Endoskopsko liječenje unutarmaternično otkrivene multilokularne interhemisferične ciste u novorođenčeta: prikaz slučaja

Interhemispheric cysts, often associated with agenesis of corpus callosum, are rare lesions. The optimal treatment is still controversial. Placement of cystoperitoneal shunt and open microsurgery are traditional treatments. Neuroendoscopy in children is due to its minimal invasiveness a new emerging option. There have been a few published cases on neuroendoscopic treatment of interhemispheric cyst in children. The authors document the youngest reported child with multiloculated interhemispheric cyst that was treated with neuroendoscopy. The cyst was detected in a male fetus in 35th week of gestation and in utero magnetic resonance imaging was performed in 37th week of gestation. After delivery, progressive macrocrania with signs of raised intracranial pressure developed. Endoscopic cystoventriculocisternostomy was performed 28 days after the birth. There was a marked symptom relief. One month after the surgery, magnetic resonance showed shrinkage of the cyst and expansion of the brain parenchyma. After a 2-month follow up period, the child showed normal neurologic development and head circumference increased by only 0.5 cm. The created fenestrations enabled the brain to expand. Neuroendoscopic treatment of interhemispheric cysts should be considered the operative technique of choice in newborns. Although the intracranial pressure and the size of the cyst have decreased, long-term follow up is necessary and future studies on more cases are needed.Interhemisferične ciste, često s pridruženom agenezom korpusa kalozuma, rijetko se pojavljuju. Optimalno liječenje je još uvijek sporno. Cistoperitonealna drenaža i otvoreni mikrokirurški zahvat su tradicionalne metode. Neuroendoskopija u djece je obećavajuća metoda zbog svoje minimalne invazivnosti. Dosad je objavljeno svega nekoliko slučajeva neuroendoskopskog liječenja interhemisferične ciste u djece. U ovom članku su autori opisali slučaj najmlađeg djeteta s multilokularnom interhemisferičnom cistom operiranog neuroendoskopskom tehnikom. Cista je bila otkrivena u muškog fetusa u 35. tjednu trudnoće, a u 37. tjednu je učinjena magnetska rezonancija unutar maternice. Nakon poroda se razvio ubrzan rast glave i znaci povišenog intrakranijskog tlaka. Učinjena je endoskopska cistoventrikulocisternostomija 28. dana nakon poroda i nastupilo je značajno poboljšanje. Mjesec dana nakon zahvata kontrolna magnetska rezonancija je pokazala smanjivanje ciste i širenje tkiva mozga. Nakon dvomjesečnog praćenja utvrđen je normalan neurološki razvoj djeteta, a opseg glave je porastao za samo 0,5 cm. Otvori u membrani ciste su omogućili širenje mozga. Neuroendoskopsko liječenje interhemisferične ciste bi trebalo smatrati metodom izbora u novorođenčadi. Međutim, iako su se intrakranijski tlak i volumen ciste smanjili, potrebna su daljnja istraživanja na većem broju bolesnika i uz dugoročno praćenje

Trans-endoskopska operacija kraniofaringeoma i oporavak vida nakon sljepoće u odrasle bolesnice - prikaz slučaja

We report a case of trans-endoscopic transventricular approach to a large cystic craniopharyngioma. Surgery was performed three days after visual acuity on both eyes deteriorated to blindness. Magnetic resonance imaging before surgery revealed a large lesion in the suprasellar region that severely compressed the optic chiasm and displaced the third ventricle upward. The lesion was operated through the trans-endoscopic transventricular approach, with the aim of urgent decompression of the optic apparatus. At first, wide ventriculo-cysto-cisternostomy was performed, and then tumor tissue was removed. Postoperatively, visual acuity significantly improved on one eye. Our case shows that this minimally invasive technique is safe and effective and can be an alternative treatment for large cystic craniopharyngiomas. The reported case also shows that loss of vision can still be recovered even after the 72-hour period in adults.U radu je prikazana trans-endoskopska operacija velikog cističnog kraniofaringeoma transventrikulskim pristupom. Bolesnica je operirana tri dana nakon što je potpuno oslijepila. Magnetska rezonanca prije operacije je pokazala veliku cističnu leziju u supraselarnoj regiji s izrazitom kompresijom optičke kijazme i treće moždane komore. Učinjena je trans-endoskopska operacija transventrikulskim pristupom s ciljem hitne dekompresije optičkog aparata. Najprije je šupljina ciste povezana sa subarahnoidnim prostorom i trećom moždanom komorom, a nakon toga je odstranjen solidni dio tumora. Nakon zahvata se vid na jednom oku značajno popravio. Ovaj slučaj pokazuje da trans-endoskopska, minimalno invazivna transventrikulska operacija može biti sigurna i učinkovita metoda u liječenju velikih cističnih kraniofaringeoma. Također pokazuje da je oporavak vida u nekim slučajevima moguć i nakon 72 sata potpune sljepoće u odraslog bolesnika

Preprečevanje venskih trombembolizmov pri nevrokirurških operacijah – Stališča Kliničnega oddelka za nevrokirurgijo in Kliničnega oddelka za žilne bolezni Univerzitetnega kliničnega centra Ljubljana

Venski trombembolizmi (VTE) so pogost in resen zaplet po nevrokirurških operacijah. Najbolj učinkovita so pri preprečevanju VTE protitrombotična zdravila, ki pa lahko povečajo tveganje za krvavitev. Posledice morebitne intrakranialne ali intraspinalne krvavitve so pogosto hujše kot korist ob preprečitvi VTE. Ker se nevrokirurške operacije razlikujejo glede tveganja za VTE ali za krvavitev, je treba ob vsaki operaciji uporabiti za konkretni poseg optimalno metodo za preprečevanje VTE. V prispevku so po prikazu obstoječe literature prikazana stališča, ki jih je oblikovala delovna skupina s Kliničnega oddelka za nevrokirurgijo in Kliničnega oddelka za žilne bolezni Univerzitetnega kliničnega centra Ljubljana

The impact of biomarkers CD9 and TRIM28 on overall survival of patients with glioblastoma

Ozadje: Glioblastom (GB) je eden izmed najmalignejših možganskih tumorjev s povprečnim preživetjem bolnikov zgolj 12–15 mesecev. Glavni razlogi za njegovo visoko malignost in slabo prognozo so invazivnost, heterogenost in odpornost glioblastomskih matičnih celic (GMC) na zdravljenje. Opredelitev bioloških označevalcev GMC in natančnejša razdelitev GB v podvrste bi lahko doprinesli k boljšemu poznavanju bolezni in učinkovitejšemu zdravljenju bolnikov. Kot možna označevalca GMC sta bila v nedavnih raziskavah prepoznana tetraspanin CD9 in transkripcijski dejavnik TRIM28. Metode: V prospektivno raziskavo smo vključili 89 bolnikov z GB, operiranih od leta 2012 do januarja 2020 na Kliničnem oddelku za nevrokirurgijo Univerzitetnega kliničnega centra Ljubljana. Opredelili smo histopatološke in molekularne značilnosti tumorjev, značilnosti zdravljenja in preživetje bolnikov. Iz vzorcev tumorja smo izolirali ribonukleinsko kislino in z verižno reakcijo s polimerazo na mikrofluidnem čipu analizirali nivoje izražanja 15 izbranih genov za opredelitev podvrst GB. S tako prilagojeno klasifikacijo po Behnanu smo vzorce GB razvrstili v klasično (CL), mezenhimsko (MES) in pronevralno (PN) podvrsto. Preostale vzorce GB, ki kriterijev za uvrstitev v omenjene podvrste niso izpolnjevali, pa smo uvrstili v mešano (MIX) podvrsto. V GB podvrstah smo določili nivo izražanja genov CD9 in TRIM28 ter preverili njun vpliv na preživetje bolnikov. Vzpostavili smo tudi celične linije tumorskih celic, ki so bile pridobljene iz biopsij tumorjev. Preverili smo vpliv ciljanja označevalcev CD9 in TRIM28 na rast človeških GMC in GB celic in vivo na modelu zarodkov rib cebric. Označevalec TRIM28 smo zavirali z nanoprotitelesom NB237, gen CD9 pa smo utišali z lentivirusnim vektorjem. Z invertnim fluorescentnim mikroskopom smo prvi in tretji dan po vsaditvi celic v možgane zarodkov rib cebric opredelili velikost in fluorescenco tumorja ter tako in vivo določili invazijo in proliferacijo GB celic. Pri preskušanju domnev smo vrednost p < 0,05 privzeli kot statistično značilno. Rezultati: Povprečna starost bolnikov ob operaciji je bila 62 ± 13 let, 65,2 % je bilo moških. Tumor se je pogosteje nahajal v desni možganski hemisferi (56,2 %), v večini primerov je bil omejen na en reženj (82,2 %). S prilagojeno klasifikacijo po Behnanu smo GB razdelili v CL (n = 2123,6 %), MES (n = 55,6 %) in PN (n = 77,9 %) podvrsto. 62,9 % vseh GB (n = 56) ni bilo moč uvrstiti v omenjene tri podvrste, zato smo jih uvrstili v MIX podvrsto. Izražanje označevalca CD9 je bilo statistično značilno povečano v CL podvrsti v primerjavi z MES (p = 0,003) in MIX podvrsto (p 0,05). Primerjava izražanja označevalca TRIM28 v različnih podvrstah ni pokazala statistično značilnih razlik (vsi p > 0,05). Pri vseh bolnikih je bila opravljena vsaj delna resekcija tumorja, pri 42,7 % bolnikov je bila resekcija popolna. Celokupno preživetje bolnikov z GB je bilo 14,1 mesecev (95 % interval zaupanja 11,1–17,0 mesecev). Kot neodvisna napovedna dejavnika preživetja sta se izkazala obseg resekcije tumorja (nepopolna vs. popolna odstranitev: razmerje ogroženosti 2,4295 % interval zaupanja 1,40–4,20) in pooperativna ocena zmogljivosti bolnika po Karnofskem (? 70 vs. 0,05). Preživetje bolnikov s CL podvrsto je bilo krajše kot preživetje bolnikov z MIX podvrsto (p = 0,013), med preostalimi podvrstami pa v preživetju ni bilo značilnih razlik. In vivo v možganih zarodkov rib cebric se je po aplikaciji nanoprotitelesa TRIM28 invazija GB celic NB237 zmanjšala za 13–15 %, invazija GMC pa za 25 % (vsi p < 0,05). Invazija GMC se je v skupini s z utišanim genov CD9 zmanjšala za 20 % (p < 0,001), invazija GB celic U87 pa za 24 % (p < 0,05). Sklepi: Prilagojena klasifikacija po Behnanu, ki smo jo v raziskavi uporabili za razvrstitev GB v različne podvrste, se morda ni izkazala za optimalno, saj smo velik del tumorjev uvrstili v MIX podvrsto, kar lahko kaže na heterogenost GB. Izražanje označevalca CD9 je bilo statistično značilno povečano v CL podvrsti v primerjavi z MES in MIX podvrsto, izražanje označevalca TRIM28 pa se med podvrstami ni pomembno razlikovalo. Stopnja izražanja označevalcev CD9 in TRIM28 ni imela vpliva na preživetje bolnikov z GB. Ugotovili pa smo, da imata tako CD9 kot TRIM28 pomembno vlogo pri invaziji GB celic in GMC, ki smo jo z utišanjem gena ali ciljanjem s selektivnimi nanotelesi zmanjšali. Z raziskavo smo validirali zaviralno nanoprotitelo proti TRIM28, kar odpira vrata novim možnostim zdravljenja. Ugotovili smo, da je s kirurškega vidika predvsem pomembno stremeti k popolni resekciji GB, saj se je le-ta izkazala kot neodvisen napovedni dejavnik boljšega preživetja. Kljub vsem trenutnim možnostim zdravljenja pa ostaja GB bolezen z zelo slabo prognozo. Njegova nizka pojavnost ter velika inter- in intratumorska heterogenost, ki smo jo prikazali tudi z našimi rezultati, otežujeta njegovo raziskovanje. Med raziskavo smo v slovenskem prostoru vzpostavili biobanko GB poimenovano Gliobanka, kar nam bo omogočilo izvedbo raziskav na večjem številu vzorcev in učinkovitejše proučevanje bolezni.Introduction: Glioblastoma (GB) is one of the most malignant brain tumors with an average overall patient survival of 12–15 months. The main reasons for its high malignancy and poor prognosis are the invasiveness, heterogeneity and resistance of glioblastoma stem cells (GSC) to treatment. The definition of GSC biomarkers and a more accurate classification of GB into subtypes could contribute to a better understanding of the disease and more efficient treatment of patients. The tetraspanin CD9 and the transcription factor TRIM28 have been suggested as possible markers of GSC in recent studies. Methods: In a prospective study, we included 89 patients with GB who were operated from 2012 to January 2020 at the Clinical department of neurosurgery at the University medical centre Ljubljana. We determined the histopathological and molecular characteristics of the tumors and patient survival. To define of GB subtypes, we isolated ribonucleic acid from tumor samples and analyzed the expression levels of 15 selected genes using polymerase chain reaction on a microfluidic chip. With such application of adapted of Behnan classification, GB samples were classified into classical (CL), mesenchymal (MES) and proneural (PN) subtypes. The remaining GB samples, which did not meet the criteria for inclusion in the aforementioned substypes, were classified as the mixed (MIX) subtype. We determined the expression level of CD9 and TRIM28 genes in GB subtypes and analysed their effect on patient survival. We also established cell lines from tumor cells obtained from tumor biopsies. We examined the effect of CD9 and TRIM28 markers targeting on the growth of human GSC and GB cells in vivo in the zebrafish embryo model. The TRIM28 protein was inhibited with its selective nanobody NB237, and the CD9 gene was silenced with a lentiviral vector. On the first and third day after the implantation of cells into the brain of zebrafish embryos, we determined the size and fluorescence of the tumor using the fluorescence microsopy, thus in vivo determining the invasion and proliferation of GB cells. When testing hypotheses, we assumed a value of p < 0.05 as statistically significant. Results: The average age of the patients was 62 ± 13 years, 65.2% were men. The tumor was more often located in the right cerebral hemisphere (56.2%) and in most cases it was limited to one lobe (82.2%). Using the adapted Behnan classification, GB were divided into CL (n = 2123.6%), MES (n = 55.6%) and PN (n = 77.9%) subtypes. 62.9% of all tumors (n = 56) could not be classified into the mentioned GB subtypes, so we classified them as the MIX subtype. CD9 marker expression was statistically significantly increased in CL subtype compared to MES (p = 0.003) and to MIX subtype (p 0.05). Comparison of TRIM28 marker expression in different subtypes showed no statistically significant differences (all p > 0.05). The tumor resection was complete In 42.7% of patients. The average survival of patients with GB was 14.1 months (95% confidence interval 11.1–17.0 months). The extent of tumor resection (incomplete vs. complete resection: hazard ratio 2.4295% confidence interval 1.40–4.20) and postoperative Karnofsky performance score (⡥ 70 vs. 0.05). The survival of patients with CL subtype was shorter than that of patients with MIX subtype (p = 0.013)there were no significant differences in survival between the remaining subtypes. In vivo in the brain of zebrafish embryos, GB cell invasion was reduced by 13–15% and GSC invasion by 25% (all p < 0.05) after addition of TRIM28 nanobody NB237. GSC invasion was reduced by 20% (p < 0.001) and U87 GB cell invasion by 24% (p < 0.05) in the group of cells silenced for CD9 gene. Conclusion: The adapted Behnan classification, which we used in the study to classify GB into different subtypes, did not prove to be optimal, since we had to classify a large part of the tumors as the MIX subtype indicating GB heterogeneity. CD9 marker expression was statistically significantly increased in the CL subtype compared to MES and MIX subtypes, while TRIM28 marker expression was not significantly different among subtypes. The expression level of CD9 and TRIM28 markers had no influence on the survival of patients with GB. However, we found that both CD9 and TRIM28 play an important role in the invasion of GB cells and GSC, which we managed to reduce by lowering their expression by gene silecing and using selective nanobodies respectively. We have validated the selective nanobody against TRIM28, which opens the door to new treatment options. Complete GB resection should be achieved, as we have proved that it was an independent predictor of better patient survival. Despite all current treatment options, GB remains a disease with a very poor prognosis. Its low incidence and great inter- and intratumoral heterogeneity, which we also demonstrated with our results, make its research difficult. During the study, we established the GB biobank in Slovenia, which will enable us to conduct GB research on a larger number of samples and to study the disease more efficiently

The Cytotoxic Effects of Cannabidiol and Cannabigerol on Glioblastoma Stem Cells May Mostly Involve GPR55 and TRPV1 Signalling

Glioblastoma (GBM) is one of the most aggressive cancers, comprising 60–70% of all gliomas. The large G-protein-coupled receptor family includes cannabinoid receptors CB1, CB2, GPR55, and non-specific ion receptor protein transporters TRPs. First, we found up-regulated CNR1, GPR55, and TRPV1 expression in glioma patient-derived tissue samples and cell lines compared with non-malignant brain samples. CNR1 and GPR55 did not correlate with glioma grade, whereas TRPV1 negatively correlated with grade and positively correlated with longer overall survival. This suggests a tumour-suppressor role of TRPV1. With respect to markers of GBM stem cells, preferred targets of therapy, TRPV1 and GPR55, but not CNR1, strongly correlated with different sets of stemness gene markers: NOTCH, OLIG2, CD9, TRIM28, and TUFM and CD15, SOX2, OCT4, and ID1, respectively. This is in line with the higher expression of TRPV1 and GPR55 genes in GSCs compared with differentiated GBM cells. Second, in a panel of patient-derived GSCs, we found that CBG and CBD exhibited the highest cytotoxicity at a molar ratio of 3:1. We suggest that this mixture should be tested in experimental animals and clinical studies, in which currently used Δ9-tetrahydrocannabinol (THC) is replaced with efficient and non-psychoactive CBG in adjuvant standard-of-care therapy

Odpornost glioblastoma na radioterapijo : vpliv rakavih matičnih celic in mikroo[ko]lja tumorja

Glioblastom je najpogostejši možganski tumor pri odraslih z zelo slabo prognozo preživetja bolnikov. Ta je posledica odpornosti glioblastoma na standardno zdravljenje, ki vključuje radioterapijo in kemoterapijo. Z namenom načrtovanja učinkovitejših pristopov zdravljenja preučujemo biološke mehanizme odpornosti glioblastoma na radioterapijo s poudarkom na mikrookolju tumorja in rakavih matičnih celicah. V predkliničnih raziskavah uporabljamo napredne in personalizirane celične modele, ki posnemajo mikrookolje tumorja v bolnikih in z večjo natančnostjo napovedo odziv bolnika na zdravljenje. Hkrati so takšni modeli pomembni za testiranje novih pristopov za zdravljenje kot je imunoterapija

TRIM28 selective nanobody reduces glioblastoma stem cell invasion

Glioblastoma (GB), is the most common and aggressive malignant primary brain tumour in adults. Intra- and inter-tumour heterogeneity, infiltrative GB cell invasion and presence of therapy-resistant GB stem cells (GSCs) represent major obstacles to favourable prognosis and poor therapy response. Identifying the biomarkers of the most aggressive tumour cells and their more efficient targeting strategies aretherefore, crucial. Recently, transcription factor TRIM28 has been identified as a GB biomarker and, in this study, we have shown high expression of TRIM28 in GB and in low grade gliomas as well as higher expression in GSCs vs. differentiated GB cells, although in both cases not significant. We demonstrated significant in vitro inhibition of GB cells and GSCs invasiveness and spread in zebrafish brains in vivo by anti-TRIM28 selective nanobody NB237. TRIM28 was also enriched in GB (tumour) core and associated with the expression of stem cell genes, but was not prognostic for overall survival. However, based on the above results, we conclude that TRIM28 nanobody NB237 offers a new opportunity as a GB therapeutic tool