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Edward R. Laws Jr. and John S. O'Connor

✓ The energy-dependent membrane transport ATPases have been quantitatively determined in 59 human brain tumors and control cerebral cortex. The values for total ATPase were significantly decreased in the 11 types of brain tumors tested, while in the glioma group there was a consistent further decrease in ATPase with increasingly malignant types. The findings suggest that a deficiency in ATPase is a characteristic of neoplasia in the central nervous system.

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Ruben J. Saez, R. Jean Campbell, and Edward R. Laws Jr.

✓ A technique of organ culture based on a three-dimensional porous matrix was employed for chemotherapeutic trials on human malignant astrocytomas. This method allows neoplasms to retain the morphological identity and the histological characteristics they possess in vivo. Success in culture was greatest with high-grade astrocytomas, the majority of which showed definite infiltration of the matrix. Lowgrade tumors, if viable, did not display active penetration. Drug trials on eight malignant astrocytomas included BCNU, methyl CCNU, VP 16–213, and Solu-Medrol. Cyanide and luciferase were used as experimental metabolic toxins. Evidence of cytotoxicity was assessed qualitatively by histological changes on microscopic preparations of treated and control cultures. Microfluorometric determinations of reduced nicotinamide adenine dinucleotide (NADH) were applied to these trials in an effort to detect a quantitative biochemical index of drug effects. A variable rise in mean NADH levels above controls was recorded from the majority of treated cultures although correlation with microscopic changes was inconsistent. Because of its potential merits, organ culture may be a valuable tool for further work on pharmacological management of malignant gliomas.

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Edward R. Laws Jr., James C. Trautmann, and Robert W. Hollenhorst Jr.

✓ A review of recent experience with transsphenoidal surgery for lesions in and about the sella turcica establishes the value of this approach for the management of patients with visual loss. The lesions encountered consisted of pituitary adenoma in 45 cases, craniopharyngioma in 10 cases, and miscellaneous tumors involving the sella in the remaining seven cases. Sixty of the 62 patients in this series had quantitative determination of preoperative and postoperative visual status; after surgery, vision was improved in 81%, unchanged in 11%, and worse in 5%. Two patients (3%) died during the immediate postoperative period before their visual status could be evaluated.

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Thomas J. Rosenbaum, O. Wayne Houser, and Edward R. Laws

✓ The authors report a case of pituitary apoplexy occurring several hours after carotid angiography. The event was associated with stupor, focal headache, and left hemiparesis. Repeat angiography demonstrated intracranial occlusion of the right internal carotid artery. At surgery, a hemorrhagic pituitary adenoma was found to be compressing the internal carotid artery, and the removal of the tumor resulted in restoration of flow. The mechanism, presenting symptoms and signs, and treatment of pituitary apoplexy causing compression of a major vessel are discussed.

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Neurosurgical management of acromegaly

Results in 82 patients treated between 1972 and 1977

Edward R. Laws Jr., David G. Piepgras, Raymond V. Randall, and Charles F. Abboud

✓ A consecutive series of 82 acromegalic patients who underwent transsphenoidal surgery during a 5-year period is presented. Preoperative and postoperative values for human growth hormone (HGH) were available in 80 cases. Microadenomas were present in 18 patients with a mean preoperative HGH value of 25.2 ng/ml, diffuse adenomas in 39 patients with mean of 53.8 ng/ml, and invasive adenomas in 25 with mean of 68.0 ng/ml. There was no operative mortality. The results reflected the classification of the tumors, with apparent cures accomplished in 87.5% of previously untreated patients with microadenoma, all of whom had anterior pituitary function preserved. The percentages of apparent cures in cases of diffuse adenoma (68%) and invasive adenoma (54%) were much less satisfactory. Transsphenoidal microsurgery is capable of achieving good results, particularly in patients with microadenoma.

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Charles F. Abboud and Edward R. Laws Jr.

✓ The authors review the present knowledge of the hypothalamic-pituitary endocrine axis. The physiology and pathophysiology are discussed along with outlines of standard approaches to diagnosis of disorders. An appendix of useful provocative tests is included.

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Edward R. Laws Jr.

✓ The rationale for the transsphenoidal approach in the surgical management of craniopharyngioma is presented, based on experience with 26 cases. In 14 patients without prior therapy, nine had “total” removal of the lesion, and only two had permanent postoperative diabetes insipidus. One operative death occurred in this group, and two patients had cerebrospinal fluid leaks. In 12 patients who had undergone prior craniotomy, successful palliation was accomplished, at least temporarily, in every case. Vision was improved postoperatively in 15 of the 16 patients who presented with visual loss. Enlargement of the sella by the tumor is the critical feature allowing for successful transsphenoidal management.

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Pineal tumors in children and adolescents

Treatment by CSF shunting and radiotherapy

Eustaquio O. Abay II, Edward R. Laws Jr., Gordon L. Grado, James E. Bruckman, Glenn S. Forbes, Manuel R. Gomez, and Mark Scott

✓ Tumors of the pineal region account for 3% to 8% of pediatric intracranial tumors. The treatment of such tumors has been in a state of flux between conservative therapy (cerebrospinal fluid shunting and radiotherapy) and direct surgical removal. A brief history and review of the literature with analysis of both approaches is given, and the Mayo Clinic's experience with conservative treatment of tumors in the pineal region in patients 20 years old and younger (27 cases) is studied and analyzed. The series comprises 21 boys and six girls, with an age range of 1 to 20 years (mean 13.7 years). Follow-up examinations are complete and range from 1 to 24 years, with a mean follow-up period of 7.8 years. The median survival time for these patients treated with shunt and radiotherapy is 17.7 years. There was no mortality from treatment and complications were rare. The details of the clinical presentation, diagnostic findings, pathology, therapy, recurrence, and survival are presented.

All patients under 6 years of age (six cases) had recurrences, 50% in other areas in the brain and 50% in the spinal cord, perhaps pointing to the need for whole-brain and spinal-axis irradiation in patients in this age group. The results of this study of the conservative approach form a standard against which results of any other type of therapy may be compared.

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Stephen G. Harner and Edward R. Laws Jr.

✓ Cerebrospinal fluid (CSF) otorhinorrhea may occur as a complication of surgery for removal of acoustic neurinomas. The CSF leak usually appears within the first 2 weeks after surgery, and the diagnosis is obvious. The fistulous site is frequently inaccessible and may be difficult to repair by reexploring the suboccipital craniectomy. Successful closure of the fistula is accomplished by obliterating the space between the posterior fossa dura and the eustachian tube orifice with homograft muscle, using a radical translabyrinthine approach.