplitude was set at 2.2 μT or 4.4 μT. We calculated and compared the magnetization transfer ratio (MTR) and difference of MTR asymmetry between normal tissue and tumor (ΔMTR asymmetry) on APT CEST images between mouse models of brain tumors. Then, we performed hematoxylin and eosin (HE) staining and Ki-67 immunohistochemical staining to compare the APT CEST effect on tumor tissues and the pathological findings. ResultsPhantom study of the amide proton phantom containing chicken egg white, z-spectra obtained at a pulse length of 500 ms showed smaller peaks, whereas those obtained at a pulse length of 2000 ms showed slightly higher peaks. The APT CEST effect on tumor tissues was clearer at a pulse amplitude of 2.2 μT than at 4.4 μT. For all mouse models of brain tumors, ΔMTR asymmetry was higher at 2.2 μT than at 4.4 μT. ΔMTR asymmetry was significantly higher for the Neuro-2A model than for the MDA-MB231 model. HE staining revealed light bleeding in Neuro-2A tumors. Immunohistochemical staining revealed that the density of Ki-67-positive cells was higher in Neuro-2A tumors than in C6 or MDA-MB231 tumors. ConclusionThe MTR was higher at 4.4 μT than at 2.2 μT for each concentration of egg white at a pulse length of 500 ms or 2000 ms. High-resolution APT CEST imaging on an ultra-high-field MRI system was able to provide tumor information such as proliferative potential and intratumoral bleeding, noninvasively.

Liver adenomatosis in patients with hepatocyte nuclear factor-1 alpha maturity onset diabetes of the young (HNF1A-MODY): Clinical, radiological and pathological characteristics in a French series.

Liver adenomatosis (LA) is a rare disease resulting from biallelic inactivation of the hepatocyte nuclear factor-1 alpha (HNF1A) gene, which induces the proliferation of adenoma cells in liver parenchyma. Liver adenomatosis has only been documented in case reports from patients carrying a HNF1A germline mutation. We have evaluated the frequency of LA among a large cohort of patients with HNF1A-maturity onset diabetes of the young (MODY), previously termed "MODY3," and herein describe its clinical, radiological, and pathological characteristics. In all, 137 HNF1A-MODY subjects from 74 families were screened by liver ultrasonography in 13 centers, and 15 additional cases of LA were later included in the series. Liver adenomatosis was confirmed by liver computed tomography, magnetic resonance imaging (MRI), and/or histopathology. Among 137 carriers of an HNF1A mutation, 9 patients (6.5%) from seven families were diagnosed with LA. Diabetes mellitus was present in 87.5% of patients with LA. In 25% of patients, LA was diagnosed due to intra-abdominal or intratumoral bleeding. Liver biochemistry was near normal in all patients. Liver imaging showed adenomas of various sizes and numbers. On MRI, most nodules had the radiological characteristics of steatotic adenomas. Histopathological confirmation of LA was available in 13 cases, and these adenomas were mostly steatotic. Surgery was initially performed in 37.5% of patients, and liver disease progression was observed in 30%. No disease progression was observed in 14 pregnancies. The frequency of LA in a cohort of screened HNF1A-MODY patients and the high incidence of LA progression and/or hemorrhage warrants systematic screening for liver adenomatosis in HNF1A-MODY families.

Intratumoural renal cell carcinoma haemorrhage following stereotactic radiotherapy: a case report

BackgroundStereotactic radiotherapy is an emerging treatment option for patients with inoperable renal cell carcinoma (RCC). Haemorrhage has not previously been reported to occur as a result of Stereotactic Body Radiotherapy (SBRT) to the kidney for primary RCC. We report an acute haemorrhage in a patient who received only one of three planned fractions of SBRT as part of a clinical trial.Case presentationA 74 year old female had a left renal mass under observation for 4 years, during which time she was imaged repeatedly using ultrasound and CT scans. There has been no evidence of metastases, and the lesion has demonstrated a steady pattern of growth over the 4-year period. Fine needle aspiration histologically confirmed RCC.Following a multidisciplinary review, the patient was recommended for SBRT as she was not considered a surgical candidate. Treatment was planned for an ablative 42Gray (Gy) to be delivered in 3 fractions at 14Gy/fraction as part of a clinical trial. Our patient presented to the emergency department (ED) suffering left flank pain, fever and vomiting within 3 h of the first fraction of SBRT. CT showed the mass to have markedly increased in size, measuring 8.7 × 8.1 × 7.0 cm, from 6.5 × 5.4 × 5.6 cm. It was reported as an internal haemorrhage into the malignancy. The patient was admitted for analgesia, anti-pyretics, and transfusion of 2 units of packed red blood cells. The patient recovered without any further intervention but radiotherapy was discontinued. The patient was alive and free from disease progression two years after the aborted treatment.ConclusionSuch events, though rare, are potentially serious, and therefore clinicians should be aware of such treatment related complications.

Acute Intratumoral Hemorrhage of a Brain Glioma during Pregnancy: Case Report and Considerations on the Management Strategy

Acute Intratumoral Hemorrhage of a Brain Glioma during Pregnancy: Case Report and Considerations on the Management Strategy

Abstract 1300: Novel thyrointegrin αvβ3 antagonist in the treatment of glioblastoma multiforme

Abstract Background: The proliferative and pro-angiogenic actions mediated by L-thyroxine, pro-inflammatory and all known growth factors in glioblastoma multiforme (GBM) are initiated at cell surface thyrointegrin αvβ3 receptors for thyroid hormone on the extracellular domain of integrin αvβ3. Thyrointegrin αvβ3 receptors are over-expressed on cancer and rapidly dividing blood vessel cells, but quiescent on normal cells. A macromolecule Polyethylene glycol-conjugated bi-TriAzole Tetraiodothyroacetic acid (P-bi-TAT) acts with high affinity (Ki 3.1 nM) and specificity for the thyrointegrin αvβ3 receptors without any significant nuclear translocation. Methods: In the present studies, three primary human GBM cells and U87 glioma cell line were implanted orthotopically or subcutaneously (s.c.) into nude mice that were treated daily for up to 21 days with P-bi-TAT at different doses. Additionally, preclinical Pharmacokinetic and Safety assessments were carried out in multiple species. Results: Pharmacokinetic profiles indicated once-a-day dosing, and safety assessment studies demonstrated high safety and tolerability at 100-fold over the anticipated human equivalent dose. Fluorescence labeled P-bi-TAT administered s.c. demonstrated high biodistribution to GBM tumor in the brain that was comparable to peripherally implanted tumor. P-bi-TAT administered daily for 10-21 days s.c. at 0.3-10 mg/kg resulted in a dose-dependent suppression of GBM tumor growth and viability monitored with IVIS imaging (p &amp;lt;0.001). Histopathological analysis of tumors revealed 95% loss of the vascularity of treated tumors at 10 days (p &amp;lt;0.001) along with extensive cellular necrosis and apoptosis, without intratumoral hemorrhage. GBM tumors had a 97% volume loss and maximal loss of GBM cell viability during a subsequent 22 days off-treatment period (p &amp;lt; 0.001). Genomic micro-array studies with human primary GBM revealed that over 30 pathways relevant to the progression of GBM are modulated by P-bi-TAT. Conclusions: P-bi-TAT is a promising lead clinical candidate effective in the treatment of human GBM. Citation Format: Shaker A. Mousa, Thangirala Sudha, Kavitha Godugu, Mehdi Rajabi, Stewart Sell, Paul J. Davis. Novel thyrointegrin αvβ3 antagonist in the treatment of glioblastoma multiforme [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1300.

Inhibition of platelet GPVI induces intratumor hemorrhage and increases efficacy of chemotherapy in mice

AbstractMaintenance of tumor vasculature integrity is indispensable for tumor growth and thus affects tumor progression. Previous studies have identified platelets as major regulators of tumor vascular integrity, as their depletion selectively rendered tumor vessels highly permeable and caused massive intratumoral hemorrhage. While these results established platelets as potential targets for antitumor therapy, their depletion is not a treatment option due to their essential role in hemostasis. Thus, a detailed understanding of how platelets safeguard vascular integrity in tumors is urgently demanded. Here, we show for the first time that functional inhibition of glycoprotein VI (GPVI) on the platelet surface with an antibody (JAQ1) F(ab)2 fragment rapidly induces tumor hemorrhage and diminishes tumor growth similar to complete platelet depletion while not inducing systemic bleeding complications. The intratumor bleeding and tumor growth arrest could be reverted by depletion of Ly6G+ cells, confirming them to be responsible for the induction of bleeding and necrosis within the tumor. In addition, JAQ1 F(ab)2–mediated GPVI inhibition increased intratumoral accumulation of coadministered chemotherapeutic agents, such as Doxil and paclitaxel, thereby resulting in a profound antitumor effect. In summary, our findings identify platelet GPVI as a key regulator of vascular integrity specifically in growing tumors and could serve as a basis for the development of antitumor strategies based on the interference with platelet function.

Cerebral pilocytic astrocytoma with spontaneous intratumoral haemorrhage in the elderly - a rare entity

Pilocytic astrocytomas (PA) are histologically are low-grade tumours, commonly found in the paediatric and young adult population. Although cases of adult and elderly pilocytic astrocytomas are described in the literature, they are quite uncommon. The rate of PAs with spontaneous bleeding is very less, with a high occurrence in children than in adults, moreover, that is in cerebellar PAs. Cerebral PAs with intratumoral haemorrhage in the older age group is extremely rare. We present a case of a 60-year female presenting with acute neurological compromise resulting from an acutely haemorrhagic Left temporal pilocytic astrocytoma. She was managed surgically with evacuation of tumoral haemorrhages, as well as resection of the tumour. Postoperatively the patient made a remarkable recovery.

First-line stereotactic radiosurgery combined with systemic targeted and immune checkpoint inhibitor therapy in melanoma patients with newly diagnosed brain metastases.

e13577 Background: Of solid tumors, melanoma has the highest propensity for central nervous system spread with historic median survivals of 5-8 months following brain metastasis diagnosis. We evaluated the impact of systemic BRAF targeted and immune checkpoint inhibitor (ICI) therapies on survival outcomes in patients receiving stereotactic radiosurgery (SRS) for melanoma brain metastases (MBM) and assessed patient treatment burden associated with prolonged survival. Methods: We retrospectively reviewed the demographics, disease characteristics, therapeutic regimens, overall survival, and first-year cumulative incidence of comorbid disease for patients with de novo MBM treated between 2013 and 2017 at a major melanoma referral center. Results: Among 123 newly diagnosed MBM patients:65% were male, 24%were 50 years old or less, 50% were BRAF mutated, 63% had multiple intracranial lesions at diagnosis . Locally, 73% received SRS as first-line treatment.Systemically, 73% received ICI, 46% received BRAF targeted therapy, and 12% received neither. With median follow up of 11 months (mo), totalcohort median OS was 13.2 mo, 20.5 mo for BRAF mutated patients, 10.8 mo for BRAF wild-type patients. Median OS for first-line SRS was 31.0 mo (47% 3-year OS) when combined with both ICI and BRAF targeted therapy, 17.5 mo (31% 3-year OS) when combined with ICI monotherapy, and 6.1 mo (22% 3-yr OS) with neither systemic therapy. SRS and BRAF targeted therapy were associated with improved OS. BRAF status, ICI therapy, intratumoral hemorrhage were not significant prognosticators for OS.At one-year follow-up, comorbid conditions with the greatest cumulative incidence were fatigue, nausea, intracranial hemorrhage, deep vein thrombosis, major depressive disorder, and pneumonia. Patients averaged one inpatient visit every 4.5 mo (1 week average length of stay), and 2 advanced imaging studies (MR/CT/PET-CT) per month following MBM diagnosis. Conclusions: In one of the largest reported MBM series, survival has improved markedly for patients receiving first-line brain radiosurgery combined with BRAF targeted therapies and immunotherapies. Simultaneously, longer life expectancy comes with increasing incidences of comorbid conditions reflecting an evolving complexity of and need for coordination of care for patients with MBM.

Thrombotic Complications in Gliomas.

Arterial and venous thromboses are common in glioma patients, both in the perioperative period and throughout the course of the disease. High-grade glioma patients harbor underlying hypercoagulability, which predisposes these high-risk patients with prolonged immobility and neurologic deficits to thrombotic events. Despite the high incidence and recurrent nature of these complications, there is no standardized approach to the management of glioma patients, and many challenges remain. Historically, the perceived risk of intracranial and intratumoral hemorrhage limited the use of anticoagulation, favoring nonpharmacological prophylaxis and treatment. Multiple studies have demonstrated the safety and efficacy of anticoagulation when indicated, with low molecular weight heparin as the preferred short- or long-term treatment. This review will discuss the epidemiology, risk factors, and therapeutic management of both venous and arterial thrombotic complications in glioma.

SUN-448 Giant Prolactinomas: A Follow-Up of 25 Years with Dopamine Agonists

Giant prolactinomas are tumors with a large size > 4 cm and/or prolactin levels higher than 3000 ng/ml and/or highly invasive growth. Today dopamine agonists, mainly cabergoline (CAB), are the first-line choice in the treatment of these tumors. Objective: To assess the efficacy, safety and long-term follow-up of patients with giant prolactinomas treated with dopamine agonists. Methods: We retrospectively reviewed the clinical records of 20 patients with giant prolactinomas. Mean age at diagnosis was: 45.2 ± 18.9 years, 75% men. The median follow-up time was 9.05 years (1.5-25.1). At diagnosis the median prolactin level was 6,545 ng/ml (3,238-15,325), the mean maximum diameter of the tumors was 4.60 ± 1.35 cm. At diagnosis, headaches were present in 55% and hypogonadism in 85% of patients; 80% had invasive tumors and 75% had visual field (VF) impairment. Since the diagnosis, almost all patients were treated with CAB except 2, one with bromocriptine LAR and the other one with oral bromocriptine, both were switched to CAB afterwards. Results: Seventy percent of patients normalized prolactin levels, this was achieved in a median time of 7.5 months (2-26) and with a mean dose 2.14 ±1.19 mg/week of CAB. Fifty-four percent of patients reached this prolactin nadir in 2-4 months with a maximum dose < 2 mg/week. The median prolactin level in the last visit was 31.23 ng/ml (12-147). Ninety percent of patients decreased prolactin level during follow-up: 50% normalized prolactin, 25% remained with a mild hyperprolactinemia, 25% with significant hyperprolactinemia. Ninety-five percent of tumors reduced their volume, 60% evolved to empty sella, the remaining achieved a mean decrease of 3.75 cm compared to the initial size (82% of average reduction compared to the initial diameter). The VF remained normal in patients in whom it was not affected, except in 1 whose VF deteriorated because of chiasmatic ptosis; in the patients who presented VF involvement: 47% improved, 40% remained unchanged and 13% worsened. The complications during the follow-up were: Cerebrospinal fluid leak in 2 patients, chiasmatic ptosis in 1 with VF impairment, intra-tumoral hemorrhage in 1. In the follow-up only 1 patient required surgery; 4 patients died, 2 because of the tumor. In 3 (15%) patients CAB was stopped at 96-180-264 months after treatment was initiated, but in all of them CAB was reinitiated due to symptomatic hyperprolactinemia. In 16 patients the treatment could never be discontinued. Conclusions: CAB was effective in the treatment of giant prolactinomas reducing tumor size (some of them evolved to empty sella) and prolactin levels in most patients, with low-moderate doses of CAB and very few complications. In our experience of 25 years of follow-up, we have not had any patients without treatment.

Preliminary utilization of radiomics in differentiating uterine sarcoma from atypical leiomyoma: Comparison on diagnostic efficacy of MRI features and radiomic features

ObjectivesTo explore whether MRI and radiomic features can differentiate uterine sarcoma from atypical leiomyoma. And to compare diagnostic performance of radiomic model with radiologists. Methods78 patients (29 sarcomas, 49 leiomyomas) imaged with pelvic MRI prior to surgery were included in this retrospective study. Certain clinical and MRI features were evaluated for one lesion per patient. Radiological diagnosis was made based on MRI features. A radiomic model using automated texture analysis based on ADC maps was built to predict pathological results. The association between MRI features and pathological results was determined by multivariable logistic regression after controlling for other variables in univariate analyses with P < 0.05. The diagnostic efficacy of radiologists and radiomic model were compared by area under the receiver-operating characteristic curve (AUC), sensitivity, specificity and accuracy. ResultsIn univariate analyses, patient’s age, menopausal state, intratumor hemorrhage, tumor margin and uterine endometrial cavity were associated with pathological results, P < 0.05. Patient’s age, tumor margin and uterine endometrial cavity remained significant in a multivariable model, P < 0.05. Diagnosis efficacy of radiologists based on MRI reached an AUC of 0.752, sensitivity of 58.6%, specificity of 91.8%, and accuracy of 79.5%. The optimal radiomic model reached an AUC of 0.830, sensitivity of 76.0%, average specificity of 73.2%, and accuracy of 73.9%. ConclusionsIll-defined tumor margin and interrupted uterine endometrial cavity of older women were predictors of uterine sarcoma. Radiomic analysis was feasible. Optimal radiomic model showed comparable diagnostic efficacy with experienced radiologists.

Contribution of Intrasellar Pressure Elevation to Headache Manifestation in Pituitary Adenoma Evaluated With Intraoperative Pressure Measurement.

Headache frequently occurs in patients with pituitary adenoma and is reported in large as well as small adenomas. However, the exact mechanism of headache derived from pituitary adenoma remains unknown. To evaluate the contribution of intrasellar pressure (ISP) to headache manifestation by using intraoperative ISP measurement. The records of 108 patients who had first-time transsphenoidal surgery for pituitary adenoma were reviewed retrospectively. Measurement of intraoperative ISP was undergone using intracranial pressure monitoring sensors and compared with radiological assessment. Among 30 patients with headache, 29 (96.7%) presented with significant headache (Headache Impact Score-6, 50 or greater). Intraoperative ISP measurement was conducted successfully in all cases, and revealed higher ISP in patients with headache (35.6 ± 9.2 mm Hg) than in those without headache (15.8 ± 5.2 mm Hg). The ISP reduction after sella floor decompression was greater in patients with headache than that in patients without headache. In patients with headache, the frequency of invasion into the cavernous sinus or sphenoid sinus was significantly lower, and the diameter of the foramen at the diaphragm sellae was narrower. In addition, intratumoral cyst or hematoma was more common in patients with headache. Postoperatively, headache was either diminished or improved in 28 patients (93.3%). Headache in patients with pituitary adenomas associated with ISP elevation, results from compromised dural integrity at the sella and intratumoral hemorrhage. The increased stretch force of the sella dura may be a notable etiology of headache in patients with pituitary adenoma.

Prognostic factors related to intratumoral hemorrhage in pediatric intracranial germ cell tumors.

Certain types of pediatric intracranial germ cell tumors (PIGCTs) are prone to intratumoral hemorrhaging (TH) and associated with poor survival outcome. However, the impact of TH on the functional prognosis of patients with PIGCTs has not been well studied. This study aimed to evaluate the clinical and MR findings in PIGCT patients with TH to identify the factors related to patient survival and functional outcome. This study included 17 patients diagnosed with PIGCT and TH between 2002 and 2016 and evaluated TH-associated clinical and MR findings. The modified Rankin scale (mRS) was used to evaluate functional outcome, which was poor when mRS ≧ 3. The volumes of hematomas and tumors were manually tracked within each brain magnetic resonance imaging slice. Among the 17 patients, 6 (35.3%) died and 9 (52.9%) had poor functional outcome. Regarding the functional outcome, the mean hematoma volume to tumor volume ratio (HTVR) was 8.5 ± 3.9% in the favorable outcome group and 42.3 ± 27.8% in the poor outcome group (p = 0.001). For the survival outcome, the mean HTVR was 15.7 ± 16.1% in the living group and 46.0 ± 31.5% in the deceased group (p = 0.016). The cutoff point of the receiver operating characteristics curve for HTVR to predict death and poor functional outcome was 19.27% and 16.8%, respectively. Our study demonstrated that patients with larger HTVR had significantly worse functional and survival outcomes than those with smaller HTVR. We suggest that early and aggressive treatment for PIGCTs in patients with large HTVR can improve their long-term prognosis.

MR imaging features of spinal pilocytic astrocytoma

BackgroundThe purpose of this retrospective review is to determine the MR imaging features of pilocytic astrocytoma (PA) in the spinal cord to help neuroradiologists preoperatively differentiate PA from other intramedullary tumors.MethodsNeuro-oncology database review revealed 13 consecutive patients with a pathological spinal PA diagnosis and availability of preoperative MR imaging. Three patients had preoperative diffusion-weighted MR imaging. Demographics and conventional and diffusion MR imaging records were retrospectively evaluated.ResultsAmong 13 cases of spinal PA, six PAs were located in the cervical region, 4 in the cervical-thoracic region, and 3 in the thoracic region. The average length of vertebral segments involved for the tumors were 4.7 ± 4.6 segments. Six tumors had associated syringomyelia. Eight PAs were located eccentrically in the spinal cord, and eleven had well-defined margins. Eight tumors (61.5%) were intermixed cystic and solid. All were contrast-enhanced, and 53.8% of all PAs showed focal nodule enhancement of the solid components. Two PAs showed intratumoral hemorrhages, and only one demonstrated cap sign. The ADC values (n = 3) of the tumors were 1.40 ± 0.28 × 10− 3 mm2/s (min–max: 1.17–1.71 × 10− 3 mm2/s).ConclusionsPA should be considered in the differential diagnosis of intramedullary tumors that occur in the cervical and thoracic regions. Eccentric growth pattern, well-defined margin, intermixed cystic and solid appearance, focal nodular enhancement of solid components and syringomyelia are relatively frequent features. Relatively high ADC values compared with normal-appearing spinal cord parenchyma are common in spinal PA.

A case of metastatic brain tumor mimicking an expanding thalamic hematoma.

Background:Brain tumor are a major etiology of secondary intracranial hemorrhage (ICH) because ICH in patients with cancer often occurs from an intratumoral hemorrhage. However, it is sometimes difficult to detect a tumor when it is tiny and buried, especially during initial examination.Case Description:A 65-year-old woman who was diagnosed with pulmonary small cell carcinoma 6 months previously developed sudden-onset consciousness disturbance and left hemiparesis. Head computed tomography (CT) showed a round, high-density lesion with a diameter of 31 mm in the right thalamus. There was no enhancement with administration of contrast agent. Five days later, CT revealed significant progression of the hematoma in the thalamus with perifocal edema. She underwent total removal of the hematoma. Histopathological examination revealed a tiny cluster of metastatic cancer tissue within the hematoma.Conclusions:When cerebral hemorrhage occurs in a cancer patient, we must consider the possibility of hemorrhage due to a brain metastasis.

High-grade Glioma Masquerading as a Small Cerebral Hemorrhage: A Case Report.

We report a rare case of a high-grade glioma masquerading as a small subcortical hemorrhage. A 71-year-old woman came to a local hospital with sudden right upper extremity numbness. Computed tomography revealed a small subcortical hemorrhage with faint perifocal edema in the left postcentral gyrus. Conservative treatment was initiated, and she was discharged from the hospital with no neurological deficits. Six months later after discharge, she suffered an acute partial seizure of the right upper extremity. Magnetic resonance imaging with gadolinium demonstrated a ring-enhancing mass surrounded by severe perifocal edema in the hemorrhagic scar. We performed complete resection of the tumor, and the histological diagnosis was anaplastic oligodendroglioma. The diagnosis of a high-grade glioma was delayed due to intratumoral hemorrhages mimicking a small subcortical hemorrhage; consequently, we suspected the hemorrhage was induced by cerebral amyloid angiopathy. It may be important to repeat radiological follow up, if necessary, and to maintain clinical observance of possible intracranial neoplasm, even when the hemorrhage is small, particularly when the cause of bleeding is unknown.

Multiple massive intratumoral hemorrhages of metastatic brain melanoma after ventriculoperitoneal shunt

A 50-year-old male presented with sudden-onset headache, diplopia, and unsteadiness due to a posterior fossa hemorrhagic melanoma causing hydrocephalus. Computed tomography of the brain showed a 2.3 cm × 2.0 cm hemorrhagic tumor in the cerebellar vermis and a concomitant fourth ventricular hemorrhage. He underwent removal of the tumor and then ventriculoperitoneal shunt insertion for hydrocephalus. Because of his widespread disease, the patient died 2 weeks later from multiple massive intratumoral hemorrhages. To avoid this unfortunate consequence, we discuss the mechanism and suggest methods for treatment improvement. The variable we could control carefully was the opening pressure of the shunt and the flow of cerebrospinal fluid drainage. Setting a higher opening pressure and changing the pressure more slowly should be considered. To achieve this goal, the use of a programmable valve and anti-siphon system should strongly be recommended in these high-risk populations with extremely high bleeding tendency.

Diagnostic value of tumor-fascia relationship in superficial soft tissue masses on magnetic resonance imaging

PurposeMany surgeons participate in the management of superficial soft tissue masses, and a preoperative incorrect diagnosis frequently results in dismal oncological outcomes. The aim of this study was to identify distinguishing magnetic resonance imaging features between malignant and non-malignant lesions.MethodsThe clinicopathological data for 219 patients (men 114; women 105) with superficial soft tissue masses treated from January 2007 to December 2016 in our institution were retrospectively analyzed. The median age at the first visit was 55.6 years (range 1–90 years). MRI findings of tumor size, margin, lobulation, intratumoral hemorrhage, peritumoral edema, and tumor-fascia relationship were compared with the final histological diagnosis and tumor grade.ResultsUnivariate analysis revealed significant relationships between histologically malignant lesions and tumor size ≥5 cm (p = 0.035), positive peritumoral edema (p = 0.031), and tumor-fascia relationship (p<0.001), but not margin (p = 0.107), lobulation (p = 0.071), and intratumoral hemorrhage (p = 0.17). In addition, using multivariate analysis, the tumor-fascia relationship (p<0.001) and tumor size were significant factors.A significant correlation between tumor-fascia relationship and malignancy (p<0.001) was observed; such a relationship was, however, not observed for tumor grade (p = 0.43).ConclusionsTumors measuring ≥5 cm and the tumor-fascia relationship on magnetic resonance imaging are highly indicative of malignancy. When superficial soft tissue masses cross the superficial fascia and form obtuse angles with the fascia, sarcoma should be considered. The tumor-fascia relationship can offer surgeons useful information regarding the status of superficial soft tissue masses.

Preliminary application of susceptibility weighted imaging in meningiomas

Objective To evaluate the preliminary application of susceptibility weighted imaging (SWI) in meningiomas. Methods Fifty meningioma patients, treated at Department of Neurosurgery of Nanjing Brain Hospital Affiliated to Nanjing Medical University between October 2015 and February 2018, were retrospectively enrolled into this study. All cases underwent brain CT, MRI and SWI scans preoperatively, and the minimum intensity projection (mIP) was obtained through processing basic SWI images by software. Compared with MRI and CT, intratumoral microhemorrhage, calcification and drainage vein in meningioma were analyzed in mIP and filtered phase imaging. Pathological examination was carried out after operation. Further comparative analysis was accomplished between microhemorrhagic group and non-microhemorrhagic group in imaging features and pathological indexes. Results Among the 50 meningioma patients examined by SWI, 7 (14%) had 24 intratumoral microhemorrhages; 24 (48%) had 47 intratumoral calcifications, including 31 calcifications that were consistent with CT and 16 which were not detected by CT; 16 (32%) clearly showed dominant draining veins originating from the tumor itself, consisting of 11 without peritumoral edema and 5 with peritumoral edema. The patients without peritumoral edema were more likely to form drainage veins than those with peritumoral edema [61%(11/18) vs. 16% (5/32), P=0.001]. All 50 patients were pathologically confirmed to have WHO Grade Ⅰ meningiomas. The edema index (EI), maximum edema width and Ki67 in the microhemorrhagic group were significant higher than those in non-microhemorrhagic group (all P 0.05). Conclusions Intratumoral microhemorrhage, microcalcification and drainage vein can be detected by SWI. Intratumoral hemorrhages infrequently occur in WHO Grade Ⅰ meningiomas. Microhemorrhagic meningiomas have higher Ki67 and more serious peritumoral edema than non-hemorrhagic ones. The efferent draining vein from meningioma itself may alleviate the formation of peritumoral edema. Key words: Meningioma; Calcinosis; Susceptibility weighted imaging; Microhemorrhage; Vein