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Francesco Certo, Giada Toccaceli, Roberto Altieri and Giuseppe M. V. Barbagallo

We present a case of a 62-year-old man with acute onset of diplopia, headache, and vomiting for a bleeding thalamomesencephalic cavernoma. The lesion was removed via the anterior transcallosal transchoroidal approach. His head was slightly flexed and a right paramedian craniotomy for an interhemispheric approach was performed. The interhemispheric fissure was split and, after callosotomy, the choroidal fissure was opened along the tenia fornicis to enter the velum interpositum and enlarge the foramen of Monro. The cavernoma was then identified and resected. There were no long-term postoperative neurological deficits. This approach is a valid alternative for thalamomesencephalic lesions.

The video can be found here: https://youtu.be/DJdorbzDnH0.

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Giuseppe M.V. Barbagallo, Francesco Certo, Giovanni Sciacca and Vincenzo Albanese

This video demonstrates the minimally invasive surgical technique used in a 56-year-old woman suffering from L-5 spondylolysis and grade 2 L5–S1 spondylolisthesis. The first author used expandable tubular retractors bilaterally to perform neural decompression, mini-open TLIF, spondylolysthesis reduction and L5–S1 pedicle screw fixation. L-5 cement augmentation was performed through cannulated and fenestrated screws to enhance resistance to screw pull-out secondary to reduction maneuvers.

Sequential surgical steps related to microsurgery, spondylolysthesis reduction and instrumentation are shown and commented.

We submit that in cases of lythic spondylolisthesis a bilateral traversing and exiting nerve roots decompression is a safer option prior to performing the deformity reduction and fixation; the proposed minimally invasive technique may help in reducing surgical morbidity and improving postoperative recovery.

The video can be found here: http://youtu.be/G4Qdg-A-Y3M.

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Giuseppe M. V. Barbagallo, Sabrina Paratore, Rosario Caltabiano, Stefano Palmucci, Hector Soto Parra, Giuseppe Privitera, Fabio Motta, Salvatore Lanzafame, Giorgio Scaglione, Antonio Longo, Vincenzo Albanese and Francesco Certo

Object

The objective of this study was to report the authors' experience with the long-term administration of temozolomide (TMZ; > 6 cycles, up to 101) in patients with newly diagnosed glioblastoma and to analyze its feasibility and safety as well as its impact on survival. The authors also compared data obtained from the group of patients undergoing long-term TMZ treatment with data from patients treated with a standard TMZ protocol.

Methods

A retrospective analysis was conducted of 37 patients who underwent operations for glioblastoma between 2004 and 2012. Volumetric analysis of postoperative Gd-enhanced MR images, obtained within 48 hours, confirmed tumor gross-total resection (GTR) in all but 2 patients. All patients received the first cycle of TMZ at a dosage of 150 mg/m2 starting on the second or third postsurgical day. Afterward, patients received concomitant radiochemotherapy according to the Stupp protocol. With regard to adjuvant TMZ therapy, the 19 patients in Group A, aged 30–72 years (mean 56.1 years), received 150 mg/m2 for 5 days every 28 days for more than 6 cycles (range 7–101 cycles). The 18 patients in Group B, aged 46–82 years (mean 64.8 years), received the same dose, but for no more than 6 cycles. O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status was analyzed for both groups and correlated with overall survival (OS) and progression-free survival (PFS). The impact of age, sex, Karnofsky Performance Scale score, and Ki 67 staining were also considered.

Results

All patients but 1 in Group A survived at least 18 months (range 18–101 months), and patients in Group B survived no more than 17 months (range 2–17 months). The long-term survivors (Group A), defined as patients who survived at least 12 months after diagnosis, were 51.3% of the total (19/37). Kaplan-Meier curve analysis showed that patients treated with more than 6 TMZ cycles had OS and PFS that was significantly longer than patients receiving standard treatment (median OS 28 months vs 8 months, respectively; p = 0.0001; median PFS 20 months vs 4 months, respectively; p = 0.0002). By univariate and multivariate Cox proportional hazard regression analysis, MGMT methylation status and number of TMZ cycles appeared to be survival prognostic factors in patients with glioblastoma. After controlling for MGMT status, highly significant differences related to OS and PFS between patients with standard and long-term TMZ treatment were still detected. Furthermore, in Group A and B, the statistical correlation of MGMT status to the number of TMZ cycles showed a significant difference only in Group A patients, suggesting that MGMT promoter methylation was predictive of response for long-term TMZ treatment. Prolonged therapy did not confer hematological toxicity or opportunistic infections in either patient group.

Conclusions

This study describes the longest experience so far reported with TMZ in patients with newly diagnosed glioblastomas, with as many as 101 cycles, who were treated using GTR. Statistically significant data confirm that median survival correlates with MGMT promoter methylation status as well as with the number of TMZ cycles administered. Long-term TMZ therapy appears feasible and safe.