Surgical Anatomy of the Temporal Lobe

The temporal lobe is a unique structure in the human brain and one of the most important structures involved in the surgical treatment of intractable epilepsy. Knowledge of the temporal lobe??s structures and function allow us to better understand the complex phenomenology of temporal lobe seizures and the positive and negative effects of surgical resections in the area. We reviewed the parenchymal and vascular anatomy and the white matter tracts of temporal lobe, and the relationships to surrounding structures such as dural structures and cistern.ope

Defining the Interval between the Development of New Lesion on Follow Up Study and 1st Gamma Knife Radiosurgery without Whole-Brain Radiation Therapy in the Management of Brain Metastases

The aim of this retrospective study is to define the interval between the development of new lesion on follow up study and 1st gamma knife radiosurgery (GKS) without whole brain radiation therapy (WBRT) in the management of brain metastases. Between May 1992 and January 2006, 378 patients (207 males and 174 females) with brain metastases were treated with radiosurgery at the Yonsei University Medical Center. Reviewing the follow up study was available in 357 (81.7%) cases, and new lesions were found in 83 (23.2%) cases. We classified the development of new lesions after 1st GKS as missed, invisible, true new and undetermined lesions；missed lesions are those which were visible on MRI at the time of 1st GKS retrospectively, but omitted；invisible lesions, too small to be visualized on MRI at the time of 1st GKS, may be less than 1mm in size at that time and will be new lesions, visible on MRI within 4months after 1st GKS；true new lesions, newly metastasized to brain after GKS, developed 8 months after 1st GKS； undetermined lesions, new lesions developed 5 to 7 months after 1st GKS. There were 12 patients (18.18%) of missed lesions, and the number of those lesions was 17；10 patients (15.15%) of invisible, and the number, 51；25 patients (37.88%) of undetermined, and the number, 166；19 patients (28.79%) of true new lesions, and the number, 100. The incidence of new lesion development was high between 5th and 7th months after GKS, and after that, it decreased suddenly. And that low incidence was even after 7th months. GKS without adjuvant WBRT showed good effect, however, strict MRI follow up at 4 and 7months after GKS is necessary to detect and treat the invisible and missed lesions.ope

Analysis of the Non-diagnostic Results after Stereotactic Biopsy

Objective: Although stereotactic brain biopsy has played an important role in the diagnosis and management of brain lesions, there is a significant number of patients in whom a histologic diagnosis is not achieved. The non-diagnostic result of stereotactic biopsy poses a management dilemma. The goal of this study was to analyze the non-diagnostic results after stereotactic biopsy, subsequent management, progress and final diagnosis. Methods: The authors reviewed the clinical and radiological records of 158 patients who underwent stereotactic brain biopsies using Leksell stereotactic frame. We included 138 patients who were followed more than 6 months in this study. Results: The results were diagnostic in 118 cases and the overall diagnostic yield of the procedure was 85.6%. A definite histological diagnosis was not made in 20 patients: gliosis in 10, normal white matter in 5, necrosis in 2, infiltration of inflammatory cell in 2, and insufficient material in 1. The subsequent managements, progress and their final diagnoses were described. Conclusion: Stereotactic biopsy has evolved as a powerful and safe tool to provide tissue diagnoses with minimal disruption of normal functioning brain. Multiple serial biopsy, intraoperative histological diagnosis, and updated imaging-guided biopsy should be tried to minimize the sampling error. Clinical and radiological follow-up are essential for further diagnosis and management in non-diagnostic cases.ope

Surgical Management of Central Neuropathic Pain Using the Neuroablative Procedures of Brain

Central pain is defined as pain initiated or caused by a primary lesion or dysfunction within the central nervous system and has proved the most difficult pain to control. Many intracranial ablative procedures have been tried, including stereotactic cingulotomy, thalamotomy, and mesencephalotomy, which have been described to be effective in about 50% to 60% although the relief of pain is faded out with time. Anterior cingulotomy is effective for the relief of cancer pain and noncancer chronic pain. Although few side effects are potential benefits of cingulotomy, the effectiveness for central pain is not yet established. Mesencephalotomy is particular value in central denervation pain, cancer pain involving the head, neck but its use is limited due to significant morbidity. The value of thalamotomy for treatment of central pain is not documented. Trigeminal tractotomy and nucleotomy are beneficial for vagoglossopharyngeal neuralgia, geniculate neuralgia, and the caudalis DREZ is beneficial for atypical facial pain, postherpetic neuralgia. Recently neurostimulation is recommended for the treatment of central pain or neuropahic pain rather than neuroablation. The use of destructive central procedures for central pain and noncancer chronic pain has not yet been well defined. With the potential benefit being less certain, priority might be given to a procedure with less risk.ope

Angioleiomyoma in the Orbital Apex: A Case Report

A 56-year woman presented eyeball pain and blurred vision. MRI revealed a small well-delineated solid tumor in the apex of right orbit with optic nerve compression. Intraoperatively, the tumor was found very fibrous, hypervascular and adhesive to surrounding structures. The tumor was completely removed with the combination of endoscopic and microscopic technique. Patient experienced transient oculomotor nerve palsy, which completely recovered 3 months after surgery. Herein we report a rare case of angioleiomyoma in the orbital apex.ope

Overexpression of CD99 Increases the Migration and Invasiveness of Human Malignant Glioma Cells

The malignant glioma is the most common primary human brain tumor, and its migration and invasiveness away from the primary tumor mass are considered a leading cause of tumor recurrence and treatment failure. Recently, gene expression profiling revealed that the transmembrane glycoprotein CD99 is more highly expressed in malignant glioma than in normal brain. Although its function is not completely understood, CD99 is implicated in cell adhesion and migration in a variety of different cell types. CD99 has wild-type and splice variant isoforms. Previous studies have shown that wild-type CD99 may be an oncosuppressor in some tumors, distinct from the role of the splice variant isoform. In this study, our data reveal that only wild-type CD99 is expressed in human glioma cells and tissues. Using a tissue microarray, we validated that gliomas demonstrate higher expression of CD99 compared with nonneoplastic brain. To assess the role of CD99 in glioma migration and invasion, we inhibited CD99 expression by siRNA and demonstrated decreased glioma migration and invasion. In contrast, when CD99 was overexpressed in glioma cells, we observed enhancement of cell migration and invasiveness. An orthotopic brain tumor model demonstrates that CD99 overexpression significantly increases invasiveness and decreases survival rate. Interestingly, Rac activity was decreased and Rho activity was increased in CD99 overexpressing glioma cells, and the proportion of amoeboid cells to mesenchymal cells was significantly increased. Taken together, our findings suggest that CD99 may play an important role in the migration and invasion of human gliomas independent of Akt, ERK, or JNK signaling pathways. Moreover, CD99 might be involved in amoeboid-mesenchymal transition in glioma migration. CD99 may be an important future target to inhibit migration and invasion, especially in CD99-expressing gliomas.ope

The Results of Gamma Knife Radiosurgery for Brain Metastases from Renal Cell Carcinoma

Objective: Renal cell carcinoma (RCC) is a rare tumor which tends to metastasize to the brain in about 4-11% of patients. Metastases from RCC raise specific therapeutic problems because they are relatively unresponsive to whole brain radiation therapy and tend to bleed. The aim of this study was to analyze the therapeutic effects after Gamma Knife radiosurgery (GKS) as a primary treatment for patients harboring brain metastases of RCC. Methods: Between May 1992 and September 2005, 26 patients with 102 brain metastases from RCC underwent 31 GKS procedures. Overall median survival, main cause of death, local control rate, and morbidity related to GKS were evaluated. Age, sex, performance status, number of metastases, volume of metastases, presenting symptom, prior history of craniotomy, prior history of fractionated radiation therapy, prior history of chemotherapy or immunotherapy, maximal dose, tumor marginal dose, number of treatment isocenters, recursive partitioning analysis (RPA) class, and latency period from diagnosis of RCC to that of brain metastases were statistically analyzed to identify significant factors related to prolonged survival. Results: The mean tumor volume was 3.3 (0.02-35.1)cc. Mean maximal and tumor margin dose were 28.0 (15-43)Gy and 17.7 (9-26.6)Gy, respectively. The period of median survival was 10.5 months after GKS and RPA class was only significant factor related to survival. Local tumor control rate was 92.0% and tumor volume was related to local control. Radiation-related edema occurred in 8.9% of cases. Additional whole brain radiation therapy could not affect survival time, local tumor control, but could increase the risk of radiation-related complication. Local and distant tumor recurrences were treated by additional GKS. There was no permanent morbidity after GKS. Conclusion: Despite of the radioresistant nature of RCC, GKS alone could effectively control brain metastases from RCC not only as a primary treatment, but also as a secondary salvage for recurrence. Early detection of brain metastases, aggressive treatment of systemic disease, and a therapeutic strategy including repeated radiosurgery without a combination of whole brain radiation therapy can offer patients an extended survival.ope

The Korean Society for Neuro-Oncology (KSNO) Guideline for WHO Grade II Cerebral Gliomas in Adults: Version 2019.01

BACKGROUND: There was no practical guideline for the management of patients with central nervous system tumor in Korea for many years. Thus, the Korean Society for Neuro-Oncology (KSNO), a multidisciplinary academic society, has developed the guideline for glioblastoma. Subsequently, the KSNO guideline for World Health Organization (WHO) grade II cerebral glioma in adults is established. METHODS: The Working Group was composed of 35 multidisciplinary medical experts in Korea. References were identified by searching PubMed, MEDLINE, EMBASE, and Cochrane CENTRAL databases using specific and sensitive keywords as well as combinations of keywords regarding diffuse astrocytoma and oligodendroglioma of brain in adults. RESULTS: Whenever radiological feature suggests lower grade glioma, the maximal safe resection if feasible is recommended globally. After molecular and histological examinations, patients with diffuse astrocytoma, isocitrate dehydrogenase (IDH)-wildtype without molecular feature of glioblastoma should be primarily treated by standard brain radiotherapy and adjuvant temozolomide chemotherapy (Level III) while those with molecular feature of glioblastoma should be treated following the protocol for glioblastomas. In terms of patients with diffuse astrocytoma, IDH-mutant and oligodendroglioma (IDH-mutant and 1p19q codeletion), standard brain radiotherapy and adjuvant PCV (procarbazine+lomustine+vincristine) combination chemotherapy should be considered primarily for the high-risk group while observation with regular follow up should be considered for the low-risk group. CONCLUSION: The KSNO's guideline recommends that WHO grade II gliomas should be treated by maximal safe resection, if feasible, followed by radiotherapy and/or chemotherapy according to molecular and histological features of tumors and clinical characteristics of patients.ope

Temozolomide during and after Radiotherapy for Newly Diagnosed Glioblastomas : A Prospective Multicenter Study of Korean Patients

OBJECTIVE: This study was performed to determine the safety and outcome of concurrent chemoradiotherapy (CCRT) and adjuvant chemotherapy with temozolomide for Korean patients with a newly diagnosed glioblastoma. METHODS: Patients were recruited from four institutions between 2004 and 2007. The patients received fractionated focal irradiation in daily fractions of 2 Gy given 5 days per week for 6 weeks and daily temozolomide, followed by 6 cycles of adjuvant temozolomide. The primary endpoint was overall survival (OS) and the secondary endpoints were progression-free survival (PFS), response, and safety. RESULTS: A total of 103 patients were enrolled in this study. Ninety-six patients (93%) completed the CCRT and 54 patients (52%) received 6 cycles of adjuvant temozolomide. The response rate was 73% (53/73) and the tumor control rate was 92% (67/73). Of the 96 patients who completed the CCRT, the median OS was 18.0 months and the 1- and 2-year OS rates were 74 and 38%, respectively. The median PFS was 10.0 months and the 1- and 2-year PFS rates were 33 and 16%, respectively. The only significant prognostic factor of survival was the extent of surgical resection (p<0.05). CCRT resulted in grade 3 or 4 hematologic toxic effects in 8% of patients. No opportunistic infections were noted. CONCLUSION: This study is the first prospective multi-institutional report of CCRT and adjuvant chemotherapy with temozolomide for patients with a newly diagnosed glioblastoma in Korea. The current protocol may prolong the survival of Korean patients with a glioblastoma and may be tolerable in terms of toxicity.ope

The Korean Society for Neuro-Oncology (KSNO) Guideline for WHO Grade III Cerebral Gliomas in Adults: Version 2019.01

BACKGROUND: There was no practical guideline for the management of patients with central nervous system tumor in Korea in the past. Thus, the Korean Society for Neuro-Oncology (KSNO), a multidisciplinary academic society, developed the guideline for glioblastoma successfully and published it in Brain Tumor Research and Treatment, the official journal of KSNO, in April 2019. Recently, the KSNO guideline for World Health Organization (WHO) grade III cerebral glioma in adults has been established. METHODS: The Working Group was composed of 35 multidisciplinary medical experts in Korea. References were identified by searches in PubMed, MEDLINE, EMBASE, and Cochrane CENTRAL databases using specific and sensitive keywords as well as combinations of keywords. Scope of the disease was confined to cerebral anaplastic astrocytoma and oligodendroglioma in adults. RESULTS: Whenever radiological feature suggests high grade glioma, maximal safe resection if feasible is globally recommended. After molecular and histological examinations, patients with anaplastic astrocytoma, isocitrate dehydrogenase (IDH)-mutant should be primary treated by standard brain radiotherapy and adjuvant temozolomide chemotherapy whereas those with anaplastic astrocytoma, NOS, and anaplastic astrocytoma, IDH-wildtype should be treated following the protocol for glioblastomas. In terms of anaplastic oligodendroglioma, IDH-mutant and 1p19q-codeletion, and anaplastic oligodendroglioma, NOS should be primary treated by standard brain radiotherapy and neoadjuvant or adjuvant PCV (procarbazine, lomustine, and vincristine) combination chemotherapy. CONCLUSION: The KSNO's guideline recommends that WHO grade III cerebral glioma of adults should be treated by maximal safe resection if feasible, followed by radiotherapy and/or chemotherapy according to molecular and histological features of tumors.ope