Showing papers by "Hee-Won Jung published in 2013"

The role of adjuvant radiotherapy in atypical meningioma

Abstract: The object of this study was to analyze treatment outcomes and to identify the prognostic factors, with a focus on the role of adjuvant radiotherapy (ART), predicting disease progression in atypical meningiomas. From 1997 to 2011, 83 patients with meningioma were included in this study. All patients were histologically confirmed as atypical meningioma and were treated with surgical resection with or without ART. As primary therapy, 27 patients received surgical resection followed by ART, and 56 received no adjuvant therapy. Of 83 evaluable patients, 55 (66.3 %) patients underwent complete resection. The median ART dose was 61.2 Gy and their median age was 52 years. The 5- and 10-year actuarial overall survival rates were 90.2 and 62.0 %, and the 5- and 10-year progression-free survival (PFS) rates were both 48.0 %, with a median follow-up of 43.0 months. Addition of ART (p = 0.016) and complete tumor resection (p = 0.002) were associated with superior PFS. When stratified to four groups according to resection status and ART, the groups of patient with incomplete resection without ART showed significantly worse PFS compared to other three groups (p < 0.001). In conclusion, surgical resection followed by ART led to lower local tumor progression in patients with atypical meningioma defined by the updated 2000/2007 WHO classification. Our results may contribute to the routine use of ART, especially after incomplete resection, until the outcomes of ongoing prospective trials are available.

Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents.

Abstract: UNLABELLED Left ventricular (LV) thrombus is one of the risk factors for systemic thromboembolism. The aims of this study were to compare the long-term clinical outcomes of LV thrombus using current therapeutics, anticoagulation, operative treatment, and antiplatelet agents and to identify independent predictors of systemic thromboembolism. METHODS We screened 86,374 patients for intracardiac thrombus in the electronic medical records and imaging databases. Records of 62 patients with LV thrombus, diagnosed between May 2003 to November 2011, were comprehensively reviewed regarding baseline characteristics, imaging data and thrombus outcomes, thromboembolic events and treatment complications by treatment group. RESULTS The majority (80.6%) had ischemic etiology. Systemic thromboembolism developed in 18 patients; 8 (45%) were post-treatment thromboembolisms while 10 events occurred before treatment began. No post-treatment thromboembolism occurred in the operative treatment group; in contrast, 7 post-treatment thromboembolisms occurred in anticoagulation group (17%) (Log rank p= 0.175). Independent predictors of post-treatment thromboembolism were dilated cardiomyopathy (HR 61.30, p= 0.001), previous cerebrovascular events (HR 7.06, p= 0.042), female gender (HR 7.11, p= 0.031), and echocardiographic left ventricular end-diastolic diameter (HR 1.15, p= 0.047). CONCLUSIONS In this study, the rate of post-treatment thromboembolism was not significantly different among the treatment groups; however, operative treatment tended towards less post-treatment thromboembolism than other treatment groups.

A practical scoring system to determine whether to proceed with surgical resection in recurrent glioblastoma.

Abstract: DepartmentofNeurosurgery,SeoulNationalUniversityCollegeofMedicine,SeoulNationalUniversityHospital(C.-K.P., D.G.K., H.-W.J.); Department of Neurosurgery,Asan Medical Center, Universityof Ulsan CollegeofMedicine(J.H.K.);andDepartmentofNeurosurgery,SamsungMedicalCenter,SungkyunkwanUniversitySchoolof Medicine, Seoul, South Korea(D.-H.N., S.-B.C., H.J.S.); Department of Neurosurgery, Seoul NationalUniversity Bundang Hospital, Gyeonggi-do (C.-Y.K., Y.-H.K.); and Department of Internal Medicine (T.M.K.,S.-H.L., D.S.H.), Department of Radiology (S.H.C.), and Department of RadiationOncology (I.H.K.), SeoulNational University College of Medicine, Seoul NationalUniversity Hospital, Seoul, South KoreaBackground. To determine the benefit of surgical man-agement in recurrent glioblastoma, we analyzed a seriesof patients with recurrent glioblastoma who had under-gone surgery, and we devised a new scale to predicttheir survival.Methods. Clinical data from 55 consecutive patientswithrecurrentglioblastomawereevaluatedaftersurgicalmanagement. Kaplan–Meier survival analysis and Coxproportional hazards regression modeling were used toidentifyprognosticvariablesforthedevelopmentofapre-dictivescale.Afterthemultivariateanalysis,performancestatus(P ¼ .078)andependymalinvolvement(P ¼ .025)were selected for inclusion in the new prognostic scale.The devised scale was validated with a separate set of 96patients from3 different institutes.Results. A 3-tier scale (scoring range, 0–2 points) com-posed of additive scores for the Karnofsky performancestatus (KPS) (0 for KPS ≥ 70 and 1 for KPS , 70) andependymal involvement (0 for no enhancement and 1forenhancementoftheventriclewallinthemagneticres-onance imaging) significantly distinguished groups withgood(0points;mediansurvival,18.0months),intermedi-ate (1 point; median survival, 10.0 months), and poorprognoses (2 points; median survival, 4.0 months). Thenew scale was successfully applied to the validationcohort of patients showing distinct prognosis among thegroups (median survivals of 11.0, 9.0, and 4.0 monthsfor the 0-, 1-, and 2-point groups, respectively).Conclusions. Wedevelopedapracticalscaletofacilitatedecidingwhethertoproceedwithsurgicalmanagementinpatients with recurrent glioblastoma. This scale wasuseful for the diagnosis of prognostic groups and can beused to develop guidelines for patient treatment.Keywords: ependymal involvement, performance status,recurrent glioblastoma, scoring system,surgery.

The role of surgical resection in the management of brain metastasis: a 17-year longitudinal study.

Abstract: Advancements over the past generation have yielded several new treatment options for the management of brain metastases. However, surgical resection (SR) still remains the mainstay of treatment and is performed especially if decompression is required. The goal of this study was to evaluate the role of surgical resection for patients with brain metastases and to find the best indications for SR. SR as an initial treatment was performed in 157 patients. Among the 157 patients, 109 (69.4 %) and 17 (10.8 %) underwent adjuvant whole-brain radiotherapy and radiosurgery, respectively. Thirty-one (19.7 %) patients did not undergo adjuvant treatment. Overall survival, tumour recurrence, and clinical outcomes were evaluated. The clinical situation was classified based on the recursive partitioning analysis (RPA) class and Karnofsky performance scale (KPS). The overall median survival was 19.3 months. Median survival according to the extent of surgical resection was 20.4 months after gross total resection (GTR) and 15.1 months after subtotal resection (STR) (P = 0.016). The patients with stable primary extracranial cancer survived longer than patients with synchronous detection of extracranial cancer (P = 0.032). The RPA I class patients showed longer survival than the RPA II class patients (P = 0.047). This difference was more prominent in the GTR group than in the STR group (GTR, P = 0.022; STR, P = 0.075). The KPS score of the GTR group changed from 82.3 to 87.0 and that of the STR group changed from 79.2 to 77.1 (P = 0.001). Adjuvant treatment did not lead to a significant improvement in the survival and clinical outcome. Surgical resection may accomplish satisfactory outcomes with technical advancement. The best indications for SR for brain metastasis are RPA I class, stable extracranial cancer, and a planned GTR of the tumour. Even with the advancements in adjuvant therapy, surgical resection plays a major role in the management of brain metastasis.

Hearing Outcomes After Stereotactic Radiosurgery for Unilateral Intracanalicular Vestibular Schwannomas: Implication of Transient Volume Expansion

Abstract: Purpose We evaluated the prognostic factors for hearing outcomes after stereotactic radiosurgery (SRS) for unilateral sporadic intracanalicular vestibular schwannomas (IC-VSs) as a clinical homogeneous group of VSs. Methods and Materials Sixty consecutive patients with unilateral sporadic IC-VSs, defined as tumors in the internal acoustic canal, and serviceable hearing (Gardner-Roberson grade 1 or 2) were treated with SRS as an initial treatment. The mean tumor volume was 0.34 ± 0.03 cm 3 (range, 0.03-1.00 cm 3 ), and the mean marginal dose was 12.2 ± 0.1 Gy (range, 11.5-13.0 Gy). The median follow-up duration was 62 months (range, 36-141 months). Results The actuarial rates of serviceable hearing preservation were 70%, 63%, and 55% at 1, 2, and 5 years after SRS, respectively. In multivariate analysis, transient volume expansion of ≥20% from initial tumor size was a statistically significant risk factor for loss of serviceable hearing and hearing deterioration (increase of pure tone average ≥20 dB) (odds ratio=7.638; 95% confidence interval, 2.317-25.181; P =.001 and odds ratio=3.507; 95% confidence interval, 1.228-10.018; P =.019, respectively). The cochlear radiation dose did not reach statistical significance. Conclusions Transient volume expansion after SRS for VSs seems to be correlated with hearing deterioration when defined properly in a clinically homogeneous group of patients.

The enigma of bifocal germ cell tumors in the suprasellar and pineal regions: synchronous lesions or metastasis?

Abstract: Object Intracranial germ cell tumors (GCTs) frequently present with bifocal lesions in both the suprasellar and pineal areas. The pathogenesis of these bifocal GCTs has been the subject of controversy. Bifocal GCTs may be caused by synchronous tumors or by metastatic spread of tumor cells from one site to the other. The prognosis associated with bifocal GCTs has also been a cause of concern. Methods The authors constructed a single-institution patient cohort comprising 181 patients with intracranial GCTs. The clinical characteristics of bifocal GCTs were compared with those of suprasellar and pineal GCTs. Results Bifocal GCTs were observed in 23 patients (12.8%). Eighteen patients presented with bifocal GCTs that were diagnosed as germinomas, but 5 patients exhibited mixed GCTs. Analyses of age distributions and comparisons of tumor sizes were compatible with a model of a metastatic origin of bifocal GCTs. Eleven patients (47.8%) presenting with bifocal GCTs exhibited tumor seeding at presentation. Tumor ...

Central neurocytoma: long-term outcomes of multimodal treatments and management strategies based on 30 years' experience in a single institute.

Abstract: BACKGROUND: A thorough investigation of the long-term outcomes of central neurocytoma (CN) after different treatments is required to establish optimal management strategies. OBJECTIVE: We retrospectively reviewed the long-term clinical outcomes of patients with CN according to various treatments and suggest treatment strategies based on 30 years of experience in a single institution. METHODS: Fifty-eight consecutive patients with CN were treated at our institution between 1982 and 2008. Patient demographics, overall survival, local control rates according to multimodal treatments, and functional outcomes were evaluated. The mean clinical and radiological follow-up periods were 119 months (range, 18-304 months) and 98 months (range, 13-245 months), respectively. RESULTS: The initial treatment modality was classified into 4 subgroups: operation only (34 patients), operation followed by radiation therapy (7 patients) or radiosurgery (7 patients), and radiosurgery alone (10 patients). The actuarial overall survival was 91% at 5 years and 88% at 10 years. The actuarial overall survival and local tumor control rate did not differ significantly according to the various treatments and the initial extent of the surgical resection. However, functional outcomes, such as the postoperative seizure outcome at the last follow-up, differed according to the surgical approach. CONCLUSION: The long-term clinical outcomes of CN after multimodal treatment seem to be excellent. Our study suggests that treatment strategies for CN should focus on the patient's quality of life, as well as on tumor control, because of the benign nature of CN.

Blood Pressure Variability and Cognitive Function in the Elderly.

Abstract: With the increase in the aging population, it is important to understand the individual diseases and their interactions which are prevalent and have a great impact on the health status of the elderly. Hypertension is one of the most common diseases in older age and may impact the health status because it is the main risk factor for cardiovascular and cerebrovascular diseases such as heart failure and stroke. Recently, much evidence has been accumulated showing that hypertension plays an important role in the development and progression of cognitive impairment and dementia. Cerebral hypoperfusion secondary to severe atherosclerosis resulting from long-standing hypertension may be a major biological pathway linking high blood pressure (BP) to cognitive decline and dementia. Furthermore, increased BP variability has also been reported to be significantly associated with white matter hyperintensities and brain atrophy, which are predisposing conditions of dementia, depression, and falls in the elderly even after adjusting for BP levels and other confounding variables. Several mechanisms have been shown to be involved in the association between BP variability and cognitive impairment in elderly individuals. In addition to an increased cerebral blood flow fluctuation, neurohumoral activation, endothelial dysfunction, inflammation, and oxidative stress have been suggested to be the underlying mechanisms. However, clinical trials provide limited evidence for a protective effect of antihypertensive therapy against dementia and stroke-related cognitive decline. In this article, we aimed to review the existing evidence of the connection between BP variability and cognitive impairment in elderly people.

Prognostic factors for visual recovery after transsphenoidal pituitary adenectomy.

Abstract: Objectives. Pituitary adenomas often cause deficits in visual acuity (VA) and visual field (VF) due to compression of the optic chiasm. This study is to identify factors most likely to predict the prognosis of VA and VF after transsphenoidal pituitary adenectomy. Materials and methods. Clinical records of patients who underwent transsphenoidal pituitary adenectomy were retrospectively reviewed. Data analysed included systemic and visual symptom duration, tumour size, presence of suprasellar tumour extension, histological classification of tumour, VA, and VF. VFs were determined using the Goldmann VF test and quantified according to methods outlined by the American Medical Association. Results. One-hundred and seventy eyes from 85 patients were included. Systemic and visual symptom duration, pre- and postoperative tumour size, and age did not correlate with postoperative VA or VF score. Patients with normal preoperative VA had a better postoperative VA than that of patients with preoperative VA of ...

Radiosurgery for central neurocytoma: long-term outcome and failure pattern

Abstract: Despite the favorable outcomes of radiosurgery for central neurocytoma (CN), these results are based on case series that included a limited number of patients and short follow-up periods because of the scarcity of CN. Because CN is a benign tumor with an indolent clinical course, long-term follow-up and analysis of failure pattern are required for the establishment of the role of radiosurgery in the management of CN. Twenty consecutive patients (10 patients who received Gamma Knife radiosurgery (GKRS) as a primary treatment and 10 patients who received GKRS as a secondary treatment) with a radiological follow-up period ≥36 months were included in this study. The mean radiological follow-up duration was 100 months (range 43–149 months). The mean tumor volume was 10.4 cm3 (range 0.4–36.4 cm3) and the mean marginal dose was 15.4 Gy (range 9–20 Gy). Local control failure was found in six patients at the last radiological follow-up. Overall actuarial local control rates were 89.5 % at 5 years and 83.1 % at 10 years. The primary GKRS group included two cases with local failure, with cyst formation or local recurrence. In contrast, in the secondary GKRS group, local control failure was found in four cases (including three cases with an “out-of-field recurrence” pattern) and occurred earlier compared with the primary GKRS group. Our study suggests that GKRS could be a primary or secondary treatment option for CN. However, long-term radiological follow-up is mandatory. In particular, more careful consideration during margin delineation and planning procedure is required in the secondary GKRS group.

The value of temozolomide in combination with radiotherapy during standard treatment for newly diagnosed glioblastoma

Abstract: The current best standard care for glioblastoma still has limitations and unsatisfactory outcomes in patients with an unmethylated O-6-methylguanine-DNA methyltransferase (MGMT) promoter. Whether the effects of temozolomide are primarily due to its concomitant use with radiotherapy or are also mediated by their independent use in the adjuvant phase remain unclear. To validate the concomitant use of temozolomide in the standard protocol, we compared the overall survival of two prospective patient groups: one treated with radiotherapy alone followed by adjuvant temozolomide (RT → TMZ group) and the other treated with concomitant radiotherapy and temozolomide followed by adjuvant temozolomide (CCRT-TMZ group). Each patient in the RT → TMZ group (n = 25) was matched with two patients in the CCRT-TMZ group (n = 50) with respect to age, extent of resection, MGMT promoter methylation status, and postsurgical performance status to minimize the influence of confounding factors. In patients with MGMT promoter methylation, the CCRT-TMZ group showed superior overall survival (OS; median, 41.0 months) and progression-free survival (PFS; median, 24.0 months) compared with the RT → TMZ group. However, the OS and PFS did not differ between the CCRT-TMZ and the RT → TMZ groups in the patients without MGMT promoter methylation. Although this data is from a retrospective analysis using small number of patients, the study might indicate that concomitant use of temozolomide with radiotherapy is a crucial step in the standard treatment for glioblastoma patients with MGMT promoter methylation. And the use of temozolomide, either concurrently or by adjuvant after radiotherapy, remains a questionable value for those with an unmethylated MGMT promoter.

Seizures during the management of high-grade gliomas: clinical relevance to disease progression

Abstract: This study was performed to evaluate the incidence of seizures with its implications on disease progression and the diagnostic value of post-ictal magnetic resonance images (MRI) during the management of high-grade gliomas (HGGs). A total of 406 consecutive patients with newly diagnosed HGGs were retrospectively reviewed. The incidence of seizures during the management was investigated. In patients who experienced a seizure, the causality between seizures and disease progression was assessed by pre-ictal, post-ictal (<1 month), and follow-up (<3 months) MRI. After a median follow-up of 17.4 months (range 0.1-88.3), seizures developed in 127 patients (31 %). Of the 127 patients, radiological progression at the post-ictal MRI was found in 83 patients (65 %) and the follow-up MRI confirmed progression in 79 patients (62 %). Four other patients (3 %) were shown to be progression-free. Among those without radiological progression at the post-ictal MRI, the follow-up MRI confirmed progression-free in 31 patients (24 %); however, 13 patients (10 %) revealed eventual progression. In the patients with a seizure, absence of preoperative seizures (p = 0.003), <95 % tumor resection (p = 0.001), and pre-ictal Karnofsky Performance Scale score ≤ 70 (p = 0.025) were significantly associated with disease progression. During the management of HGG, 31 % of patients experienced seizures; of these patients, 72 % harbored progressive disease. The post-ictal MRI is useful for detecting disease progression; however, there are pitfalls. Clinical settings should be considered together for diagnosing disease progression in patients with seizures.

Feasibility of endoscopic endonasal approach for recurrent pituitary adenomas after microscopic trans-sphenoidal approach.

Abstract: OBJECTIVE The surgical approach for recurrent pituitary adenoma after trans-sphenoidal approach (TSA) is challenging. We report the outcomes of the endoscopic TSA for recurrent pituitary adenoma after microscopic TSA. METHODS From February 2010 to February 2013, endoscopic TSA was performed for removal of 30 recurrent pituitary adenomas after microscopic TSA. Twenty-seven (90%) patients had a clinically non-functioning pituitary adenoma. Twenty-four (80%) patients suffered from a visual disturbance related to tumor growth. The clinical features and surgical outcomes were retrospectively analyzed for the ophthalmological, endocrinological, and oncological aspects. RESULTS The mean tumor volume was 11.7 cm(3), and gross total resection was achieved in 50% of patients. The volumetric analysis based on the postoperative MR showed that the mean extent of resection rates were 90%. Vision was improved in 19 (79%) of 24 patients with visual symptoms, and endocrinological cure was achieved in all of three functioning pituitary adenomas; however, the post-operative follow-up endocrinological examination revealed a new endocrinological deficit in one patient. Two patients required antibiotics management for post-operative meningitis. CONCLUSION The endoscopic TSA can be an effective treatment option for recurrent pituitary adenoma after microscopic TSA with acceptable outcome.

Skeletal Muscle Mass as a Predictor of Mortality in the Elderly Population

Abstract: Background/Aims: A U-shaped relationship between body mass index (BMI) and mortality has been reported. However, controversy exists as to whether skeletal muscle mass affects mortality in healthy older adults. We evaluated the independent association of BMI or appendicular skeletal muscle mass (ASM) with mortality in elderly people. Methods: A total of 4,261 consecutive subjects older than 65 years who underwent health examinations at Seoul National University Gangnam Center between 2005 and 2009 were included in the analysis. ASM, ASM/height² and ASM/weight were estimated by bioelectrical impedance analysis. Sarcopenia was defined as a relative skeletal muscle mass of 1-2 SD below (class I) or more than 2 SD below (class II) the gender-specific mean for healthy young adults. BMI was grouped into five groups (A-E). Results: During the follow-up period (27.2 ± 13.5 months), 63 subjects died. The subjects who died were significantly older and had a male predominance, increased levels of inflammatory markers and poor nutritional statuses. In a fully adjusted Cox proportional hazards model, BMI was not associated with mortality. However, class I sarcopenia (HR 2.11, 95% CI 1.17 3.79) and class II sarcopenia (HR 3.47, 95% CI 1.62-7.43), defined by ASM/height², were related to all-cause mortality. This association was not observed when sarcopenia was defined by ASM/weight. Class II sarcopenia defined by ASM/height² was associated with cancer-related mortality (HR 5.73, 95% CI 2.22-14.78), but not with cardiovascular mortality (HR 1.56, 95% CI 0.17 14.27). Conclusions: This study indicates that lower skeletal muscle mass is a risk marker for cancer-related and all cause mortality in Korean elderly people. (Korean J Med 2013;85:167-173)

Primary Intracerebral Malignant Fibrous Histiocytoma: CT, MRI, and PET‐CT Findings

Abstract: Primary intracranial malignant fibrous histiocytoma (MFH) is an extremely rare entity. A few reported cases have been associated with factors such as a previous history of radiation therapy or surgical trauma. We report on a rare case of intracerebral MFH in a previously healthy 47-year-old man, which was initially presumed to be a high-grade glioma. Conventional as well as advanced magnetic resonance sequences, including diffusion-weighted image and perfusion-weighted image, were used in characterization of the mass.

Mobile Computed Tomography : Three Year Clinical Experience in Korea

Abstract: Objective Obtaining real-time image is essential for neurosurgeons to minimize invasion of normal brain tissue and to prompt diagnosis of intracranial event. The aim of this study was to report our three-year experience with a mobile computed tomography (mCT) for intraoperative and bedside scanning.

Stereotactic radiosurgery for brain metastases from hepatocellular carcinoma

Abstract: The purpose of this study is to investigate the possible role of stereotactic radiosurgery (SRS) in the management of patients with brain metastases from hepatocellular carcinoma (HCC). Thirty-two consecutive patients with 80 brain metastases from HCC were treated with SRS. Twenty-eight (87.5 %) patients were male, and the mean age of the patients was 54 ± 12 years (range 22–73). Twenty-seven (84.4 %) patients were classified as RTOG RPA Class 2. The mean tumor volume was 6.14 ± 11.3 cm3 (range 0.01–67.3). The mean marginal dose prescribed was 20.1 ± 3.6 Gy (range 10.0–25.0). The median overall survival time after SRS was 11.3 ± 5.8 weeks (95 % CI 0–22.7). A greater total volume of brain metastases (>14 cm3) was the only independent prognostic factor (HR = 2.419; 95 % CI 1.040–5.624; p = 0.040). The actuarial control rate of brain metastases was 51.3 % at 4 months after SRS. The prescribed marginal dose (>18 Gy) was significantly related with the actuarial tumor control (HR = 0.254; 95 % CI 0.089–0.725; p = 0.010). The prognosis of patients with brain metastases from HCC is dismal even with the modern technology of radiosurgery. The marginal dose prescribed should be reevaluated to improve upon the current poor local control rates.

The Pulse of Asia

Abstract: s: The Pulse of Asia www.karger.com/pls © 2013 S. Karger AG, Basel