The sequential accumulation of independent genetic alterations is essential for glioma initiation and progression. We describe the recent concept of molecular pathway abnormalities in malignant gliomas as follows : (1) Signal transduction system (EGF/EGFR, PDGF/PDGFR, Ras/MAPK, PI3K-PTEN-Akt-mTOR), (2) Signal regulation system (TP53, MDM2, PTEN), and (3) cell cycle machinery system (cyclin D, cdk4/6, p16^<INK4a>, p14^<ARF>, Rb). Identifying the gene abnormalities of malignant glioma is important not only in understanding the biological behavior of the tumor, but also in estimating each patient's prognosis as well as planning therapeutic strategies.

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A systematic review was conducted to develop guidelines for radiotherapy in adult patients with newly diagnosed malignant glioma. MEDLINE was searched to identify randomized trials and meta-analyses for radiotherapy. Pooling of six randomized trials detected a significant survival benefit favouring post-operative radiotherapy compared with no radiotherapy. Two randomized trials demonstrated no significant difference in survival rate for whole brain radiation versus more local fields that encompass the enhancing primary plus a 2 cm margin. A randomized trial detected a small improvement in survival with 60 Gy in 30 fractions over 45 Gy in 20 fractions. Radiation dose intensification with hyperfractionation and brachytherapy have not demonstrated superior survival rates compared with conventionally fractionated doses of 50-60 Gy. There have been no report on randomized trials or meta-analyses of stereotactic irradiation as linac radiosurgery or gamma knife campared with conventional radiation. Clinical results in a case-control study of heavy charged ion therapy using carbon and boron neutron capture therapy demonstrated a improvement in survival. Post-operative external beam radiotherapy is recommended as a standard therapy for patients with malignant glioma. The high-volume should incorporate the enhancing tumor plus a limited margin (e.g. 2 cm) for planning the target volume, and the total dose delivered should be in the range of 50-60 Gy in fraction sizes of 1.8-2.0 Gy. Radiation dose intensification, brachytherapy and stereotactic irradiation are not recommended as standard care. Meta-analysis or randomized trials are needed for establishment of particle therapy in Japan

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This study retrospectively examined the median survival times in 370 patients with malignant astrocytic tumors treated in our institute between 1982 and 2003 ; follow-up review of these patients continued through the end of April, 2004. The study period was divided into three treatment eras as follows : 1982 to 1988, when patients underwent no preoperative magnetic resonance (MR) imaging evaluation (pre MR era) ; 1989 to 1996, when patients underwent preoperative MR imaging (post MR era) ; and after 1997, when patients underwent preoperative MR imaging with functional brain mapping and intraoperative neuronavigation system monitoring (post MAP era). Patients with glioblastoma (GB) treated after 2000 were separately classified as the 21st century era because of the large number of patients compared with other eras, and changes to radiation treatment protocols. One hundred and eighty-one patients had anaplastic astrocytoma (AA) and 189 had GB. The patients were also divided into younger (under 60 years) and elderly (60 years or over) groups, and total resection and partial resection or biopsy groups. Survival rates were determined using the Kaplan-Meier method. The statistical significance of differences between life table curves was determined using the logrank test. The median survival time of 62 patients with GB in the 21st century era was 23.1 months. The median survival time in the elderly group was significantly shorter than in the younger group in both patients with AA (p=0.0004) and GB (p<0.0001). The median survival time of patients with AA or GB in both younger and elderly groups tended to improve according to treatment advances. The total resection group had significantly longer median survival time than the partial resection or biopsy group, in both patients with AA (p<0.0001) and GB (p=0.0002) and in the younger (AA : p=0.0001, GB : p=0.0040) and elderly (AA : p=0.0230, GB : p=0.0265) groups. Therefore, the outcomes for patients with malignant astrocytic tumors improved according to treatment advances, especially following total resection, despite inhomogeneity in diagnostic criteria, determination of the extent of tumor removal, and treatment protocols.

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We investigated the efficacy of an aggressive surgical treatment followed by subsequent radiochemotherapy for patients with multiple brain metastases derived from breast cancer. We compared 29 patients with multiple brain metastases with 15 patients with single metastasis. The means survival times (mean±SEM) of the multiple and single groups were 295±38 and 478±145 days, respectively (log-rank. p>0.5). The present study showed that the combined treatment with recently developed chemotherapy and radiation therapy brought excellent benefits in some cases with multiple brain metastases derived from breast cancer.

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We report three cases of severe traumatic basal ganglia hemorrhage TBGH accompanied with multiple injuries. Case 1 was a 33-year-old man with right putaminal hematoma. Case 2 was a 51-year-old man with left putaminal hematoma. Case 3 was an 8-year-old boy with left putaminal hematoma which presented enlargement on serial CT. All patients were involved in traffic accidents and had accompanying relevant associated extracranial injuries. All cases underwent surgery to evacuate the hematoma and were treated with intentional normothermia therapy. Although intracranial pressure (ICP) could be controlled in all patients, there were two complications during the postoperative state : a disseminated intravascular coagulation (DIC) occurred in Case 1 and upper gastrointestinal (GI) bleeding brought death in Case 3. Concerning management of patients with severe TBGH, we should investigate associated injuries and perform surgical evacuation in patients with large hematoma or in those in whom there is hematoma volume enlargement or elevated ICP. Furthermore, we should take care of not only ICP control but also systemic complications including DIC and upper GI bleeding.

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We reported two rare cases of thyrotropin (TSH)-secreting pituitary microadenoma. Case 1 : A 41-year-old female presented with an over 10-year history of hyperthyroidism and diabetes mellitus. Not only her magnetic resonance imaging (MRI) suggested a microadenoma, but also in the endocrinological study, she showed inappropriately detectable serum thyrotropin levels despite elevated thyroid hormones (syndrome of inappropriate secretion of TSH : SITSH). The tumor was removed by transsphenoidal surgery. After surgery, the patient's disordered hormone level improved. Case 2 : A 33-year-old female was suspected of having subacute thyroiditis. On her endocrinological examination, even though her serum free thyroxine level was elevated, her serum TSH level was an inappropriately normal. A dynamic study of her MRI revealed a less enhanced lesion in a 7 mm diameter. Preoperative administration of sandostatin^[○!R] resulted in good control of thyrotropin and hyperthyroidism as well as tumor shrinkage. Transsphenoidal surgery was safely performed and the tumor was totally resected. Her elevated hormone levels improved. Thyrotropin-secreting adenomas have an invasive, fibrous and firm nature, which makes it difficult to achieve surgical remission. We investigated successful treatments to obtain endocrinological remission of TSH-secreting pituitary adenoma.

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