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Mitchel S. Berger

craniotomy. Such a procedure could certainly be performed through a burr hole with the ultrasound apparatus described here. However, because adequate dosimetry planning requires knowledge of the volume of the tumor, it will be necessary to develop computer software that can construct a three-dimensional image of the tumor mass from multiple ultrasound sectors before comparison with standard CT-guided implantation procedures for interstitial radiation therapy is possible. Acknowledgments The author thanks Cindy Huff for manuscript preparation and Stephen Ordway

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G. Evren Keles, Kathleen R. Lamborn, Susan M. Chang, Michael D. Prados and Mitchel S. Berger

immunodeficiency virus or had a known acquired immunodeficiency syndrome—related illness were excluded. All patients who participated in the protocol had given their informed consent. An additional inclusion criterion required that patients “be enrolled within 60 days, inclusive of the most recent documented progression.” Most importantly, “unequivocal progression [had to be] documented on imaging studies within 1 month from enrollment.” These criteria were applied to all patients and, consequently, volume measurements were performed on MR images obtained within the last month

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Ping Zhu, Xianglin L. Du, Angel I. Blanco, Leomar Y. Ballester, Nitin Tandon, Mitchel S. Berger, Jay-Jiguang Zhu and Yoshua Esquenazi

(codeletion of 1p19q and IDH1/2 mutation), and extent of resection (EOR). 24 , 41 Recent studies have reported more favorable survival outcomes in patients with various cancer types treated at academic centers (ACs), and an increasing number of studies have shown volume-outcome relationships in surgical neurooncology, 4 , 9 , 16 , 29 , 39 including glioblastoma. 54 However, little is known about the impact of facility type on LGG outcomes. Several studies have demonstrated an association between EOR and survival, and current data strongly argue in favor of achieving a

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: Letters to the Editor Response Mitchel S. Berger , M.D. University of Washington Children's Hospital Medical Center Seattle, Washington I appreciate Dr. Tsutsumi's correction of an inadvertent error in the description of the ultrasound probe. He is correct in stating that the 7.5-MHz transducer frequency is appropriate for near-field (superficial) imaging while the 5.0-MHz probe should be reserved for deeper lesions. Dr. Tsutsumi is also correct to imply that tumor volume may be accurately assessed with ultrasound and compares

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David Schiff

of LGG are suboptimal and at best represent Level II (b) evidence. For example, patients with extensive resection might do better than those undergoing biopsy because the former are less likely to have undersampled regions of anaplastic glioma, which itself confers a worse prognosis. Moreover, patients undergoing biopsy were excluded from the large, carefully reported UCSF series that showed increasing extent of resection and smaller preoperative and postoperative tumor volume correlate with improved survival. 16 Nonetheless, it is likely that postoperative tumor

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Nader Sanai and Mitchel S. Berger

resection. Emerging imaging technologies, as well as state-of-the-art intraoperative techniques, can facilitate a greater extent of resection while minimizing the associated morbidity profile. Specifically, the value of mapping motor and language pathways is well established for the safe resection of intrinsic tumors. Interestingly, controversy persists regarding prognostic factors and treatment options for both low- and high-grade hemispheric gliomas. Among the various tumor- and treatment-related parameters—including tumor volume, neurological status, timing of

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Insular glioma surgery: an evolution of thought and practice

JNSPG 75th Anniversary Invited Review Article

Shawn L. Hervey-Jumper and Mitchel S. Berger

IFOF extends posteriorly toward the occipital pole ( Fig. 1C ). For this reason, subcortical intraoperative brain mapping of language tasks is essential during dominant-hemisphere insular glioma surgery. 24 Surgery for Insular Tumors Prior to the Modern Era The argument in support of maximal EOR has evolved over the past 20 years. These efforts began with gross estimates of EOR and volume of residual tumor based on radiology reports separating patients into “subtotal” and “gross-total” resection cohorts. The next wave of studies subsequently employed cross

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Victoria T. Trinh, Jason M. Davies and Mitchel S. Berger

P roviding access to high-quality, affordable health care continues to be a matter of physician and public concern. As legislation seeks to optimize cost and quality, it is important to examine the factors that contribute to differences in health outcomes. 19 Hospital and surgeon case volume have been shown to impact outcomes across a variety of subspecialties, including neurosurgery, 2 , 3 , 7 , 8 , 25 cardiothoracic surgery, 15 , 20 gastrointestinal surgery, 4 , 13 , 24 and breast surgery. 14 Previous studies have demonstrated volume relationships

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Nader Sanai, Juan Martino and Mitchel S. Berger

neurosurgeon (M.S.B.) conducted volumetric measurements of pre- and postoperative imaging. For low-grade gliomas, manual segmentation was performed with region-of-interest analysis to measure tumor volumes (cm 3 ) on the basis of FLAIR or T2 axial slices, as previously described. Extent of resection was calculated as (preoperative tumor volume − postoperative tumor volume)/preoperative tumor volume. For high-grade gliomas, a similar calculation was made using the volume of contrast-enhancing tissue seen on T1-weighted MR imaging. The determination of volumes was made without

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Piotr Hadaczek, Hanna Mirek, Mitchel S. Berger and Krystof Bankiewicz

tumors were chosen to study AAV2-TK distribution within the tumor mass. The AAV2-TK was continually administered to each brain tumor via CED. A 27-gauge needle fused with a Teflon tube (0.02 in) and connected to a programmable microinfusion pump (Bioanalytical Systems, West Lafayette, IN) was used for delivery. The loading chamber (Teflon tubing, 0.0625-in outer diameter × 0.03-in inner diameter) and attached infusion chamber (0.0625-in outer diameter × 0.02-in inner diameter) were filled with 1.6 × 10 10 particles of AAV2-TK in a total volume of 20 µl PBS and heparin