Preoperative Karnofsky Score Research Articles

Predicting postoperative seizure development in meningiomas – Analyses of clinical, histological and radiological risk factors

IntroductionSeizures after meningioma surgery are common, with a distinct impact on postoperative life quality. Sufficient risk factors for seizure development are sparsely known but needed to improve perioperative patient counseling and, eventually, antiepileptic treatment. Materials and methodsCorrelations between clinical, radiological and histological variables and the onset of new seizures following surgery for initially diagnosed cranial meningioma were retrospectively analyzed in uni- and multivariate analyses. Results752 preoperatively seizure-naïve patients (569 females, 76 % and 183 males, 24 %) with a median age of 57 years were included. Postoperative seizures occurred in 69 cases (9 %). In univariate analyses, seizures were correlated with preoperative Karnofsky Score < 80 (OR: 1.91, 95 % CI 1.01−3.59; p = .045), convexity/parasagittal tumor location (OR: 1.77, 95 % CI 1.06−2.95; p = .030), heterogenous contrast-enhancement of the tumor (OR: 2.24, 95 % CI 1.14−4.39; p = .019) and intratumoral calcifications (OR: 3.35, 95 % CI 1.59−7.05; p = .001). Multivariable analyses revealed age at the time of surgery (OR: 1.04, 95 % CI 1.01−1.07; p = .009) and intratumoral calcifications on preoperative imaging (OR: 3.70, 95 % CI 1.73−7.92; p = .001) as risk factors for postoperative seizures. Based on multivariate analyses, a score for discrimination of patients at low (3 %), intermediate (11 %) and high risk (17 %) of postoperative seizures (AUC: 0.7, p < .001) was conducted. In subgroup analyses, postoperative hemorrhage (OR: 2.90, 95 % CI 1.13–7.46; p = .028) and hydrocephalus (OR: 3.65, 95 % CI 1.48–9.01; p = .005) were correlated with postoperative seizures. ConclusionRisk factors for postoperative seizures after meningioma surgery are sparse and can be basically taken from preoperative imaging. Among surgical complications, postoperative hemorrhage and hydrocephalus are strong seizure predictors.

Intracranial Low Grade Glioma: a Clinical Study of 35 Cases in a Teaching Institute

Objective: To determine the clinical manifestation and surgical outcome of patients with low grade Glioma.Material and Methods: This descriptive (cross sectional) study was done at the Neurosurgery Department, Mardan Medical Complex Mardan. The study period was March 2017 to February 2018. Patient of any age and gender presented to outpatient department or referred from some other medical facility and diagnosed as low grade Glioma on clinical and radiological grounds and later confirmed by histopathology were included. Results: Out of 35 patients, 20 (57%) were male and 15 (42%) were female. 20 to 80 years was the age range and mean age was 46.36 ± 17.11 years. Frontal lobe was the most frequent area of location, followed by parietal 9 (25%) and temporal 8 (22%) lobe. Pre-operativeKarnofsky score was 90 in 16 (45%), 80 in 8 (22%), 70 in 6 (17%) and 60 in 5 (14%) of patients. Gross total resection was achieved in 13 (37%), radical subtotal resection in 10 (28%), subtotal resection in 10 (28%) and biopsy taken in 02 (5%) patients. histopathology revealed Astrocytoma in 15 (42%), mixed Oligoastrocytoma in 12 (34%) and Oligodendroglioma in 8 (22%) number of patients. Post operatively surgical outcome was measured by improvement in symptomatology, Karnofsky score and seizure control. Conclusion: Conscious level, Karnofsky Performance score, seizure control are important parameters for surgical outcome in patients with low grade Gliomas. Gross total resection of the tumor is a better option for good surgical outcome.

SURG-10. GRADE TWO GLIOMA SURGERY - A LARGE SINGLE CENTRE REVIEW OF CLINICAL, HISTOLOGICAL, GENETIC AND SURGICAL OUTCOMES

Abstract We analysed the surgical outcomes in a large series of operated grade two glioma patients with emphasis on surgical resection volumes, histology, genetics and survival. All adult glioma patients (200) operated between 2009 and 2016 with histological confirmation of grade two glioma from a single United Kingdom unit were included. Baseline clinical data was obtained along with radiological assessment of the extent of tumour resection, histological diagnosis, mutation status and survival data. Univariate and multivariate statistical analysis was performed. Preliminary analysis of an initial 63 patients had an average follow up of 51 months. A mean tumour resection of 73.9% (Range 14.4–100%), with an average pre-operative tumour volume of 42.2cm3 was achieved. 48 patients underwent awake surgery. There was no significant difference between pre-operative Karnofsky score (93.0) and post-operative (91.6) function. IDH-mutant diffuse astrocytoma (55.5%), IDH-mutant 1p19q co-deleted oligodendroglioma (33.3%) and IDH wildtype diffuse astrocytoma (14.3%) were the commonest histological diagnoses. 32 patients underwent post-operative adjuvant oncology treatment, with 22 requiring repeat operation. Extent of resection in repeat surgeries was 58.6%. Preliminary statistical analysis on this initial sample has demonstrated that every additional year of age at diagnosis however is associated with a 0.5% reduction in resection (p=0.02) and a 0.2% decline in Karnofsky performance (p=&amp;lt; 0.01). Patients with 1p19q co-deletion had a significant increase in progression free survival (PFS) (p=0.04). No significant variables were found to predict the risk of second surgery. Patients with eloquent tumour locations were significantly less likely to suffer post-operative neurological deficits (p&amp;lt; 0.01) Provisional analysis of our case series demonstrates an excellent extent of resection for our cohort of grade two glioma patients. 1p19q co-deletion in this group was significantly associated with improved PFS. Full analysis of the entire patient cohort will be available in time for presenting.

Long-term survival after glioblastoma resection: hope despite poor prognosis factors.

In spite of aggressive multimodal treatment, survival for patients with glioblastoma (GBM) remains short. Nevertheless, some patients survive much longer than expected and become long-term survival patients. The extent of resection (EoR), Karnofsky Performance Scale (KPS), age and methyl-guanine methyltransferase gene (MGMT) methylation are well-defined prognostic factors, but the characteristics of patients with long-term survival (LTS, survival of at least three years after diagnosis) has not been fully determined yet. That is the reason why we analyzed the GBM patients with LTS at our center. We retrospectively reviewed all consecutive patients who underwent surgery for GBM between January 2002 and November 2011, including patients treated with surgical resection under neuronavigation with or without intraoperative MRI (ioMRI) and those who had stereotactic biopsy. We identified and further analyzed those patients with LTS. A total of 127 patients underwent surgery for GBM during the study period. 101 (79.6%) of whom had surgical resection and 26 (20.4%) of whom had stereotactic biopsy. Of the 101 patients who were treated with surgical resection, 12 had LTS. After two other pathologists reviewed the patients' cases, they confirmed that 11 (11%) of the 12 patients had a GBM (female/male ratio 4.5; average age 50 years; preoperative Karnofsky Score 82%), and one patient had an anaplastic glioma. The mean survival in the LTS patients with confirmed GBM was 74 (36-150) months. Seven of the LTS patients (63.6%) had a gross total resection (GTR), including two with an additional resection after ioMRI. Three (27.3%) had a near total resection (NTR: residue ≤5%) and one (9.1%) had a partial resection. Ten (90.9%) patients had a methylation of MGMT, only two (18.8%) had an IDH1 mutation, and seven (63.6%) received a full Stupp protocol. Among patients with a GBM who were treated with one or more resections, 11% had LTS with 90.9% with at least a near total resection (36% with ioMRI) and a methylated MGMT. 50% of the patients with a second surgery survived at least two years postoperatively. Those encouraging observations emphasize the importance of maximizing the resection by using, if possible, an intraoperative guidance method like ioMRI with an analysis of biomarkers such as MGMT and if necessary, multiple surgical procedures.

Some characteristics of gliomas managed at a Neurosurgery centre in Nigeria.

Gliomas are important primary brain tumours with varying prognosis. To study the histology characteristics of brain gliomas managed in a Neurosurgical centre in Nigeria. A retrospective analysis of prospectively recorded data of patients managed for intracranial gliomas at our Hospital for Neurosurgery, between year 2006 and 2015. Only the patients with conclusive histology diagnosis following surgery were analysed. Glioma was 23.8% of the 252 histology-confirmed brain tumours. Male-to-female ratio was 1.4:1.0. Peak age at diagnosis was in the fifth decade of life. There was an increase in the frequency of diagnosis from seven (2006-2009) to 15 (2011 and 2012) and 39 patients managed (2013 and 2015). In sub-group analysis, grade IV tumour was the most common (34.6%) followed by grade II (30.7%), grade I (18.3%) and grade III (16.7%). Seven patients of grade II oligodendroglioma and one patient each of anaplastic oligodendroglioma, subependymal giant cell astrocytoma and astroblastoma were seen. The anatomical location of the tumour was the frontal lobe in 23.3% of patients followed by the parietal lobe in 16.7% of patients. The pre-operative Karnofsky score was ≥70% in 36.7% of the patients. Gliomas are more common brain tumours than were imagined. Most patients present relatively late and with advanced disease. High-grade gliomas seem to mostly affect the middle age population in the study environment with higher proportion of grade IV lesions.

Factors Affecting Survival in Patients Undergoing Palliative Spine Surgery for Metastatic Lung and Hepatocellular Cancer: Dose the Type of Surgery Influence the Surgical Results for Metastatic Spine Disease?

BackgroundSurgical treatment for metastatic spine disease has been becoming more prominent with the help of technological advances and a few favorable reports on the surgery. In cases of this peculiar condition, it is necessary to establish the role of surgery and analyze the factors affecting survival.MethodsFrom January 2011 to April 2015, 119 patients were surgically treated for metastatic spine lesions. To reduce the bias along the heterogeneous cancers, the primary cancer was confined to either the lung (n = 25) or the liver (n = 18). Forty-three patients (male, 32; female, 11; mean age, 57.5 years) who had undergone palliative surgery were enrolled in this study. Posterior decompression and fusion was performed in 30 patients (P group), and anteroposterior (AP) reconstruction was performed in 13 patients (AP group) for palliative surgery. Pre- and postoperative (3 months) pain (visual analogue scale, VAS), performance status (Karnofsky performance score), neurologic status (American Spinal Injury Association [ASIA] grade), and spinal instability neoplastic score (SINS) were compared. The survival period and related hazard factors were also assessed by Kaplan-Meier and Cox regression analysis.ResultsMost patients experienced improvements in pain and performance status (12.3% ± 17.2%) at 3 months postoperatively. In terms of neurologic recovery, 9 patients (20.9%) graded ASIA D experienced neurological improvement to ASIA E while the remainder was status quo. In an analysis according to operation type, there was no significant difference in patient demographics. At 12 months postoperatively, cumulative survival rates were 31.5% and 38.7% for the P group and the AP group, respectively (p > 0.05). Survival was not affected by the pre- and postoperative pain scale, Tokuhashi score, neurologic status, SINS, or operation type. Preoperative Karnofsky performance score (hazard ratio, 0.93; 95% confidence interval [CI], 0.89 to 0.96) and improvement of performance status after surgery (hazard ratio, 0.95; 95% CI, 0.92 to 0.97) significantly affected survival after operation.ConclusionsThere was no significant difference in surgical outcomes and survival rates between posterior and AP surgery for metastatic lesions resulting from lung and hepatocellular cancer. Preoperative Karnofsky score and improvement of performance status had a significant impact on the survival rate following surgical treatment for these metastatic spine lesions.

Preoperative prognostic value of dynamic contrast-enhanced MRI-derived contrast transfer coefficient and plasma volume in patients with cerebral gliomas.

The prognostic value of dynamic contrast-enhanced MR imaging-derived plasma volume obtained in tumor and the contrast transfer coefficient has not been well-established in patients with gliomas. We determined whether plasma volume and contrast transfer coefficient in tumor correlated with survival in patients with gliomas in addition to other factors such as age, type of surgery, preoperative Karnofsky score, contrast enhancement, and histopathologic grade. This prospective study included 46 patients with a new pathologically confirmed diagnosis of glioma. The contrast transfer coefficient and plasma volume obtained in tumor maps were calculated directly from the signal-intensity curve without T1 measurements, and values were obtained from multiple small ROIs placed within tumors. Survival curve analysis was performed by dichotomizing patients into groups of high and low contrast transfer coefficient and plasma volume. Univariate analysis was performed by using dynamic contrast-enhanced parameters and clinical factors. Factors that were significant on univariate analysis were entered into multivariate analysis. For all patients with gliomas, survival was worse for groups of patients with high contrast transfer coefficient and plasma volume obtained in tumor (P < .05). In subgroups of high- and low-grade gliomas, survival was worse for groups of patients with high contrast transfer coefficient and plasma volume obtained in tumor (P < .05). Univariate analysis showed that factors associated with lower survival were age older than 50 years, low Karnofsky score, biopsy-only versus resection, marked contrast enhancement versus no/mild enhancement, high contrast transfer coefficient, and high plasma volume obtained in tumor (P < .05). In multivariate analysis, a low Karnofsky score, biopsy versus resection in combination with marked contrast enhancement, and a high contrast transfer coefficient were associated with lower survival rates (P < .05). In patients with glioma, those with a high contrast transfer coefficient have lower survival than those with low parameters.

Sphenoid Wing Meningiomas: Surgical Strategies and Evaluation of Prognostic Factors Influencing Clinical Outcomes

Objective: To study microsurgical technique and prognostic factors influencing clinical outcomes in a series of 53 patients with sphenoid wing meningiomas. Materials and Methods: The clinical materials of 53 patients with sphenoid wing meningiomas treated microsurgically between January 2008 and January 2012 were analyzed retrospectively. Postoperative follow-up ranged from 6 to 62 months (mean, 34 months). Clinical outcomes including postoperative quality of life and recurrence rate were evaluated. Univariate and multivariate statistical analysis were performed among the factors that might influence postoperative quality of life. Results: In our group, the mean age of patients was 49 years. Mean tumor size was 3.9 cm. Total tumor resection were achieved in 38 cases (71.7%), subtotal in 10 cases (18.9%) and partial resection in 5 cases (9.4%). Within the follow-up period, 10 patients (18.9%) recurred and 3 patients (5.7%) died. Through univariate analysis, we found the postoperative Karnofsky Score (KPS) improvement was determined by various factors, including extent of tumor resection, peritumoral edema, tumor blood supply, size of the tumor, adhesion to the surrounding structures, encasement of major vessels and preoperative Karnofsky score .However, multivariate analysis showed that extent of tumor removal, tumor blood supply, adhesion to the surrounding structures, and encasement of the neurovascular structures were the most influential factors. Conclusions: The extent of tumor removal and intraoperatively defined tumor characteristics played an important role in identifying postoperative functional status. An individual treatment strategy after careful preoperative evaluation could improve quality of life.

Permanent Iodine-125 Interstitial Radiation Therapy in the Treatment of Non-Glioblastoma multiforme High-Grade Gliomas

Background: This study evaluates prognostic factors influencing survival outcomes for 60 patients with permanent iodine-125 implants in the primary treatment of non-glioblastoma multiforme (GBM) high-grade gliomas. Methods: Stereotactic treatment planning aimed to encompass the contrast-enhancing rim of the tumor visualized by CT, with an initial dose rate of 0.05 Gy/h with ¹²⁵I, delivering 100 Gy at 1 year and 103.68 Gy at infinity. Survival was evaluated using the Kaplan-Meier method for univariate analysis and the Cox regressional method for multivariate analysis. In addition to the implant, 34 patients received external radiation therapy (5,000–6,000 cGy) before the implant; 13 patients were implanted without additional external beam radiation, and 13 patients underwent external radiation therapy before implant placement. Results: With a mean follow-up of 77.6 months (range 3.5–164 months), 1-, 3-, 5- and 10-year survival were 86.7% (±0.05%), 60% (±0.07%), 50% (±0.07%) and 45.7% (±0.7%), respectively. The median survival time was 57 months. Second surgery was performed following the implant in 19 patients. Findings were tumor recurrence in 11 patients (22.5%), radiation necrosis in 7 patients (14.3%) and brain abscess in 1 patient (2%). Age, sex, tumor location, side of brain, tumor volume, Karnofsky score and neurological status were correlated with survival outcome. Favorable prognostic factors were age younger than 45 years, superficial tumor location and preoperative Karnofsky score greater than 70. RPA classification was used to define this group of patients. In RPA classes I and II (n = 43), 1-year survival was 93%, while 3-, 5- and 10-year survival was 67.4, 60.5 and 55.5%, respectively, and median survival time was 91 months. In RPA class III (n = 7), 1-year survival was 71.4%, while 3- and 5-year survival was 42.9 and 28.6%, respectively, and median survival time was 47 months. In RPA class IV (n = 10), 1-year survival was 60%, while 3-, 5- and 10-year survival was 50, 22.2 and 11.1%, respectively, and median survival time was 37 months. Conclusion: Brachytherapy with permanent implant of ¹²⁵I appears promising in the treatment of primary non-GBM malignant gliomas. It improved survival time and reduced the incidence of complications and provided good quality of life. In order to further confirm these results, multicenter randomized prospective studies are needed. RPA analysis is a valid tool to define prognostically distinct survival groups. In this study, 2-year survival and median survival time were improved in all prognostic classes. This would suggest that selection bias alone does not account for the survival benefit seen with ¹²⁵I implants. Further randomized studies with effective stratification are needed.

Prognostic Factors for Patients with Microsurgically Resected Brain Metastases

Background: With the advent of new therapies for metastatic carcinoma to the brain, patterns of intracranial disease and factors influencing survival become important considerations when examining treatment options. This study was conducted at a single institution to determine prognostic factors for tumor response and patient survival after microsurgical resection of brain metastases. Patients and Methods: 187 consecutive patients who underwent microsurgical resection of brain metastases between July 1989 and September 1996 were retrospectively reviewed and statistically analyzed. The primary cancers included lung cancer (85), gastrointestinal cancer (20), renal cell cancer (19), breast cancer (17), malignant melanoma (8) and 38 cases of various other carcinomas or of unknown primary site. 111 patients received whole-brain radiation therapy (WBRT) with a mean dose of 32 Gy after tumor resection. The influence of number, size, and localization of brain metastases as well as histology of the primary tumor, preoperative performance status, presence of extracranial systemic disease, time course and adjuvant radiation therapy were statistically evaluated (uni- and multivariate) as prognostic factors for survival. Results: Early postoperative Karnofsky score was improved in 59%, unchanged in 32% and worse in 9% of patients. Median survival time (MST) was 9.8 months (range 1 day–5.3 years). The most important parameter showing a significant influence on survival time was the histology of the primary tumor, with prediction of a bad outcome especially for patients with metastases from renal-cell cancer and malignant melanomas. Patients with breast cancer showed longer survival than patients with other primary cancers. Furthermore, survival varied significantly depending on location of brain metastases, performance status at time of craniotomy and duration of symptoms. None of the other studied variables gained prognostic significance. Conclusion: Microsurgical resection of one or more brain metastases followed by WBRT still is a useful and efficient treatment in a carefully selected patient group to prolong median survival and improve or stabilize the performance status. Among the factors determining the survival times in this patient group, histology of the primary tumor is most important, together with preoperative Karnofsky score, location of metastasis and preoperative duration of symptoms.

Surgical results for spinal meningiomas

Among a series of 782 spinal tumors, 130 spinal meningiomas in 117 patients were operated in the Department of Neurosurgery at the Nordstadt Hospital in Hannover, Germany, between 1977 and 1998. Patients were followed postoperatively for up to 13 years (mean 20 ± 33 months). Comparing the period of 1977 through 1987, before magnetic resonance imaging (MRI) was available, to the period of 1988 to 1998 revealed that the average history until diagnosis shortened by about 6 months during the second decade of this study (24 ± 33 to 18 ± 29 months; not significant). Consequently, the preoperative Karnofsky Score increased significantly (59 ± 15 and 66 ± 16; p < 0.05). The rates of complete resection and the postoperative neurological outcome, however, remained unchanged. Even though the overall prognosis of neurological deficits is favorable after complete resection of a meningioma, a subset of 18 patients had either en plaque growing or recurrent tumors that were more likely to be removed incompletely and to cause postoperative neurological problems, with a significantly worse Karnofsky Score after 1 year (57 ± 12 and 77 ± 12, respectively; p < 0.01) and a significantly higher recurrence rate after 5 years (86.7% and 20.4%, respectively; log rank test p = 0.0014). In conclusion, a favorable postoperative neurological outcome requires complete resection of the spinal meningioma. The advent of MRI has shortened the time until diagnosis and made it possible to perform surgery before severe deficits have occurred, but did not have a major impact on postoperative results. En plaque and recurrent meningiomas remain surgical challenges, as infiltration of surrounding structures and associated arachnoid scarring may render complete resection difficult to achieve.

Management of glioblastoma multiforme: with special reference to recurrence

Between 1985 and 1995, 46 patients underwent craniotomy for glioblastoma multiforme. The mean age was 47, varying from 9 to 71 years. The influence of such prognostic factors as age, preoperative Karnofsky score, extent of resection, tumour site, tumour size, radiotherapy, reoperation as well as initial symptoms upon survival were studied. Of these, gross complete removal, radiotherapy, preoperative Karnofsky score, and reoperation were shown to be statistically significant to the survival time according to logrank and univariate tests. However, age, preoperative Karnofsky score, tumour size and temporal localisation remained as significant factors in multivariate analysis. The overall median survival was 53 weeks, with no patients surviving more than 3 years. Of the patients, 41% survived over a year and 8.6% lived over two years. Twenty-six patients developed a recurrent mass after an interval of 32 weeks. The median interval time from operation to recurrence was longer in those patients who underwent gross removal than in those who had a subtotal resection, 28.2 against 20 weeks ( P < 0.05). Of patients who had a recurrent mass, 16 were reoperated on, with a subsequent median survival time of 26.5 weeks. Our experience suggests that the survival of patients with glioblastoma depends on many factors, including radical surgery as an initial step. In addition, the gross total removal of the tumour also delays the development of recurrence.

Management of glioblastoma multiforme: with special reference to recurrence.

Between 1985 and 1995, 46 patients underwent craniotomy for glioblastoma multiforme. The mean age was 47, varying from 9 to 71 years. The influence of such prognostic factors as age, preoperative Karnofsky score, extent of resection, tumour site, tumour size, radiotherapy, reoperation as well as initial symptoms upon survival were studied. Of these, gross complete removal, radiotherapy, preoperative Karnofsky score, and reoperation were shown to be statistically significant to the survival time according to logrank and univariate tests. However, age, preoperative Karnofsky score, tumour size and temporal localisation remained as significant factors in multivariate analysis. The overall median survival was 53 weeks, with no patients surviving more than 3 years. Of the patients, 41% survived over a year and 8.6% lived over two years. Twenty-six patients developed a recurrent mass after an interval of 32 weeks. The median interval time from operation to recurrence was longer in those patients who underwent gross removal than in those who had a subtotal resection, 28.2 against 20 weeks (P < 0.05). Of patients who had a recurrent mass, 16 were reoperated on, with a subsequent median survival time of 26.5 weeks. Our experience suggests that the survival of patients with glioblastoma depends on many factors, including radical surgery as an initial step. In addition, the gross total removal of the tumour also delays the development of recurrence.

Cost and Survival Analysis of Metastatic Cerebral Tumors Treated by Resection and Radiation

The surgical treatment of metastatic brain tumors remains controversial, primarily because of the limited prognosis of patients with metastatic cancer. The cost effectiveness of even standard therapies is of increasing concern to third-party payers. We reviewed the records of patients who had a single metastatic brain tumor resected at the Medical Center Hospital of Vermont (a referral center in a rural state) since cost data recording began. The 32 patients ranged in age from 35 to 77 years, with a 2.2:1 female-to-male ratio. Thirty-four percent of tumors originated in the lung, 15.6% were renal, 12.5% were breast, 12.5% were gynecological, 9.4% were gastrointestinal, and 9.4% were ultimately of unknown origin. Thirty-one tumors were completely resected; 30 patients were irradiated, most after surgery (mean dose, 3,908 +/- 1,250 cGy). Karnofsky scores improved from 80 +/- 11 to 88 +/- 16 postoperatively (P = 0.0038, one-tailed paired t-test). Patients were hospitalized an average of 8.22 +/- 6.26 days postoperatively, with total operative and postoperative charges of $19,190 +/- 5,684, noninclusive of radiotherapy. The expected median survival of all patients was 26 months (Kaplan-Meier estimate). The presence of disseminated disease was not significantly correlated with survival (P = 0.237). The number of postoperative days was more for patients with disseminated disease (P = 0.0274), but not for patients with infratentorial tumors (P = 0.6991). Age higher than the median was not correlated with an increased number of postoperative days (P = 0.1366) nor was a preoperative Karnofsky score of 70 or less (P = 0.1382).(ABSTRACT TRUNCATED AT 250 WORDS)

P53 protein in low-grade astrocytomas: a study with long-term follow-up.

The immunohistochemical expression of p53 protein (p53) was examined in 52 patients out of a series of 66 patients with low-grade astrocytomas with long-term follow-up. All patients were also evaluated for several clinical and histological features, among which only preoperative Karnofsky score and the extent of surgery were statistically significant parameters to predict outcome on multivariate analysis. p53 accumulation was seen in 46.1% of patients, with a wide range of percentage of positive cells. Median survival for p53-positive and p53-negative patients was 41 and 37 months respectively. The survival curves of p53-positive and -negative patients were not statistically different. However, the curves showed a trend towards a more aggressive course in p53-positive patients beginning 3-4 years after surgery. Five years after diagnosis the survival estimate with the Kaplan-Meier method was 21.2% for patients with p53-positive tumours and 45.9% for patients with p53-negative tumours. This trend is not due to different distribution of major clinical prognostic factors (age, incomplete resection or Karnofsky status). The trend could be related to the time needed by the p53-positive clone to outgrow the rest of the p53-negative neoplastic cell population. This hypothesis is further supported by the fact that the five recurrences which were surgically removed (one anaplastic astrocytoma and four glioblastomas) derived from p53-positive tumours and were themselves intensely p53 positive.

Acoustic neurinoma in the elderly: factors predictive of postoperative outcome.

The authors present the results of acoustic neurinoma surgery in 61 elderly patients (age, > or = 65 years). All the patients were operated upon via the lateral suboccipital approach. Complete tumor removal was achieved in all but two patients. There was no operative mortality. Fifty-seven patients (93%) were independent of nursing assistance at the time of discharge from the hospital. Preservation of the facial nerve was achieved in 95% of the patients, and hearing was preserved in 41%. A risk analysis identified three factors exerting a significant influence on the outcome in these cases: the American Society of Anesthesiology score, the preoperative Karnofsky score, and the size of the tumor. The patients' age was not correlated with the postoperative outcome. These results suggest that, in the majority of elderly patients with acoustic tumors, complete tumor removal can be achieved safely and with minimal postoperative morbidity. Preoperative clinical, neurological, and radiological factors can be helpful in the selection of patients for surgical treatment and may predict postoperative outcome.

The role of stereotactic biopsy in the management of HIV-related focal brain lesions.

The criteria for brain biopsy in patients with acquired immunodeficiency syndrome (AIDS) remain unclear and without universal acceptance. In order to shed more light on this issue, the authors reviewed the records of 25 AIDS patients with focal cerebral lesions who consecutively underwent stereotactic biopsy between November 1988 and October 1990. The most frequently occurring diagnoses were lymphoma (36%), progressive multifocal leukoencephalopathy (24%), and toxoplasmosis (8%). Patients whose central nervous system disease resulted in their initial presentation (approximately 40%) survived a median of 37 weeks, as opposed to 6 weeks for those who had previous AIDS-related infections. The proportion of biopsies of contrast-enhancing lesions that were diagnostic and thereby contributed to the patients' therapeutic management was 87.5%. On the other hand, only 67% of the biopsies of nonenhancing lesions were diagnostic, and none of these lesions were treatable. All of the lymphoma patients had had AIDS for some time and, despite a reasonable preoperative Karnofsky score and postoperative radiation therapy, their median survival was only 6 weeks; however, biopsy was critical to their therapeutic management. Early brain biopsy, rather than empiric antitoxoplasmosis therapy, appears indicated for aggressive therapy of contrast-enhancing lesions in patients who have had previous manifestations of AIDS. The role for biopsy of nonenhancing lesions is less clear, but it may provide prognostic information.

Reoperation for recurrent glioblastoma and anaplastic astrocytoma.

The advisability of a second operation for recurrent glioblastoma multiforme or anaplastic astrocytoma depends on the expected duration and quality of subsequent survival. We reviewed the results in 70 consecutive patients who underwent reoperation for supratentorial glioblastoma multiforme (n = 39) or anaplastic astrocytoma (n = 31) between 1975 and 1984. The operative morbidity rate was 5.7% (4 of 70 patients); the 6-week postoperative mortality rate was 4.3% (3 of 70 patients). The median duration of survival after reoperation was 36 weeks in patients with glioblastoma multiforme and 88 weeks in those with anaplastic astrocytoma. The median duration of high quality survival (defined as the period during which the patient had a Karnofsky performance score of at least 70) after reoperation was 10 weeks for patients with glioblastoma multiforme and 83 weeks for patients with anaplastic astrocytoma. Age and preoperative Karnofsky score in patients with glioblastoma multiforme and age in patients with anaplastic astrocytoma had statistically significant effects on the duration of high quality survival after reoperation, but not on postoperative survival independent of quality. Although age and functional status do not significantly affect the duration of survival after reoperation, they do have a significant effect on the quality of life after reoperation. Frequently, a patient can expect to spend a greater portion of his life at a higher level of function than he would have without reoperation. As adjunctive forms of therapy improve, reoperation will play an increasingly prominent role in the management of recurrent malignant astrocytic tumors.