The new 2016 WHO brain tumor classification defines diffuse gliomas according to their IDH mutations and 1p/19q codeletion status. The diagnosis of oligodendroglioma requires both IDH mutations and 1p/19q codeletion. Oligoastrocytomas are categorized as either astrocytoma or oligodendroglioma, based on their IDH and 1p/19q status. Grade Ⅱ glioma is a progressive tumor and tends to develop malignant progression. Extensive and early surgical resection could improve patients’ outcome, but it should be noted that tumor recurrence often occurs even after total resection. Radiotherapy plays an important role in the treatment of grade Ⅱ or Ⅲ glioma, but long-term neurocognitive sequelae remain a serious problem. Recent clinical trials have shown a survival benefit from adding chemotherapy to radiotherapy compared with initial treatment using radiotherapy alone in grade Ⅱ or Ⅲ gliomas. The combination of procarbazine, lomustine, and vincristine has been shown to be effective. Several clinical trials, including temozolomide, are underway in Europe, U.S.A, and Japan. The optimal chemotherapeutic treatment will be determined following these. In the future, a molecular-based approach will define the tumor more narrowly, identify biomarkers, which predict the benefit of chemotherapy, develop targeted therapy, and eventually improve patients’ outcomes.
Prolonged survival in glioblastoma was achieved by supplementing temozolomide with radiotherapy and through adjuvant chemotherapy with temozolomide. Numerous trials have aimed to improve the survival time in glioblastoma, but no further advancements with chemotherapy have yet been achieved. In this review, we focus on standard therapy for newly diagnosed glioblastoma, comprising maximal resection followed by radiotherapy supplemented with temozolomide. Furthermore, we discuss the therapeutic efficacy of 5-aminolevulinic acid, carmustine wafers, bevacizumab, and tumor treating fields (TTF). In addition, we introduced the current social problems associated with glioblastoma treatment and its prospects for future research.
Primary central nervous system lymphoma (PCNSL) is a rare variant of non-Hodgkin’s lymphoma that is confined to the central nervous system. It comprises approximately 2 to 7% of primary central nervous system tumors and its incidence has been increasing in the immunocompetent, elderly patient population in Japan. Although high-dose methotrexate-based chemotherapy and whole-brain radiation therapy (WBRT) has improved disease control and survival in patients with PCNSL, most patients eventually experience a relapse, and uncontrolled PCNSL remains the primary cause of death. The aims of this review are to understand current treatment modalities and their problems, and novel trials that aim to improve survival and functional outcome. Currently, multiple treatment regimens using high-dose MTX-based multi-agent chemotherapy have been reported, but overall survival has plateaued around 3 to 4 years. Also, WBRT produces considerable neurotoxicity, especially in elderly patients. To improve functional outcome, it has been reported that deferring WBRT was associated with reduced neurotoxicity without worsening the prognosis. To reduce recurrence after MTX-based chemotherapy, encouraging results have been published recently of trials using high-dose myeloablative chemotherapy with autologous hematopoietic stem cell transplantation (HDCT/ASCT). This strategy could replace consolidation radiotherapy. Clarification of pathogenesis and pathophysiology, including molecular analysis, is indispensable in developing new treatment modalities. Additionally, it is imperative that novel treatment modalities should be developed to improve survival and functional outcome. Deferral of radiation therapy by introducing HDCT/ASCT is one such candidate.
The cellular mechanism of cancer growth and its metastases is complex. It is clear that any single treatment including surgical management cannot lead to the complete cure of cancer. As survival rates in patients of cancer continue to improve with the advancement of comprehensive management, it is likely that the prevalence of spinal tumors of vertebral or intramedullary metastases will certainly increase. Metastatic spine tumors may also carry the risk of significant aggravation of not only the patient’s activity of daily living but also their quality of life if the appropriate management is not given. Surgical treatment is truly one of the management options for patients of spinal metastases. Surgical options include vertebroplasty, decompression alone, decompression with fusion, combined anterior and posterior surgery and radical resection of the cancer. Surgeons need to assess the patient’s condition accurately and without delay. The primary objective of surgical treatment is to improve the paralysis and pain caused by spinal metastases. Finally, the indication for palliative or radical surgery should be determined from the point of view of multidisciplinary management.
As reported before, we have introduced a so-called “Neurosurgery Hotline” to detect stroke, severe head injuries and seizures without burdening duty doctors. All 556 registered cases during the last 3 years (January 2014 to December 2016) were compared to the registered 546 patients’ data between 2009 and 2012. The number of patients (557 vs. 546) and male/female ratio was almost the same as the former data (289/261 vs. 285/261) but the mean age increased with statistical significance (69.0 years old vs. 65.0). The concordance rates of initial symptoms with an exact stroke improved from 49.9% to 57.2% and number of properly referred patients also improved from 372 (68%) to 415 (74.6%). Speech disturbance (79.7%), paralysis (92.5%) and coma (93.3%) still showed high concordance rates. On the contrary, representative stroke mimics such as, benign paroxysmal positional vertigo (26 to 15), hypertension (22 to 11), inflammatory diseases (22 to 15) and hypoglycemia (10 to 1) significantly decreased. Our hotline system has improved and still works well as a method for broad stroke triage. Finally, further work to eliminate and decrease stroke mimics is the key to improving this system.
A 68-year-old man was admitted with disturbance of consciousness. Computed tomography (CT) scanning revealed subcortical hemorrhage in the right temporal lobe. Endoscopic hematoma evacuation was performed. Three months later, contrast-enhanced T1-weighted magnetic resonance imaging showed a mass with ring-like enhancement in the right temporal lobe. The patient underwent surgery, and the histological diagnosis was epithelioid glioblastoma. Focal irradiation and chemotherapy were performed. Fourteen days after the start of chemoradiotherapy, a CT scan of the chest revealed multiple round nodules and masses of varying size in both lungs, and small bilateral pleural effusions. The patient died of acute respiratory failure 32 days after the start of chemoradiotherapy. Autopsy revealed metastases in the lungs and heart. Although the relevant published literature is limited, extracranial metastasis of glioblastoma appears to be very rare and is associated with poor outcomes. The role of prognostic staging and optimal treatment selection should be investigated.