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Progress in Neurological Surgery

Takashi Komori, Yoshihiro Muragaki, Mikhail F Chernov
Current World Health Organization (WHO) classification of the neuroepithelial tumors is cell lineage-oriented and based on a presumed developmental tree of the central nervous system (CNS). It defines three main groups of gliomas, namely astrocytomas, oligodendrogliomas, and ependymomas, and additionally presumes their 4-tiered histopathological grading (WHO grades I to IV). Nevertheless, the impact of tumor pathology on clinically related parameters may be frequently much better predicted by genetics, than by histological appearance of the lesion...
2018: Progress in Neurological Surgery
Andrea Pace, Veronica Villani
Clinicians dealing with patients affected by malignant brain tumors are frequently involved in providing palliative and supportive care, particularly at the end of life. It requires a multidisciplinary approach by a well-trained specialized neuro-oncology team. Early initiation of palliative care integrated with standard anticancer therapy may be effective for symptom management and results in improvement of the quality of life. However, studies specifically addressing these issues are very limited, thus do not allow the creation of any reliable evidence-based guidelines...
2018: Progress in Neurological Surgery
Julija Andrejeva, Olesya V Volkova
Patients with brain tumor frequently experience a combination of physical, cognitive, and communication deficits. These may cause severe psycho-emotional stress altering biological and mental conditions and complicating the course of the primary disease, and thus necessiate physical and psychological rehabilitation. While existing data on the effectiveness of such treatment in patients with intracranial glioma are limited and inconsistent, it is possible to suggest that systematic and multidisciplinary rehabilitation plays a very important therapeutic role and leads to improvements in functional independence, mental and emotional state, and quality of life...
2018: Progress in Neurological Surgery
Jethro Hu, Santosh Kesari
Are truly effective therapies for glioma finally within reach? An explosion of technologies and treatments in recent years brings with it the hope that the revolution is nigh, but decades of gains that can at best be considered incremental understandably temper optimism. Concepts such as "targeted therapy" and "personalized medicine" have grabbed the attention of the oncology community for over a decade; yet when applied to glioblastoma, our initial efforts have amounted to running into battle with limited armaments and an incomplete understanding of the enemy...
2018: Progress in Neurological Surgery
Jasmin Jo, Patrick Y Wen
Angiogenesis plays a critical pathologic role in malignant gliomas. In the past few years, numerous studies using bevacizumab (BEV), a humanized monoclonal antibody against vascular endothelial growth factor (VEGF), have been conducted in patients with brain tumors. Current evidence suggests that such treatment produces favorable results in patients with recurrent glioblastoma multiforme (GBM), but is not associated with any benefits in newly diagnosed GBM and recurrent WHO grade III gliomas. Initial experience using BEV for management of central nervous system radiation necrosis demonstrated radiographic improvement in the majority of cases, but optimal dose and treatment duration in such cases still remain in question...
2018: Progress in Neurological Surgery
Riccardo Soffietti, Federica Franchino, Michela Magistrello, Alessia Pellerino, Roberta Rudà
Histopathological typing and grading are the cornerstones of the World Health Organization classification of the central nervous system tumors. It provides clinicians with information on the natural course of the disease and thus guides therapeutic choices. Nonetheless, patients with histologically identical tumors may have different outcomes and response to therapy. In recent years, extensive research has been done on three molecular markers in adult gliomas, namely MGMT promoter methylation, 1p/19q co-deletion, and IDH1/IDH2 mutations...
2018: Progress in Neurological Surgery
Keita Terashima
Under specific indications, chemotherapy may play an important role in the treatment of pediatric patients with intracranial gliomas. It can be effectively administered in inoperable low-grade tumors, particularly with the use of combination regimens based on carboplatin and vincristine. In very young children with high-grade gliomas (HGG), chemotherapy may result in control of tumor growth, which allows to postpone fractionated radiation therapy (FRT). At the same time, in difference with adults, there is no current evidence that addition of chemotherapy to aggressive surgical resection followed by FRT has any positive impact on survival of pediatric patients with non-pontine HGG...
2018: Progress in Neurological Surgery
Jan Drappatz, Frank Lieberman
Oligodendrogliomas are therapy-responsive tumors, which have better prognosis compared to their astrocytic counterparts. The goal of treatment in such cases is not only prolongation of the patients' survival, but maintaining high neurologic functioning and quality of life. Traditionally, after maximal surgical resection fractionated radiation therapy was given. However, prospective randomized trials comparing irradiation alone and its combination with chemotherapy demonstrated strong impact of the latter on prolongation of overall survival in 1p/19q co-deleted anaplastic and "high-risk" low-grade gliomas...
2018: Progress in Neurological Surgery
Yoshitaka Narita
The effectiveness of chemotherapy or chemoradiotherapy for diffuse astrocytoma (DA) has been largely unknown until recently. However, a randomized controlled study (RTOG 9802) showed that adding of procarbazine, CCNU, and vincristine (PCV) chemotherapy to fractionated radiotherapy (FRT) in patients with "high-risk" WHO grade II gliomas, including DA, has significant positive impact on both progression-free survival and overall survival. Effectiveness of temozolomide (TMZ) in cases of low-grade gliomas was also reported, and a randomized phase III trial comparing FRT alone or in combination with TMZ in cases of unresectable DA (JCOG 1303) is currently ongoing...
2018: Progress in Neurological Surgery
Vinay K Puduvalli, Nguyen Hoang
Malignant gliomas have been historically considered unresponsive to chemotherapy due to their intrinsic resistance to conventional anticancer medications and the role of the blood-brain barrier in preventing access of the cytotoxic agents to the tumor. However, recent studies have demonstrated the efficacy of specific drugs in subsets of patients with high-grade astrocytomas that has revived the enthusiasm for the role of systemic chemotherapy against these neoplasms. Temozolomide, a monofunctional alkylator, was the first chemotherapeutic agent to definitively improve survival in adults with newly diagnosed glioblastoma used in combination with radiation therapy with the most pronounced effect being in a subgroup of tumors with MGMT promoter methylation...
2018: Progress in Neurological Surgery
Randi J Cohen, Minesh P Mehta
Malignant gliomas are the most common primary brain tumors and have devastatingly high mortality rates. Most recurrences are close to the surgical bed, despite adjuvant fractionated radiotherapy (FRT). Localized FRT to total dose of 60 Gy with concurrent and adjuvant temozolomide (TMZ) resulted in a statistically significant survival improvement of patients with newly diagnosed glioblastoma compared to those treated with FRT alone, and has emerged as the cornerstone of therapy. Despite this progress, long-term survival remains poor...
2018: Progress in Neurological Surgery
Rolf-Dieter Kortmann, Clemens Seidel, Klaus Müller, Franz Wolfgang Hirsch
Attainment of local control is a cornerstone in the management of brain tumors in children. Treatment of progressive low-grade and all high-grade gliomas traditionally includes resection followed by fractionated radiotherapy (FRT) or FRT alone in neoplasms not amenable to surgical removal. While in younger children chemotherapy is typically used as a first-line non-surgical management option, FRT in such patients remains the standard of salvage therapy. Recent improvements in techniques for radiation treatment planning and delivery allow conformal and selective coverage of the target volume with a prescribed dose, sparing adjacent normal tissues to assure maximal tumor control and minimal toxicity...
2018: Progress in Neurological Surgery
Silke Birgit Nachbichler, Friedrich-Wilhelm Kreth
Interstitial implantation of radioactive materials (brachytherapy [BT]) has been designed to protractedly deliver a high radiation dose to a well-defined target volume, while minimizing irradiation of the adjacent normal tissues. Even though promising results have been reported over time, the role of this treatment modality in the management of brain tumors is still poorly defined, and only a few centers worldwide apply it in clinical practice. Nevertheless, temporary or permanent interstitial implantation of low activity (<20 mCi) and low dose rate (≤10 cGy/h) iodine-125 (125I) seeds as possible therapy of intracranial gliomas is currently undergoing a definite revival, and several indications for its use have been identified...
2018: Progress in Neurological Surgery
Jeremy C Ganz
Low-grade gliomas (LGG), corresponding to WHO grades I and II, are an uncommon and heterogeneous group of tumors, which include several distinct histopathological types and subtypes. Because of their rarity, acquiring adequate data on which to base therapeutic decisions in such cases is difficult. According to present knowledge, it is reasonable to consider radiosurgery (in particular, Gamma Knife surgery) as a therapeutic option for some LGG. Nevertheless, there is a clear need for multicenter cooperation in order to augment the currently scanty data...
2018: Progress in Neurological Surgery
Ajay Niranjan, Edward A Monaco, Hideyuki Kano, John C Flickinger, L Dade Lunsford
Management options for residual or recurrent glioblastoma multiforme (GBM) are limited despite advances in surgical, chemotherapeutic, and radiotherapeutic techniques. Stereotactic radiosurgery (SRS) is often beneficial in such cases providing improved survival of patients, but still remains underutilized as part of the multimodality management of malignant gliomas. During the last 20 years, 297 patients with histologically proven residual or recurrent GBM underwent Gamma Knife surgery in the University of Pittsburgh...
2018: Progress in Neurological Surgery
Amol J Ghia
Fractionated radiotherapy (FRT) plays a critical role in the management of gliomas. For glioblastoma, the irradiation dose of 60 Gy in 30 fractions with concomitant and adjuvant temozolomide is currently considered as a standard of treatment, and further dose escalation has failed to be of benefit in clinical trials. Hypofractionated radiation schedules may be applied in elderly patients or those with poor performance status. For anaplastic gliomas, the high-risk region is typically irradiated to a total dose of approximately 60 Gy in 1...
2018: Progress in Neurological Surgery
Vivek Sudhakar, R Mark Richardson
Gene therapy is a clinical tool that may eventually provide therapeutic benefit to patients suffering from movement disorders through a few potential mechanisms: direct correction of the pathogenic mechanism, neuroprotection, neurorestoration or symptom control. The therapeutic mechanism is therefore dependent on knowledge of disease pathogenesis and the required temporal and spatial specificities of gene expression. An additional critical challenge is achieving the most complete transduction of the target structure while avoiding leakage into neighboring regions or perivascular spaces...
2018: Progress in Neurological Surgery
Neil Barua, Steven Gill
There has been substantial research interest in delivering therapeutic neurotrophic factors directly to the brain for the treatment of Parkinson's Disease (PD) and other movement disorders. Direct infusion of glial cell-line derived neurotrophic factor has been investigated in both pre-clinical models and clinical trials. In this chapter we discuss past and present research investigating the potential of direct drug delivery to the brain for the treatment of PD and other movement disorders.
2018: Progress in Neurological Surgery
Martijn Beudel, Hayriye Cagnan, Simon Little
Deep brain stimulation (DBS) has markedly changed how we treat movement disorders including Parkinson's disease (PD), dystonia, and essential tremor (ET). However, despite its demonstrable clinical benefit, DBS is often limited by side effects and partial efficacy. These limitations may be due in part to the fact that DBS interferes with both pathological and physiological neural activities. DBS could, therefore, be potentially improved were it applied selectively and only at times of enhanced pathological activity...
2018: Progress in Neurological Surgery
Ausaf A Bari, Jasmine Thum, Diana Babayan, Andres M Lozano
Deep brain stimulation (DBS) has become an established treatment for medically refractory movement disorders including Parkinson's disease, essential tremor, and dystonia. The field of DBS continues to evolve with advances in patient selection, target identification, electrode and pulse generator technology, and the development of more effective stimulation paradigms such as closed-loop stimulation. Furthermore, as the safety and efficacy of DBS improves through better hardware design and deeper understanding of its mechanisms of action, the indications for DBS will continue to expand to cover a wider range of disorders...
2018: Progress in Neurological Surgery
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