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Innovations in the Diagnosis and Surgical Management of Low-Grade Gliomas

Uribe-Cardenas, Rafael; Giantini-Larsen, Alexandra M; Garton, Andrew; Juthani, Rupa Gopalan; Schwartz, Theodore H
Low-grade gliomas are a broad category of tumors that can manifest at different stages of life. As a group, their prognosis has historically been considered to be favorable, and surgery is a mainstay of treatment. Advances in the molecular characterization of individual lesions has led to newer classification systems, a better understanding of the biological behavior of different neoplasms, and the identification of previously unrecognized entities. New prospective genetic and molecular data will help delineate better treatment paradigms and will continue to change the taxonomy of central nervous system tumors in the coming years. Advances in the field of radiomics will help predict the molecular profile of a particular tumor through noninvasive testing. Similarly, more precise methods of intraoperative tumor tissue analysis will aid surgical planning. Improved surgical outcomes propelled by novel surgical techniques and intraoperative adjuncts and emerging forms of medical treatment in the field of immunotherapy have enriched the management of these lesions. We review the contemporary management and innovations in the treatment of low-grade gliomas.
PMID: 36192864
ISSN: 1878-8769
CID: 5353042

Challenges in the Diagnosis and Management of Low-Grade Gliomas

Giantini-Larsen, Alexandra M; Pannullo, Susan; Juthani, Rupa Gopalan
Low-grade gliomas are clinically challenging entities. Patients with these tumors tend to be relatively young at presentation, and lesions are often incidental findings or are identified because the patient presents with a seizure. Rapidly emerging and evolving molecular classifications of gliomas have influenced treatment paradigms. Importantly, low-grade gliomas can be classified on the basis of IDH mutation status, whereby low-grade astrocytomas harbor the IDH mutation, while oligodendrogliomas are defined by both IDH mutant status and 1p/19q co-deletion. Given the importance of molecular classification for diagnosis, treatment planning, and prognostication, tissue samples are necessary for proper management. Literature supports improved overall survival and outcomes with increased extent of resection for low-grade glioma. Awake craniotomies and resection of insular low-grade gliomas both have been demonstrated as safe and improve outcomes for patients with lesions located in eloquent areas. Given the younger age at diagnosis of these lesions compared with higher-grade gliomas, fertility, fertility preservation, and potential malignant transformation should be discussed with patients of childbearing age.
PMID: 36192863
ISSN: 1878-8769
CID: 5353032

Foundations of the Diagnosis and Management of Low-Grade Gliomas

Norman, Sofya; Juthani, Rupa Gopalan; Magge, Rajiv
In the past, low-grade gliomas-World Health Organization (WHO) grade I and II tumors-were generally expected to have a much better prognosis than higher-grade (WHO grade III and IV) gliomas. However, diffuse gliomas (WHO grade II), unlike WHO grade I gliomas, are by definition infiltrative, limiting resection and potentially contributing to poor outcomes like those seen with malignant gliomas. Rapid progress in the understanding of the pathogenesis of these tumors indicates that specific molecular factors, especially isocitrate dehydrogenase mutation status and the presence or absence of the 1p/19q codeletion (deletion of the short arm of chromosome 1 and long arm of chromosome 19), are much more important than grade in determining prognosis and response to treatment. These molecular characteristics outweigh the histologic distinctions and have been quickly incorporated into the WHO classification of gliomas. Management of these tumors with surgery, radiation, and chemotherapy has similarly been transformed by these developments, highlighting the need for a customized approach for patients with low-grade gliomas.
PMID: 36192862
ISSN: 1878-8769
CID: 5353022

Novel approaches to the management of patients with 5-15 brain metastases: a narrative review

Giantini-Larsen, Alexandra M; Juthani, Rupa Gopalan; Pannullo, Susan C; Knisely, Jonathan P S
BACKGROUND AND OBJECTIVE/OBJECTIVE:The management of metastatic disease has been greatly influenced by molecular-based tumor classification and associated therapeutic targets, leading to a significant improvement in survival in many cases. This improvement, in both progression free survival and overall survival, has led to an increased incidence of brain metastases (BM) in a population with systemically well controlled disease or patients with promising therapeutic options available. Within this review, we discuss the paradigm of treatment for 5 to 15 BM, and how the treatment has evolved away from short-term palliation towards providing long term intracranial control. METHODS:A review of literature pertaining to treatment of multiple BM was performed. We searched in PubMed to identify literature on treatment of multiple brain metastases. Only English literature published until February 1st, 2022 was reviewed. KEY CONTENT AND FINDINGS/UNASSIGNED:The management of 5-15 BM include multi-modality treatment pathways that are tailored towards each individual's primary cancer and burden of disease. Surgical resection of a dominant metastasis is still reserved for large symptomatic lesions, and is combined with post-operative local disease control. Overall, there is a shift away from whole brain radiation therapy (WBRT) due to side effect profile towards stereotactic radiosurgery (SRS). However, advances in WBRT continue to be studied, as well as the use of immunotherapy, targetable mutations, and synergistic effects between SRS and targeted therapies. CONCLUSIONS:The use of SRS to treat 5 to 15 BM is an increasingly acceptable and well-regarded practice, along with a combinatorial approach taking into account systemic options during all treatment timepoints.
PMID: 35534795
ISSN: 2304-3873
CID: 5353012

Acromegaly: Medical and Surgical Considerations

Giantini-Larsen, Alexandra M; Uribe-Cardenas, Rafael; Juthani, Rupa Gopalan
Acromegaly results from excessive secretion of insulinlike growth factor-1 and growth hormone, which most commonly occurs because of pituitary somatotrophinoma. Diagnostic features of acromegaly include elevated insulinlike growth factor-1 and growth hormone; lesion on brain MRI; and clinically dysmorphic features, such as soft tissue swelling, jaw prognathism, and acral overgrowth. Transsphenoidal resection is the primary therapy for individuals with acromegaly, even in the cases where gross total resection is not possible because of parasellar extension and cavernous sinus involvement. For recurrent or persistent disease after resection, systemic medications and stereotactic radiosurgery are used.
PMID: 35256175
ISSN: 1557-8259
CID: 5353002

Spine registries

Chapter by: Bydon, M; Alvi, M; Yolci, Y; Juthani, Rupa; Krishnaney, A
in: Benzel's spine surgery : techniques, complication avoidance, and management by Steinmetz, Michael P; et al (Eds)
Philadelphia, PA : Elsevier, [2017]
pp. ?-?
ISBN: 9780323826860
CID: 5457302

Characterization of Hemorrhagic and Ischemic Stroke in a Diverse Cohort of COVID-19 Patients

Ramos, Alexander D; Koyfman, Feliks; Byrns, Kory; Wu, Alan; Yasen, Jay; Elreda, Lauren; Boddu, Srikanth; Pishanidar, Sammy; Allen, Baxter; Juthani, Rupa G
BACKGROUND AND PURPOSE/OBJECTIVE:COVID-19 is a known risk factor for stroke. There is limited data on the influence of demographics, risk factors, and hematologic function on outcomes in COVID-19 stroke patients. METHODS:All patients with acute ischemic or hemorrhagic stroke tested for COVID-19 and treated from March 13 through May 19, 2020 were retrospectively analyzed. COVID+ patients were compared to COVID- patients and a historical cohort from 2019. RESULTS:84 patients with radiographic acute stroke from the 2020 study period and 152 patients in the historical cohort were included. Stroke incidence in COVID+ patients was 1.5%, with a significant decline in total stroke presentations during this period compared to 2019. 37 patients were COVID+ and 47 patients were COVID-. 32% of COVID+ stroke patients were Hispanic compared to 15% and 18% in the COVID- and 2019 cohorts respectively (p = 0.069 and 0.07). COVID+ stroke patients were younger, had higher rates of hemorrhagic conversion (p = 0.034), higher initial NIHSS (p < 0.001), increased cryptogenic stroke mechanism (p = 0.02), and higher mortality independent of COVID-19 severity. COVID+ patients had higher rates of thrombocytopenia (p = 0.02), and were less likely to be on antiplatelet therapy (p = 0.025). In multivariable analysis, only COVID-19 status independently predicted mortality. CONCLUSIONS:COVID status, independent of severity, was significantly associated with higher mortality in stroke patients. COVID+ stroke patients were younger and less likely to be on antiplatelets, with higher rates of thrombocytopenia, suggesting a possible role for antiplatelet use in this population.
PMID: 34567389
ISSN: 1941-8744
CID: 5352992

Impact of the COVID-19 pandemic on neuro-oncology outcomes

Norman, Sofya; Ramos, Alexander; Giantini Larsen, Alexandra M; Bander, Evan; Goldberg, Jacob; Parker, Whitney; Juthani, Rupa G
INTRODUCTION/BACKGROUND:The Coronavirus disease 2019 (COVID-19) pandemic has uprooted healthcare systems worldwide, disrupting care and increasing dependence on alternative forms of health care delivery. It is yet to be determined how the pandemic affected neuro-oncology patient outcomes, given that the majority of even "elective" neurosurgical oncology procedures are time-sensitive. This study quantifies changes in neuro-oncological care during the height of the pandemic and investigates patient outcomes in 2020 compared to a historical control. METHODS:We performed a retrospective review of patients with malignant brain tumor diagnoses who were seen at our institution between March 13 and May 1 of 2020 and 2019. Alterations in care, including shift from in-person to telehealth, delays in evaluation and intervention, and treatment modifications were evaluated. These variables were analyzed with respect to brain tumor control and mortality. RESULTS:112 patients from 2020 to 166 patients from 2019 were included. There was no significant difference in outcomes between the cohorts, despite significantly more treatment delays (p = 0.0160) and use of telehealth (p < 0.0001) in 2020. Patients in 2020 who utilized telehealth visits had significantly more stable tumor control than those who had office visits (p = 0.0124), consistent with appropriate use of in-person visits for patients with progression. CONCLUSIONS:Our study showed that use of telehealth and selective alterations in neuro-oncological care during the COVID-19 pandemic did not lead to adverse patient outcomes. This suggests that adaptive physician-led changes were successful and may inform management during the ongoing pandemic, especially with the emergence of the Delta variant.
PMID: 34510329
ISSN: 1573-7373
CID: 5352982

COVID-19: A Time Like No Other in (the Department of) Neurological Surgery

Pannullo, Susan C; Guadix, Sergio W; Souweidane, Mark M; Juthani, Rupa G; Baaj, Ali A; Dupree, Tracey; Strybing, Kristin; Henry, Roseann F; Linen, Harry; O'Neill, John; Stieg, Philip E
Coronavirus disease 2019 (COVID-19) has disrupted lives and indelibly impacted the practice of medicine since emerging as a pandemic in March 2020. For neurosurgery departments throughout the United States, the pandemic has created unique challenges across subspecialties in devising methods of triage, workflow, and operating room safety. Located in New York City, at the early epicenter of the COVID-19 crisis, the Weill Cornell Medicine Department of Neurological Surgery was disrupted and challenged in many ways, requiring adaptations in clinical operations, workforce management, research, and education. Through our department's collective experience, we offer a glimpse at how our faculty and administrators overcame obstacles, and transformed in the process, at the height of the COVID-19 pandemic.
PMID: 33770848
ISSN: 1878-8769
CID: 4830202

Neurosurgery in COVID-19 Ground Zero: The Weill Cornell Medicine Experience

Winston, Graham M; Garton, Andrew L A; Chae, John K; Odigie, Eseosa R; Sehgal, Ryka R; Rivera, Maricruz; Goldberg, Jacob L; Hussain, Ibrahim; Juthani, Rupa G; Virk, Michael; Pannullo, Susan C
The mobilization of subspecialty departments in reaction to the unique demands of the onset of the coronavirus disease 2019 (COVID-19) pandemic in New York City was swift and left little time for reflection and commemoration. The early days of the pandemic brought unprecedented stressors on the medical system that necessitated a restructuring of hospitals, reallocation of health care workers, and a shift in care and education paradigms to meet patient care demands and public health needs. As the number of cases, intensive care unit patients, and deaths skyrocketed in New York City, many struggled with a somewhat paradoxical difficulty in perceiving the human value of what these numbers mean. Easily lost in the statistics are the stories and experiences of the physicians and trainees who were counted on to halt their own clinical practices and adapt their skillsets to tackle the pandemic. In this article, we present 10 brief narratives from the student members of the Neurosurgery Publication Group at Weill Cornell Medical College and members of the Weill Cornell Medicine Neurological Surgery Residency Program and Department of Neurological Surgery faculty. Reflecting on these individual experiences gives us an opportunity to simultaneously contribute to a history of New York City's reaction to COVID-19 and commemorate the individuals who were impacted by or succumbed to this disease.
PMID: 33770849
ISSN: 1878-8769
CID: 5352972