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Toshihiko Wakabayashi, Jun Yoshida, Hisao Seo, Kyoto Kazo, Yoshiharu Murata, Nobuo Matsui and Naoki Kageyama

✓ Monoclonal antibodies were produced by immunization of the human glioma cell line SK-MG-4. One of the antibodies, designated G-22, reacted with 18 of 20 glioma cell lines, two melanoma cell lines, and three lung cancer cell lines, but not with 39 cell lines derived from sarcoma, carcinoma, or hematopoietic tumors. The antigen was expressed in the brain of human fetuses in early gestation (9 weeks) but not in late gestation (8 months) or in normal adult brain, suggesting that the antibody recognizes neural differentiation antigens expressed by neuroectodermal origin. A high incidence of positive antigens has been observed in gliomas but not in the other neural tumors, such as ependymomas, meningiomas, and neuroblastomas. Thus, the antigen defined by the G-22 monoclonal antibody could be defined as glioma-associated antigen. Pulse-labeling with tritiated leucine and subsequent immunoprecipitation of the solubilized cell membrane revealed that the antigen recognized by this antibody had a molecular weight of 67 kD on sodium dodecyl sulfate-poly-acrylamide gel electrophoresis (SDS-PAGE).

It was shown by dot-blot enzyme-linked immunospecific assay (ELISA) that the antigen could be detected in the cerebrospinal fluid (CSF) from patients with gliomas. From analysis of affinity chromatography and SDS-PAGE, the antigen present in the CSF had a molecular weight similar to that of a 1% Nonidet P-40 (NP-40) extract from a glioma cell line. When the antigen in CSF was quantitatively assayed by ELISA, the mean antigen level (expressed as optical density at 450 nm) in the CSF of seven patients was 0.8 ± 0.28 (mean ± standard deviation), which was significantly higher than the 0.38 ± 0.14 level observed in the CSF of 15 patients with nonglioma brain tumors and the 0.23 ± 0.09 level in the CSF of four patients without brain tumors. These results indicate that the monoclonal antibody G-22 is useful for the diagnosis of glioma.

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Kenkou Maeda, Masaaki Mizuno, Toshihiko Wakabayashi, Syuntarou Takasu, Tetsurou Nagasaka, Masaki Inagaki and Jun Yoshida

Object. The nature and origin of multinucleated giant cells in glioma have not been made clear. To investigate the phosphorylation of intermediate filaments, the authors studied multinucleated giant cells in vitro and in vivo by using mitosis-specific phosphorylated antibodies.

Methods. Cultured human glioma cells were immunostained with monoclonal antibodies (mAbs) 4A4, KT13, and TM71, which recognized the phosphorylation of vimentin at Ser55, glial fibrillary acidic protein at Ser13, and vimentin at Ser71, respectively. Subsequently, the nature of multinucleated giant cells was investigated using laser scanning confocal microscopy. In addition, paraffin-embedded tissue sections obtained in three patients with giant cell glioblastoma were also investigated.

Multinucleated giant cells were immunoreacted with the mAb 4A4 and not with KT13 and TM71 in vitro and in vivo. In addition, the authors obtained these results in multinucleated giant cells under natural conditions, without drug treatments.

Conclusions. Findings in this investigation indicated that multinucleated giant cells are those remaining in mitosis between metaphase and telophase, undergoing neither fusion nor degeneration.

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Yuichi Nagata, Tadashi Watanabe, Tetsuya Nagatani, Kazuhito Takeuchi, Jonsu Chu and Toshihiko Wakabayashi

OBJECTIVE

Parasellar tumors that extend far laterally beyond the internal carotid artery or that are fibrous and adhere firmly to critical structures are difficult to remove totally via the endoscopic transsphenoidal approach alone. In such cases, a combined transsphenoidal-transcranial approach is effective to achieve maximal resection in a single stage. In this paper, a new minimally invasive surgical technique for complicated parasellar lesions, a fully endoscopic combined transsphenoidal–supraorbital keyhole approach, is presented.

METHODS

A retrospective review of patients who had been treated via a fully endoscopic combined transsphenoidal–supraorbital keyhole approach for complicated parasellar lesions was performed. The data for resection rate, perioperative mortality and morbidity, and postoperative outcomes were analyzed.

RESULTS

A total of 12 fully endoscopic combined transsphenoidal–supraorbital keyhole approaches were performed from March 2013 to February 2016; 10 were for pituitary adenomas and 2 were for craniopharyngiomas. Gross-total resection or near-total resection was achieved in 7 of 12 cases. Among the 11 patients who had presented with preoperative visual disturbances, 7 had visual improvement. However, 1 patient showed deterioration in visual function. No patient experienced postoperative hemorrhage, needed additional surgical treatment, or had postoperative CSF leakage.

CONCLUSIONS

In the combined transsphenoidal and transcranial approach, safe and effective cooperative manipulation with 2 surgical corridors can be performed for complicated parasellar lesions. The goal of this procedure is not to achieve gross-total resection, but to achieve safe resection. Moreover, this new surgical approach offers neurosurgeons a simpler operative field with less invasiveness than the conventional microscopic combined approach. The fully endoscopic combined endonasal–supraorbital keyhole approach is an efficacious procedure for complicated parasellar lesions with acceptable results.

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Kazuhito Takeuchi, Takashi Handa, Jonsu Chu, Kentaro Wada and Toshihiko Wakabayashi

Intraventricular hemorrhage and intracerebral aneurysms are relatively frequent complications associated with moyamoya disease. Prevention of aneurysm rerupture is important because it significantly decreases the morbidity and mortality rates. Aneurysms arising distal to collateral flow are sometimes observed in patients with intraventricular hemorrhage; however, the treatment of these aneurysms remains challenging because of their deep-seated location in the brain and accompanying narrow surgical corridor. The authors describe a neuroendoscopic aneurysm clipping technique performed in 2 cases using a small-diameter tubular retractor for intraventricular aneurysms of the distal lateral posterior choroidal artery. In this technique, the surgical field was continuously irrigated with artificial CSF to keep the ventricle size intact, and aneurysm clipping was performed through a tubular retractor that was introduced with neuronavigational guidance. The patients’ postoperative courses were uneventful, and CT angiography revealed complete clipping of the aneurysms and patent parent arteries. Endoscopic clipping using a tubular retractor is an effective and less invasive alternative for treating intraventricular aneurysms. The wet-field endoscopic technique is performed in an aqueous field and maintains an intact ventricle size, allowing for a clear surgical view and a wider, enhanced surgical field.

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Takayuki Ishikawa, Kazuhito Takeuchi, Yuichi Nagata, Jungsu Choo, Teppei Kawabata, Tomotaka Ishizaki and Toshihiko Wakabayashi

OBJECTIVE

Transsphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results.

METHODS

All patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect.

RESULTS

There were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito’s grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively.

CONCLUSIONS

Dural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.

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Katsumi Taniguchi, Toshihiko Wakabayashi, Tazuka Yoshida, Masaaki Mizuno, Kazuhiro Yoshikawa, Akihiko Kikuchi, Nobuo Nakashima and Jun Yoshida

Object. The enzyme DNA topoisomerase IIα (Topo IIα) was tested as a measure of cell proliferation in gliomas.

Methods. Immunostaining for the Topo IIα and for the Ki-67 antigen (MIB-1 antibody) was performed in paraffin-embedded tissue sections obtained from 25 resected human gliomas. Additionally, cultured human glioma cells were subjected to simultaneous flow cytometry to determine Topo IIα and DNA content.

Using flow cytometric analysis, the authors found that the Topo IIα antibody labeled cells in the S, G2, and M phases of the cell cycle and also those in some parts of the G0 and G1 phases. In histological sections, Topo IIα showed more distinct staining than MIB-1, particularly in older archival cases. The proliferative indices (PIs) based on cells staining for MIB-1 and Topo IIα correlated highly with one another (r = 0.96). The Topo IIα PI immunopositivity was seen in 4.07% of cells in the low-grade astrocytoma group, 11.97% in the anaplastic astrocytoma group, and 13.84% in the glioblastoma multiforme group, representing significant differences between low-grade astrocytoma and both anaplastic astrocytoma and glioblastoma. A Topo IIα PI less than 5% predicted longer patient survival (p = 0.003).

Conclusions. Immunostaining for Topo IIα represents a useful alternative to MIB-1 as a proliferative index in human gliomas.

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Kenichiro Iwami, Hiroyuki Momota, Atsushi Natsume, Sayano Kinjo, Tetsuya Nagatani and Toshihiko Wakabayashi

Object

Mouse models have been widely used in developing therapies for human brain tumors. However, surgical techniques such as bone drilling and skin suturing to create brain tumors in adult mice are still complicated. The aim of this study was to establish a simple and accurate method for intracranial injection of cells or other materials into mice.

Methods

The authors performed micro CT scans and skull dissection to assess the anatomical characteristics of the mouse postglenoid foramen. They then used xenograft and genetically engineered mouse models to evaluate a novel technique of percutaneous intracranial injection via the postglenoid foramen. They injected green fluorescent protein–labeled U87MG cells or virus-producing cells into adult mouse brains via the postglenoid foramen and identified the location of the created tumors by using bioluminescence imaging and histological analysis.

Results

The postglenoid foramen was found to be a well-conserved anatomical structure that allows percutaneous injection into the cerebrum, cerebellum, brainstem, and basal cistern in mice. The mean (± SD) time for the postglenoid foramen injection technique was 88 ± 15 seconds. The incidence of in-target tumor formation in the xenograft model ranged from 80% to 100%, depending on the target site. High-grade gliomas were successfully developed by postglenoid foramen injection in the adult genetically engineered mouse using virus-mediated platelet-derived growth factor B gene transfer. There were no procedure-related complications.

Conclusions

The postglenoid foramen can be used as a needle entry site into the brain of the adult mouse. Postglenoid foramen injection is a less invasive, safe, precise, and rapid method of implanting cells into the adult mouse brain. This method can be applied to both orthotopic xenograft and genetically engineered mouse models and may have further applications in mice for the development of therapies for human brain tumors.

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Toru Arima, Atsushi Natsume, Hisashi Hatano, Norimoto Nakahara, Mitsugu Fujita, Dai Ishii, Toshihiko Wakabayashi, Manabu Doyu, Tetsuro Nagasaka and Jun Yoshida

✓ A rare case of chordoid meningioma in the lateral ventricle observed in an adult is reported. The first clinical manifestation of the disease was a prolonged fever of unknown origin. Abnormalities in the patient's blood chemistry, principally polyclonal hypergammaglobulinemia (immunoglobulin [Ig]G, IgA, and markedly IgE) and an elevated serum level of C-reactive protein, were associated with the disease. The tumor was histologically confirmed to be a chordoid meningioma, and its surgical removal resulted in complete resolution of the patient's symptoms. By combining reverse transcription—polymerase chain reaction and immunohistochemical analysis, it may be shown that cytokine production, including that of interleukin (IL)-6, IL-1β, and vascular endothelial growth factor, plays a role in the pathogenesis of chordoid meningioma associated with Castleman syndrome.

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Mitsugu Fujita, Masaaki Mizuno, Tetsuro Nagasaka, Toshihiko Wakabayashi, Kenkou Maeda, Dai Ishii, Toru Arima, Aie Kawajiri, Masaki Inagaki and Jun Yoshida

Object. The origin of multinucleated giant cells in glioma has not been made clear. In a previous paper the authors studied multinucleated giant tumor cells by using mitosis-specific phosphorylated antibodies to determine the phosphorylation of intermediate filaments and demonstrated that these cells stay in the early mitotic stage, undergoing neither fusion nor degeneration. In the current study the authors investigated the possible genetic causes of multinucleated giant tumor cells.

Methods. Cultured mono- or multinucleated human glioma cells were immunostained with monoclonal antibodies (mAbs) 4A4, YT33, TM71, HTA28, YG72, and αAIM-1. The three former antibodies revealed a particular mitotic cell cycle through site-specific phosphorylation of vimentin; that is, the early phase, mid phase, and late phase, respectively. The three later antibodies demonstrated phosphorylation of H3 at Ser28, phosphorylation of vimentin at Ser72, and aurora-B, respectively, making it possible to identify aurora-B distribution and function during mitosis. In addition, paraffin-embedded tissue sections obtained in three patients with giant cell glioblastoma were also examined.

Multinucleated giant tumor cells immunoreacted with the mAb 4A4 and αAIM-1 but not with YT33, TM71, HTA28, and YG72 in vitro and in vivo.

Conclusions. Findings in this study indicated that multinucleated giant tumor cells remain in the early mitotic phase because of aurora-B dysfunction, effecting aberrations in cytoplasmic cleavage without affecting nuclear division.

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Satoshi Maesawa, Masazumi Fujii, Miyako Futamura, Yuichiro Hayashi, Kentaro Iijima and Toshihiko Wakabayashi

Few studies have examined the clinical characteristics of patients with lesions in the deep parietal operculum facing the sylvian fissure, the region recognized as the secondary somatosensory area (SII). Moreover, surgical approaches in this region are challenging. In this paper the authors report on a patient presenting with SII epilepsy with a tumor in the left deep parietal operculum. The patient was a 24-year-old man who suffered daily partial seizures with extremely uncomfortable dysesthesia and/or occasional pain on his right side. MRI revealed a tumor in the medial aspect of the anterior transverse parietal gyrus, surrounding the posterior insular point. Long-term video electroencephalography monitoring with scalp electrodes failed to show relevant changes to seizures. Resection with cortical and subcortical mapping under awake conditions was performed. A negative response to stimulation was observed at the subcentral gyrus during language and somatosensory tasks; thus, the transcortical approach (specifically, a transsubcentral gyral approach) was used through this region. Subcortical stimulation at the medial aspect of the anterior parietal gyrus and the posterior insula around the posterior insular point elicited strong dysesthesia and pain in his right side, similar to manifestation of his seizure. The tumor was completely removed and pathologically diagnosed as pleomorphic xanthoastrocytoma. His epilepsy disappeared without neurological deterioration postoperatively. In this case study, 3 points are clinically significant. First, the clinical manifestation of this case was quite rare, although still representative of SII epilepsy. Second, the location of the lesion made surgical removal challenging, and the transsubcentral gyral approach was useful when intraoperative mapping was performed during awake surgery. Third, intraoperative mapping demonstrated that the patient experienced pain with electrical stimulation around the posterior insular point. Thus, this report demonstrated the safe and effective use of the transsubcentral gyral approach during awake surgery to resect deep parietal opercular lesions, clarified electrophysiological characteristics in the SII area, and achieved successful tumor resection with good control of epilepsy.