Diffuse gliomas are the commonest malignant primary brain tumour in adults. Herein, we present analysis of the genomic landscape of adult glioma, by whole genome sequencing of 403 tumours (256 glioblastoma, 89 astrocytoma, 58 oligodendroglioma; 338 primary, 65 recurrence). We identify an extended catalogue of recurrent coding and non-coding genetic mutations that represents a source for future studies and provides a high-resolution map of structural variants, copy number changes and global genome features including telomere length, mutational signatures and extrachromosomal DNA. Finally, we relate these to clinical outcome. As well as identifying drug targets for treatment of glioma our findings offer the prospect of improving treatment allocation with established targeted therapies.

Background: Studies from the UK reporting on awake craniotomy (AC) include a heterogenous group of patients which limit the evaluation of the true impact of AC in high-grade glioma (HGG) patients. This study aims to report solely the experience and outcomes of AC for HGG surgery from our centre. Methods: A prospective review of all patients who underwent AC for HGG from 2013 to 2019 were performed. Data on patient characteristics including but not limited to demographics, pre- and post -operative Karnofsky performance status (KPS), tumour location and volume, type of surgery, extent of resection (EOR), tumour histopathology, intra- and post -operative complications, morbidity, mortality, disease recurrence, progression -free survival (PFS) and overall survival (OS) from the time of surgery were collected. Results: Fifteen patients (6 males; 9 females; 17 surgeries) underwent AC for HGG (median age 1/4 55 years). Two patients underwent repeat surgeries due to disease recurrence. Median pre- and post -operative KPS score was 90 (range:80-100) and 90 (range:60-100), respectively. The EOR ranges from 60 to 100 % with a minimum of 80 % achieved in 81.3 % cases. Post -operative complications include focal seizures (17.6 %), transient aphasia/ dysphasia (17.6 %), permanent motor deficit (11.8 %), transient motor deficit (5.9 %) and transient sensory disturbance (5.9 %). There were no surgery -related mortality or postoperative infection. The median PFS and OS were 13 (95%CI 5-78) and 30 (95%CI 21-78) months, respectively. Conclusion: This is the first study in the UK to solely report outcomes of AC for HGG surgery. Our data demonstrates that AC for HGG in eloquent region is safe, feasible and provides comparable outcomes to those reported in the literature. (c) 2023 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Purpose: Day-case surgery for selected procedures has the potential to reduce healthcare costs and improve patient experience.In neurosurgery, brain biopsies have been performed as day-case procedures for selected patients.The purpose of this study is to demonstrate the safety and feasibility of a clinical pathway that facilitates day-case brain biopsy surgery to improve the generalisability of the evidence and inform wider adoption of this practice.Materials and methods: A single centre, retrospective study of patients aged ≥18 years requiring a brain biopsy for presumed tumour between November 2009 and December 2017 was performed.All patients received pre-admission radiology imaging +/-trajectory planning (as required), an operation on a morning theatre list and post-biopsy CT head 4-6 hours to rule out haemorrhage or other complications.Discharge was aimed at 6 hours post-biopsy if observations and CT were satisfactory.All data was collected via an institution operative database and descriptive statistical analysis was conducted.Results: A total of 447 brain tumour biopsies performed over the eight-year study period of which a total of n=160 (35.8%) were planned day-case.The proportion of biopsies performed as day-case increased over the study period, from four in 2009 to 33 per annum in 2017, an increase from only 10% (n=4) to 66% (n=33) of the total annual biopsies for this centre.Of the 160 planned day-cases, 135 (84.4%) were actual day-cases and successfully discharged on the same day as the operation.The mean patient age was 58 years.Twenty-five cases had at least one overnight unplanned stay, revealing a failure rate of 15.6%.Conclusions: This study demonstrates the safety of our day-case brain tumour biopsy service and is consistent with other centres' experiences.This represents an opportunity for neurosurgeons to confidently contribute to an increasing provision of day-case surgery across the service.

Prototheca wickerhamii is a common, indolent alga that seldom causes central nervous system infections in humans. We report the first UK case of cerebral protothecosis in an immunocompetent 56-year-old woman who presented with a 5-month history of intermittent fatigue followed by a 2-week history of symptoms, including right arm and leg weakness, a loss of fine motor coordination, worsening gait, right facial tingling, diplopia and a metallic oral taste. MRI scans revealed a multifocal abnormality suggestive of high-grade glioma. Given the clinical presentation, absence of immunodeficiency and characteristic MRI features, a diagnosis of high-grade glioma was deemed most likely by the multidisciplinary team. Surgical biopsy provided material for histopathological and microbiological diagnosis. She underwent a 2-year course of antimicrobials with surveillance MRI scans. The patient made a good functional recovery but still retains mild neurological sequelae.

Introduction: Papilloedema is an important clinical sign in the assessment of neurosurgical patients presenting with suspected shunt malfunction. Methods: We describe our 18-month experience using a newly acquired nonmydriatic digital retinal camera to acquire fundal photographs for this purpose. Results: It was used to take digital photographs in 67 patients presenting with suspected shunt malfunction and 54% of these images were discussed with the on-call ophthalmology team for advice. Of these 81% had instant input provided by ophthalmology and the remainder were sent to the ophthalmology department for formal assessment. Of all shunt related regional referrals in the same time period, we found that only 13% of the referred patients were discussed with the on-call ophthalmology team. The rest had decisions made by the on-call neurosurgical team. Conclusions: We believe this new integrated pathway is clinically and cost-effective and recommend it as a useful tool in other neurosurgical units.

Glioblastoma (GBM) is an aggressive cancer with a very poor prognosis. Generally viewed as weakly immunogenic, GBM responds poorly to current immunotherapies. To better understand this problem we used a combination of NK cell functional assays together with gene and protein expression profiling to define the NK cell response to GBM and explore immunosuppression in the GBM microenvironment. In addition, we used transcriptome data from patient cohorts to classify GBM according to immunological profiles. We show that glioma stem-like cells, a source of post-treatment tumour recurrence, express multiple immunomodulatory cell surface molecules and are targeted in preference to normal neural progenitor cells by natural killer (NK) cells ex vivo . In contrast, GBM-infiltrating NK cells express reduced levels of activation receptors within the tumour microenvironment, with hallmarks of TGF-β mediated inhibition. This NK cell inhibition is accompanied by expression of mutiple immune checkpoint molecules on T cells. Single cell transcriptomics demonstrated that both tumour and haematopoietic-derived cells in GBM express multiple, diverse mediators of immune evasion. Despite this, immunome analysis across a patient cohort identifies a spectrum of immunological activity in GBM, with active immunity marked by co-expression of immune effector molecules and feedback inhibitory mechanisms. Our data show that GBM is recognised by the immune system but that anti-tumour immunity is restrained by multiple immunosuppressive pathways, some of which operate in the healthy brain. The presence of immune activity in a subset of patients suggests that these patients will more likely benefit from combination immunotherapies directed against multiple immunosuppressive pathways.

BACKGROUND:The postoperative outcomes and the predictors of seizure control are poorly studied for supratentorial cavernous angiomas (CA) within or close to the eloquent brain area. OBJECTIVE:To assess the predictors of preoperative seizure control, postoperative seizure control, and postoperative ability to work, and the safety of the surgery. METHODS:Multicenter international retrospective cohort analysis of adult patients benefitting from a functional-based surgical resection with intraoperative functional brain mapping for a supratentorial CA within or close to eloquent brain areas. RESULTS:A total of 109 patients (66.1% women; mean age 38.4 ± 12.5 yr), were studied. Age >38 yr (odds ratio [OR], 7.33; 95% confidence interval [CI], 1.53-35.19; P = .013) and time to surgery > 12 mo (OR, 18.21; 95% CI, 1.11-296.55; P = .042) are independent predictors of uncontrolled seizures at the time of surgery. Focal deficit (OR, 10.25; 95% CI, 3.16-33.28; P < .001) is an independent predictor of inability to work at the time of surgery. History of epileptic seizures at the time of surgery (OR, 7.61; 95% CI, 1.67-85.42; P = .003) and partial resection of the CA and/or of the hemosiderin rim (OR, 12.02; 95% CI, 3.01-48.13; P < .001) are independent predictors of uncontrolled seizures postoperatively. Inability to work at the time of surgery (OR, 19.54; 95% CI, 1.90-425.48; P = .050), Karnofsky Performance Status ≤ 70 (OR, 51.20; 95% CI, 1.20-2175.37; P = .039), uncontrolled seizures postoperatively (OR, 105.33; 95% CI, 4.32-2566.27; P = .004), and worsening of cognitive functions postoperatively (OR, 13.71; 95% CI, 1.06-176.66; P = .045) are independent predictors of inability to work postoperatively. CONCLUSION:The functional-based resection using intraoperative functional brain mapping allows safe resection of CA and the peripheral hemosiderin rim located within or close to eloquent brain areas.

ObjectivesTo provide a formative educational test of knowledge that allows clinicians to measure themselves against their peers.DesignAnnual Neurosurgery and Neurology knowledge tests, supported by the ABN & SBNS, have been available since 2014 (NSurg) and 2017 (Neurol). The NSurg test requires all candidates to participate over 3 days, answers are available after the test whereas the Neurol formative questions are available over 6 weeks, answers are available immediately.SubjectsThere have been 821 first attempts at the formative questions; NSurg; 44, 63,187,143,164 and Neurol; 74, 146. Candidates are mostly from UK (NSurg 92%, Neurol 69%) and mostly specialty trainees (NSurg 98%, Neurol 63%).MethodsThe formative questions are delivered through the ebrain virtual learning platform, statistics are generated automatically. Proposed questions are written by candidates as ‘payment’ for doing the formative test.ResultsMean Cronbach’s alpha was 87.3%. The mean score for the tests was 60.4% (Range 55.9%–77.9%). Feedback is voluntary: In 2018 17 feedback comments were received, 10 were unambiguously positive, 5 were mixed including criticism of one or more questions, 2 were judged to be neutral. Examples of feedback comments received this year included ‘Comprehensive exam that covers a wide range of topics’ and ‘This is of great value’.ConclusionsThis formative educational initiative has high internal consistency and solid feedback. Although set up differently, it is proving both valuable and popular in both specialties.

We assessed prognostic factors in relation to OS from progression in recurrent glioblastomas. Retrospective multicentric study enrolling 407 (training set) and 370 (external validation set) adult patients with a recurrent supratentorial glioblastoma treated by surgical resection and standard combined chemoradiotherapy as first-line treatment. Four complementary multivariate prognostic models were evaluated: Cox proportional hazards regression modeling, single-tree recursive partitioning, random survival forest, conditional random forest. Median overall survival from progression was 7.6 months (mean, 10.1; range, 0–86) and 8.0 months (mean, 8.5; range, 0–56) in the training and validation sets, respectively (p = 0.900). Using the Cox model in the training set, independent predictors of poorer overall survival from progression included increasing age at histopathological diagnosis (aHR, 1.47; 95% CI [1.03–2.08]; p = 0.032), RTOG–RPA V–VI classes (aHR, 1.38; 95% CI [1.11–1.73]; p = 0.004), decreasing KPS at progression (aHR, 3.46; 95% CI [2.10–5.72]; p < 0.001), while independent predictors of longer overall survival from progression included surgical resection (aHR, 0.57; 95% CI [0.44–0.73]; p < 0.001) and chemotherapy (aHR, 0.41; 95% CI [0.31–0.55]; p < 0.001). Single-tree recursive partitioning identified KPS at progression, surgical resection at progression, chemotherapy at progression, and RTOG–RPA class at histopathological diagnosis, as main survival predictors in the training set, yielding four risk categories highly predictive of overall survival from progression both in training (p < 0.0001) and validation (p < 0.0001) sets. Both random forest approaches identified KPS at progression as the most important survival predictor. Age, KPS at progression, RTOG–RPA classes, surgical resection at progression and chemotherapy at progression are prognostic for survival in recurrent glioblastomas and should inform the treatment decisions.

Renal cell carcinoma is the most common renal tumour in adult that often metastasises to the lung, liver or bone. Head and neck lesions are uncommon with no early warning signs and presents with overt metastases at primary presentation in 25%–30% of reported cases. The incidence of haemangiomas that suggest malignancy are similar to that of bone metastasis. Calvarial haemangiomas usually present as asymptomatic and discovered incidentally on imaging or postmortem examination. We report a case where an initial diagnosis of benign tumour of the skull was made based on clinical presentation and calvarial haemangioma on CT head but was confirmed as metastatic clear cell carcinoma of the kidney after histopathological results. Skull metastases are rare and present late in the course of the disease. It is unusual for metastatic lesion to be the primary presentation in a clinically silent renal cell carcinoma.

INTRODUCTION:Formative assessment is a key component in medical education and that it is a helpful process for all involved. Until recently there was no national formative examination for neurosurgical trainees. The Neurosurgery Annual in Training Examination (NAiTE) is an annual online, formative assessment that was introduced in 2014. In this paper, we seek to discuss how well NAiTE relates to established educational practice and principles and its fitness for purpose by discussing its rationale, structure and utility.METHODS:A national online examination was introduced in 2014. The NAiTE consists of 100 single best answer multiple choice questions. The examination and questions with were reviewed and the global results presented. The existing literature and educational theory are used to guide subjective assessment of the process.RESULTS:In 2016, 191 candidates participated in the NAiTE, of whom 154 were trainees working in UK neurosurgical units. The mean score for early stage UK trainees (years 1-3) was 52.4%, intermediate (years 4-5) 58.5% and senior (years 6-8) 65.4%. The NAiTE was found to be a reliable (Cronbach-Alpha of 0.89) and valid assessment of trainees with scores approximating those attained in the Intercollegiate Specialty Examination itself.DISCUSSION:Potential areas for improvement are highlighted, including reference to some that have already been implemented.CONCLUSION:Overall, the examination is a cheap, viable and reliable means of testing trainees and encouraging their onward development and learning as they work towards the Intercollegiate Specialty Examination.

BACKGROUND: Gross total resection (GTR) of glioblastoma multiforme (GBM) can be variably defined. One definition is tumour residuum < 0.175 cm3 that has notably been used by Stummer and colleagues. We studied factors influencing the extent of resection according to this definition of GTR and attendant overall survival (OS) and functional performance. METHODS: Consecutive patients who underwent debulking surgery for histologically proven GBM between September 2013 and February 2016 by sub-specialty surgeons at a single institution were included. Data were collected on demographics, tumour location, tumour size pre- and post- debulking using volumetric analysis of magnetic resonance imaging, histology, oncological therapy and functional performance. Survival data and correlations were calculated using Kaplan–Meier and linear regression analyses. RESULTS: 100 patients were analysed with a mean age of 59.9 years (range, 17 – 85 years), and a male:female ratio of 1:1. Mean tumour size pre- and post - operatively were 37.2 cm3 and 1.78 cm3, respectively, representing a mean 95% extent of resection. Median OS across the cohort was 14.9 months. Pre-operative WHO performance status was 0–1 in 60% of cases and 2 in 37% of cases, and there was no significant change in these proportions post-operatively (p > 0.05). GTR with tumour residuum < 0.175 cm3 was achieved in 66% of small tumours (< 37.2 cm3) whilst in 34% of large tumours (> 37.2 cm3) (p < 0.05). Furthermore, volume of tumour residuum was significantly correlated with pre-operative tumour volume on linear regression analysis (p = 0.01). GTR was achieved in 53% versus 29% of tumours involving a single versus multiple lobes respectively (p = 0.08). There was no difference in the number of GTRs achieved amongst tumours of dominant versus non-dominant lobes. There was no significant difference in median OS between patients who had undergone GTR versus subtotal resection as per Stummer’s definition (15.1 vs 14.9 months, respectively, Log-Rank, p = 0.40). We note that in this cohort nearly two-thirds of patients achieved > 99% extent of resection. Comparison of 24 patients with complete resection versus 52 patients with near total resection (thin rim of enhancement) versus 24 patients with subtotal resection did yield significant differences in survival (15.9 vs 13.2 vs 11.1 months respectively, Log-Rank p = 0.03). CONCLUSIONS: Factors influencing GTR include pre-operative size of the tumour and involvement of more than one lobe. GTR as per Stummer’s definition does not appear to confer a survival advantage in our cohort but the vast majority of patients had very small tumour residuum. Categorising patients with respect to complete, near total and subtotal resection did yield small but significant differences in survival. Further prospective studies are needed to elucidate the most meaningful definition of gross total resection. KEYWORDS: glioblastoma multiforme; gross total resection; tumour residuum; extent of resection; overall survival.

Introduction. - Intraoperative application of electrical current to the brain is a standard technique during brain surgery for inferring the function of the underlying brain. The purpose of intraoperative functional mapping is to reliably identify cortical areas and subcortical pathways involved in eloquent functions, especially motor, sensory, language and cognitive functions.Material and methods. - The aim of this article is to review the rationale and the electrophysiological principles of the use of direct bipolar electrostimulation for cortical and subcortical mapping under awake conditions.Results. - Direct electrical stimulation is a window into the whole functional network that sustains a particular function. It is an accurate (spatial resolution of about 5 mm) and a reproducible technique particularly adapted to clinical practice for brain resection in eloquent areas. If the procedure is rigorously applied, the sensitivity of direct electrical stimulation for the detection of cortical and subcortical eloquent areas is nearly 100%. The main disadvantage of this technique is its suboptimal specificity. Another limitation is the identification of eloquent areas during surgery, which, however, could have been functionally compensated postoperatively if removed surgically.Conclusion. - Direct electrical stimulation is an easy, accurate, reliable and safe invasive technique for the intraoperative detection of both cortical and subcortical functional brain connectivity for clinical purpose. In our opinion, it is the optimal technique for minimizing the risk of neurological sequelae when resecting in eloquent brain areas. (C) 2017 Elsevier Masson SAS. All rights reserved.

Introduction. - Surgical resection of supratentorial cavernous angiomas located in eloquent areas poses a significant risk to the patient of postoperative neurological impairment and justifies intraoperative functional monitoring.Methods. - Multicentre retrospective series of adult patients with cavernous angiomas located within eloquent areas and treated with functional-based surgical resection according to functional boundaries under intraoperative functional cortico-subcortical monitoring under awake conditions.Results. - Fifty patients (18 males, mean 36.3 +/- 10.8 year-old) underwent surgical resection with intraoperative cortico-subcortical functional mapping using direct electrostimulation under awake conditions for a cavernous angioma located in eloquent areas with a mean postoperative follow-up of 21.0 +/- 21.2 months. At presentation, the cavernous angioma had previously resulted in severe impairment (neurological deficit in 34%, seizures in 70%, uncontrolled seizures in 34%, reduced Karnofsky Performance Status score of 70 or less in 24%, inability to work in 52%). Functional-based surgical resection allowed complete removal of the cavernous angioma in 98% and of the haemosiderin rim in 82%. Postoperative seizures and other complications were rare, and similarly so across all centres included in this series. Postoperatively, we found functional improvement in 84% of patients (reduced Karnofsky Performance Status score of 70 or less in 6%, uncontrolled seizures in 16%, and inability to work in 11%).Conclusion. - Functional-based surgical resection aids the safe and complete resection of cavernous angiomas located in eloquent areas while minimizing the surgical risks. Functional mapping has to be considered in such challenging cases. (C) 2016 Elsevier Masson SAS. All rights reserved.

OBJECTIVE There are no guidelines for the management of postoperative lateral sinus thrombosis following posterior fossa surgery. Introducing treatment-dose anticoagulant therapy during the immediate postoperative period increases the risk of intracranial bleeding. This study assessed the incidence of and risk factors associated with postoperative lateral sinus thrombosis and the complications related to thrombosis and/or anticoagulation. METHODS This study was a retrospective monocentric analysis of adult patients who underwent surgical removal of a posterior fossa space-occupying lesion with available postoperative imaging. Postoperative lateral sinus thrombosis was defined as a T2* hypointensity within the venous sinus and/or a filling defect on postcontrast MRI or CT scan. RESULTS Among 180 patients, 12 (6.7%; 95% CI 3.0–10.4) were found to have lateral sinus thrombosis on postoperative imaging, none of whom were symptomatic. Unadjusted risk factors for postoperative lateral sinus thrombosis were a history of deep venous thrombosis (p = 0.016), oral contraceptive pill (p = 0.004), midline surgical approach (p = 0.035), and surgical exposure of the sinus (p < 0.001). Seven of the patients (58.3%) with a postoperative lateral sinus thrombosis received immediate treatment-dose anticoagulant therapy. Lateral sinus recanalization occurred radiologically at a mean time of 272 ± 23 days in 85.7% of patients (6 of 7) undergoing treatment-dose anticoagulant therapy and in 20% of patients (1 of 5) not receiving treatment-dose anticoagulant therapy. Postoperative complications occurred in 56.2% of patients (9 of 16) who received treatment-dose curative anticoagulant therapy and in 27% of patients (45 of 164) who did not. CONCLUSIONS Incidental radiological lateral sinus thrombosis following posterior fossa surgery has an incidence of 6.7%. To further define the benefit-to-risk ratio of a treatment-dose anticoagulant therapy, a prospective trial should be considered.

Introduction. - The aim of brain glioma surgery is to maximize the quality of resection, while minimizing the risk of sequelae. Due to the frequent location of gliomas near or within eloquent areas, owing to their infiltrative feature, and because of major interindividual variability, the anatomofunctional organization and connectivity must be studied individually. Therefore, to optimize the benefit-to-risk ratio of surgery, intraoperative functional mapping is extensively used.Material and methods. - This article aims at describing the rationale, indications and practical aspects of intraoperative direct electrical bipolar electrostimulation for cortical and subcortical mapping under awake conditions using the asleep-awake asleep anaesthetic protocol in the setting of cerebral gliomas. We will address the operative approach, including patient positioning, functional mapping resection strategy, anaesthetic conditions, as well as tips and pitfalls.Results. - The intraoperative direct electrical bipolar electrostimulation enables: (i) to study the real-time individual cortical functional organization; (ii) to study the anatomofunctional subcortical connectivity along the resection; (iii) to tailor the resection according to individual corticosubcortical functional boundaries. This is an easy, accurate, reliable, well-tolerated and safe detection technique of both cortical and subcortical functionally essential structures during resection. It should be performed in the context of a standardized protocol involving members of both anaesthesiology and neurosurgery teams at neurosurgical centers specialized in surgical neuro-oncology.Conclusion. - Intraoperative direct electrical bipolar electrostimulation for cortical and subcortical mapping under awake conditions is currently considered the "gold standard" clinical tool for brain mapping during cerebral resection in neuro-oncology. (C) 2016 Elsevier Masson SAS. All rights reserved.

Immune checkpoint inhibitors, including those targeting programmed cell death protein 1 (PD-1), are reshaping cancer therapeutic strategies. Evidence suggests, however, that tumor response and patient survival are determined by tumor programmed death ligand 1 (PD-L1) expression. We hypothesized that preconditioning of the tumor immune microenvironment using targeted, virus-mediated interferon (IFN) stimulation would up-regulate tumor PD-L1 protein expression and increase cytotoxic T cell infiltration, improving the efficacy of subsequent checkpoint blockade. Oncolytic viruses (OVs) represent a promising form of cancer immunotherapy. For brain tumors, almost all studies to date have used direct intralesional injection of OV, because of the largely untested belief that intravenous administration will not deliver virus to this site. We show, in a window-of-opportunity clinical study, that intravenous infusion of oncolytic human Orthoreovirus (referred to herein as reovirus) leads to infection of tumor cells subsequently resected as part of standard clinical care, both in high-grade glioma and in brain metastases, and increases cytotoxic T cell tumor infiltration relative to patients not treated with virus. We further show that reovirus up-regulates IFN-regulated gene expression, as well as the PD-1/PD-L1 axis in tumors, via an IFN-mediated mechanism. Finally, we show that addition of PD-1 blockade to reovirus enhances systemic therapy in a preclinical glioma model. These results support the development of combined systemic immunovirotherapy strategies for the treatment of both primary and secondary tumors in the brain.

Objectives: We studied factors influencing the extent of resection of glioblastoma multiforme (GBM) and attendant overall survival (OS) and functional performance. Methods: Retrospective data were collected on 100 consecutive patients who underwent debulking surgery for histologically proven GBM between September 2013 and February 2016 by sub-specialty surgeons at a single institution. Survival data and correlations were calculated using the Kaplan-Meier and linear regression analyses. Results: Gross total resection (GTR) with tumour residuum<0.175 cm3 was achieved in 66% of small tumours (<37.2 cm3) whilst in 34% of large tumours (>37.2 cm3) (p<0.05). Volume of tumour residuum was significantly correlated with pre-operative tumour volume (p = 0.01). GTR was achieved in 53% versus 29% of tumours involving single versus multiple lobes respectively (p = 0.08). Comparison of 24 patients with complete resection versus 52 patients with near total resection (thin rim of enhancement) versus 24 patients with subtotal resection did yield significant differences in survival (15.9 vs 13.2 vs 11.1 months, respectively, Log-Rank p = 0.03). We also found significant correlation between post-operative tumour volume and overall survival. Conclusions: Factors influencing GTR include pre-operative tumour size and involvement of more than one lobe. Categorising patients with respect to complete, near total and subtotal resection did yield small but significant differences in survival, and the size of post-operative tumour volume is correlated with survival.

OBJECTIVE:Incidentally discovered diffuse low-grade gliomas progress in a fashion similar to their symptomatic counterparts. Their early detection allows more effective pre-emptive and individualized oncological treatment. We assessed the safety and efficacy of maximal safe resection according to functional boundaries for incidental diffuse low-grade gliomas in eloquent areas. MATERIAL AND METHODS:Two-centre retrospective series of adult patients with incidental diffuse low-grade gliomas located within/close to eloquent areas in the dominant hemisphere, treated with maximal surgical resection according to functional boundaries under intraoperative functional cortico-subcortical monitoring under awake conditions, and with a minimal follow-up of 24months. RESULTS:The series included 19 patients (8 men, 11 women) with no preoperative neurological deficit but with a radiologically enlarged glioma. No intraoperative seizure, postoperative infection, haematoma or wound-healing problem was observed. In the immediate postsurgical period, a transient neurological worsening occurred in 10 patients. The resection (mean rate 96.4%; range, 82.4-100) was supratotal in 5 cases, total in 5 cases, subtotal in 7 cases, and partial in 2 cases. Six months after surgery, all patients recovered after functional rehabilitation, with no permanent neurological deficit, Karnofsky Performance Status was 100 (except for one patient who received early postoperative radiotherapy) and no seizures were observed. The survival without progression requiring oncological treatment was significantly longer in patients with a total/supratotal resection than in patients with a partial/subtotal resection. CONCLUSIONS:These results suggest the reproducibility, safety, and effectiveness of an early maximal functionally based resection within cortico-subcortical functional boundaries for incidental diffuse low-grade gliomas in adults in centres hyperspecialized in surgical neuro-oncology.

We report a case of an intra-adenoma pituitary metastasis secondary to undiagnosed lung cancer. An 80-year-old man presented with rapid visual loss effecting his left eye secondary to a pituitary tumour. Following endoscopic transphenoidal resection, histology revealed that the pituitary tumour consisted of a metastatic lung adenocarcinoma contained within a pituitary adenoma. This case highlights a rare cause to be considered in the differential diagnosis of a patient presenting with abrupt visual loss.