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Richard B. Schwartz, B. Leonard Holman, Basem M. Garada, Paulo A. Carvalho, Rebecca Folkerth, Marc S. Schwartz, Jay S. Loeffler, Dennis C. Shrieve, Joseph F. Polak, Peter McL. Black and Eben Alexander III

This study was conducted to determine the sensitivity of dual-isotope single-photon emission computerized tomography (SPECT) in predicting tumor recurrence and survival in patients treated with high-dose radiotherapy for malignant gliomas.

Studies using SPECT with thallium-201 (Tl-201) and technetium-99m (Tc-99m) hexamethypropyleneamine oxime (HMPAO) in 50 consecutive patients with malignant astrocytomas treated by surgery and high-dose radiotherapy were performed 1 day before reoperation. Maximum uptake of Tl-201 in the lesion was expressed as a ratio to that of the contralateral scalp, and uptake of Tc-99m HMPAO was expressed as a ratio to that of the cerebellar cortex. Patients were stratified into groups based on maximum radioisotope uptake values in their tumor beds. Differences in tumor histopathology at reoperation and 1-year survival between SPECT groups were determined by using chi-square analysis.

The majority of patients in Group IA (Tl-201 ratio less than 2 or Tc-99m HMPAO ratio less than 0.5) showed radiation changes in their biopsy specimens (85.7%); they had an 85.7% 1-year survival rate. Group II (Tl-201 ratio between 2 and 3.5) had predominantly infiltrating tumor (78.6%); they had a 42% 1-year survival rate. Almost all of the patients in Group III (Tl-201 ratio greater than 3.5) had solid tumor (93.3%) and they had a 6.7% 1-year survival. Survival and pathological data differed significantly among groups (p less than 0.009).

Dual-isotope SPECT data correlates with histological findings on reoperation and postoperative survival in patients with malignant gliomas.

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Richard B. Schwartz, B. Leonard Holman, Joseph F. Polak, Basem M. Garada, Marc S. Schwartz, Rebecca Folkerth, Paulo A. Carvalho, Jay S. Loeffler, Dennis C. Shrieve, Peter McL. Black and Eben Alexander III

Object. The study was conducted to determine the association between dual-isotope single-photon emission computerized tomography (SPECT) scanning and histopathological findings of tumor recurrence and survival in patients treated with high-dose radiotherapy for glioblastoma multiforme.

Methods. Studies in which SPECT with 201Tl and 99mTc-hexamethypropyleneamine oxime (HMPAO) were used were performed 1 day before reoperation in 47 patients with glioblastoma multiforme who had previously been treated by surgery and high-dose radiotherapy. Maximum uptake of 201Tl in the lesion was expressed as a ratio to that in the contralateral scalp, and uptake of 99mTc-HMPAO was expressed as a ratio to that in the cerebellar cortex. Patients were stratified into groups based on the maximum radioisotope uptake values in their tumor beds. The significance of differences in patient gender, histological characteristics of tissue at reoperation, and SPECT uptake group with respect to 1-year survival was elucidated by using the chi-square statistic. Comparisons of patient ages and time to tumor recurrence as functions of 1-year survival were made using the t-test.

Survival data at 1 year were presented according to the Kaplan—Meier method, and the significance of potential differences was evaluated using the log-rank method. The effects of different variables (tumor type, time to recurrence, and SPECT grouping) on long-term survival were evaluated using Cox proportional models that controlled for age and gender.

All patients in Group I (201Tl ratio < 2 and 99mTc-HMPAO ratio < 0.5) showed radiation changes in their biopsy specimens: they had an 83.3% 1-year survival rate. Group II patients (201T1 ratio < 2 and 99mTc-HMPAO ratio of ≥ 0.5 or 201Tl ratio between 2 and 3.5 regardless of 99mTc-HMPAO ratio) had predominantly infiltrating tumor (66.6%); they had a 29.2% 1-year survival rate. Almost all of the patients in Group III (201Tl ratio > 3.5 and 99mTc-HMPAO ratio ≥ 0.5) had solid tumor (88.2%) and they had a 6.7% 1-year survival rate. Histological data were associated with 1-year survival (p < 0.01); however, SPECT grouping was more closely associated with 1-year survival (p < 0.001) and was the only variable significantly associated with long-term survival (p < 0.005).

Conclusions. Dual-isotope SPECT data correlate with histopathological findings made at reoperation and with survival in patients with malignant gliomas after surgical and high-dose radiation therapy.

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Ganesh M. Shankar, Li Chen, Albert H. Kim, Gina L. Ross, Rebecca D. Folkerth and Robert M. Friedlander

Extraadrenal paragangliomas are most commonly found in the carotid body and are also found with lower frequency in the CNS. These lesions are derived from the sympathoadrenal lineage of neural crest cells. Here, the authors report a rare case of a composite paraganglioma with ganglioneuromatous components found at the filum terminale in a patient who presented with a brief history of low-back pain and paresthesias in the inguinal region. Immunohistochemical analysis of the resected lesion revealed admixed elements of neuroendocrine and neuroblastoma lineages, indicating the presence of divergent differentiation of sympathoadrenal progenitor cells. This case represents a unique opportunity to understand the cell fate of sympathoadrenal progenitor cells. Here, the authors propose that paragangliomas at the filum terminale can revert to a neural crest cell precursor fate, giving rise to divergent neoplastic populations.

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Osama Jamil, Shakti Ramkissoon, Rebecca Folkerth and Edward Smith

Meningioangiomatosis consists of benign hamartomatous lesions of the brain and the leptomeninges, which typically present with seizure. Management is predicated on resection and control of seizures with medication. Lesions are typically solitary. Multifocal meningioangiomatosis is extremely rare, with only 2 cases reported in adults and none in children. The authors report the first case, to their knowledge, of multifocal meningioangiomatosis in a child. This unique case highlights therapeutic challenges associated with these lesions and demonstrates that multifocality is possible in the pediatric population. This finding has implications for diagnosis and follow-up for children afflicted with these tumors.

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Hussam Abou-Al-Shaar, Muhammad M. Abd-El-Barr, Hasan A. Zaidi, Eleanor Russell-Goldman, Rebecca D. Folkerth, Edward R. Laws Jr. and E. Antonio Chiocca

There is a wide group of lesions that may exist in the sellar and suprasellar regions. Embryologically, there is varying evidence that many of these entities may in fact represent a continuum of pathology deriving from a common ectodermal origin. The authors report a case of a concomitant suprasellar craniopharyngioma invading the third ventricle with a concurrent frontal lobe cystic dermoid tumor. A 21-year-old man presented to the authors' service with a 3-day history of worsening headache, nausea, vomiting, and blurry vision. Magnetic resonance imaging depicted a right frontal lobe lesion associated with a separate suprasellar cystic lesion invading the third ventricle. The patient underwent a right pterional craniotomy for resection of both lesions. Gross-total resection of the right frontal lesion was achieved, and subtotal resection of the suprasellar lesion was accomplished with some residual tumor adherent to the walls of the third ventricle. Histopathological examination of the resected right frontal lesion documented a diagnosis of dermoid cyst and, for the suprasellar lesion, a diagnosis of adamantinomatous craniopharyngioma. The occurrence of craniopharyngioma with dermoid cyst has not been reported in the literature before. Such an association might indeed suggest the previously reported hypothesis that these lesions represent a spectrum of ectodermally derived epithelial-lined cystic lesions.