The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 6/29 FRI - 30 SAT 6/29 FRI 18:30 6/30

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1 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 6/29 FRI - 30 SAT 6/29 FRI 18:30 6/30 SAT 08:20-17:40

2 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting

3 인사말 대한뇌종양학회회원님, 제28차대한뇌종양학회정기학술대회와제12차한 중뇌종양학술대회에회원여러분을초대합니다. 회원님들의헌신적인노고덕분에우리학회의위상이국내외적으로나날이발전하고있으며회원간의유대관계가공고한학회로더욱커나가고있습니다. 전임회장님들과회원여러분의열정과수고에다시한번감사말씀을드립니다. 이번정기학술대회에서는그동안다소제한적이었던자유연제발표세션을대폭확대하여, 많은회원분들이발표할수있는기회를최대한제공하고자합니다. 회원여러분들의적극적인참여와관심이이번학회를보다알차게만들것입니다. 또한, 지난 12년동안양국을오가며지속되고있는한 중뇌종양학술대회를통해양국뇌종양전문가들의학문적, 인적교류를더욱증진시키겠습니다. 해외연자로는두개저수술경험이많은 Kenji Ohata 교수와 Michihiro Kohno 교수를초대하였습니다. 수술적접근이어려운추체사대부수막종과복잡한두개인두종수술, 그리고소뇌교뇌각수막종과청신경초종에대한두분석학들의경험을직접듣고의견교환하실수있는좋은기회가될것으로기대합니다. 이번정기학술대회전야제에서는이번집행부의주요추진사업이었던뇌종양한글교과서출판기념식이진행될예정입니다. 전공의뿐아니라, 뇌종양을전공하고있는여러회원님들에게도뇌종양을보다쉽게이해하고접근하는계기가될것으로봅니다. 청정골화순에많은회원님들께서오셔서학문적정보도공유하시고많은친교도더욱맺으시길바랍니다. 회원여러분! 전남대학교화순캠퍼스에서뵙겠습니다 년 6 월대한뇌종양학회회장정신 3

4 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting TABLE OF CONTENTS Part I. General Information Program at a Glance _ 5 전임회장단 _ 7 상임운영위원회구성 _ 8 학술프로그램 _ 9 등록안내 _ 11 좌장및연자유의사항 _ 12 Part II. Abstract Scientific Session I _ 13 Scientific Session II _ 21 Honored Lecture _ 29 Symposium _ 33 Luncheon Seminar _ th Chinese-Korean Brain Tumor Joint Meeting _ 51 Scientific Session III _ 63 간호사세션 _ 71 Scientific Session IV _ 75 Scientific Session V _ 81 Poster Session _ 87 Part III. Appendix 대한뇌종양학회회칙 _ 97 4

5 PROGRAM-AT-A-GLANCE 08:20-09:00 Registration 09:00-10:00 Scientific Session I (Room A) 좌장 : 이선일 ( 인제대 ), 김세혁 ( 아주대 ) 09:00-10:00 Scientific Session II (Room B) 좌장 : 이채혁 ( 인제대 ), 유헌 ( 국립암센터 ) 10:00-10:10 Opening Remark 대한뇌종양학회회장정신 10:10-10:40 Honored Lecture 좌장 : 정신 ( 전남대 ) From startup to scaleup neuro-oncology 홍용길 ( 가톨릭대 ) 10:40-11:00 Coffee Break 11:00-11:50 Symposium: Tumors in Challenge 좌장 : 김오룡 ( 영남대 ), 고용 ( 한양대 ) 1) Petroclival meningiomas resected via a combined transpetrosal approach: surgical outcomes in 60 cases and a new scoring system for clinical evaluation Kenji Ohata(Osaka City University, Japan) 2) Facial nerve preservation in surgery for large vestibular schwannomas Michihiro Kohno(Tokyo Medical University, Japan) 12:00-13:00 Luncheon Seminar: Peri-operative Medical Issues (Room B) 좌장 : 박봉진 ( 경희대 ), 곽호신 ( 국립암센터 ) 1) Anticoagulation 나상훈 ( 서울대내과 ) 2) Delirium 김정란 ( 충남대정신건강의학과 ) 3) Nutritional Support Team(NST) 정미란 ( 전남대외과 ) 13:00-13:20 Commemorative Photo & Break 13:20-14:40 12 th Chinese-Korean Brain Tumor Joint Meeting 좌장 : 정용구 ( 고려대 ), Zhixiong Lin(Capital Medical University, China) 1) Hypoxia induce glioma stem-like cells to transdifferentiate into endothelial cells and promote glioma resistance to temozolomide by providing more JAG1 and DLL4(keynote) Zhixiong Lin(Capital Medical University, China) 2) Response assessment in glioma treatment: to be or not to be(keynote) Ke Sai(Sun Yat-sen University, China) 3) Clinical application analyses of IDH1 genetic testing combined CD-DST drug sensitivity test to guide the adjuvant chemotherapy in gliomas Zhang Ye(China Medical University, China) 4) Introduction of endoscopic transorbital approach for orbit, middle fossa, and Meckel's cave lesions 공두식 ( 성균관대 ) 5) Developing an endoscopic neurosurgical training model with 3-D printing technologies 노태훈 ( 아주대 ) 14:40-15:00 Coffee Break 5

6 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting PROGRAM-AT-A-GLANCE 15:00-16:00 Scientific Session III (Room A) 좌장 : 이창훈 ( 한국원자력의학원 ), 이기택 ( 가천대 ) 15:00-16:00 간호사세션 : 뇌종양환자에서전문간호사의역할 (Room B) 좌장 : 장성현 ( 칠곡경북대병원 ), 최민선 ( 서울아산병원 ) 1) Infection control after craniotomy 이도운 ( 화순전남대병원 ) 2) Role of PA in the comprehensive care 배진영 ( 분당서울대병원 ) 3) PA as a neurosurgeon's partner 장용준 ( 연세대세브란스병원 ) 16:00-17:00 Scientific Session IV (Room A) 좌장 : 김영규 ( 충북대 ), 김정훈 ( 울산대 ) Keynote Lecture: Approach selection in surgery for cerebellopontine angle and skull base meningiomas Michihiro Kohno (Tokyo Medical University, Japan) 16:00-17:00 Scientific Session V (Room B) 좌장 : 차승헌 ( 부산대 ), 권정택 ( 중앙대 ) Keynote Lecture: Aggressive surgery based on an anatomical subclassification of craniopharyngiomas Kenji Ohata (Osaka City University, Japan) 17:00-17:30 General Assembly and Academic Awards 17:30 Closing Remark 대한뇌종양학회회장정신 6

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8 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 8

9 학술프로그램 Scientific Session I (Glioma) 좌장 : 이선일 ( 인제대 ) / 김세혁 ( 아주대 ) The preclinical efficacy study of MSCs expressing TRAIL and CD for glioblastoma / 안스데반 ( 가톨릭대 ) 14 Supratentorial extraventricular ependymoma (STEE): retrospective analysis of 15 patients at a single institution / 변준호 ( 울산대 ) 15 ADC value as a predictive biomarker for survival in patients with treatment-naïve glioblastoma using quantitative multiparametric MR profiling / 김병섭 ( 고신대 ) 16 Proteomics analysis of LGR5 knockdown in neuroblastoma cells / 한명훈 ( 한양대 ) 17 Efficacy and safety of low dose temozolomide plus metformin as combination chemotherapy compared with low dose temozolomide plus placebo in patient with recurrent or refractory 18 glioblastoma: a randomized, prospective, multi-center, double-blind, controlled, phaseⅡ trial - an interim report/ 양승호 ( 가톨릭대 ) Altered expression of the T-cell regulators on the glioblastoma cells can be epigenetically 20 modulated by the histone methylase or demethylase and influence on the prognosis of the glioblastoma patients / 김영준 ( 성균관대 ) Scientific Session II (Brain Tumor, Others) 좌장 : 이채혁 ( 인제대 ) / 유헌 ( 국립암센터 ) Gamma knife radiosurgery and systemic chemotherapy for synchronous brain metastasis from non-small cell lung cancer / 정민호 ( 전남대 ) 22 The clinical usefulness of postoperative diffusion weighted magnetic resonance image (DWI) for brain tumor surgery / 김영일 ( 가톨릭대 ) 23 Analysis of the difference in accuracy of navigation MRI according to the position of MRI for posterior fossa lesions / 도윤식 ( 서울대 ) 24 Follow-up and treatment of the patients with coexisting brain tumor and intracranial aneurysms / 이희승 ( 울산대 ) 25 Machine learning-based automatic detection and segmentation of meningioma and pituitary 26 adenoma for gamma knife radiosurgery / 윤상열 ( 경북대 ) Avoidance of complications in frameless navigation guided biopsy of the brain / 이채혁 ( 인제대 ) 27 Honored Lecture 좌장 : 정신 ( 전남대 ) From startup to scaleup neuro-oncology / 홍용길 ( 가톨릭대 ) 30 Symposium: Tumors in Challenge 좌장 : 김오룡 ( 영남대 ) / 고용 ( 한양대 ) Petroclival meningiomas resected via a combined transpetrosal approach: surgical outcomes in 60 cases and a new scoring system for clinical evaluation 34 / Kenji Ohata(Osaka City University, Japan) Facial nerve preservation in surgery for large vestibular schwannomas / Michihiro Kohno(Tokyo Medical University, Japan) 36 Luncheon Seminar: Peri-operative Medical Issues 좌장 : 박봉진 ( 경희대 ) / 곽호신 ( 국립암센터 ) Anticoagulation / 나상훈 ( 서울대내과 ) 40 Delirium / 김정란 ( 충남대정신건강의학과 ) 46 Nutritional Support Team(NST) / 정미란 ( 전남대외과 ) 48 12th Chinese-Korean Brain Tumor Joint Meeting 좌장 : 정용구 ( 고려대 ) / Zhixiong Lin(Capital Medical University, China) Hypoxia induce glioma stem-like cells to transdifferentiate into endothelial cells and promote 52 glioma resistance to temozolomide by providing more JAG1 and DLL4(keynote) / Zhixiong Lin(Capital Medical University, China) Response assessment in glioma treatment: to be or not to be(keynote) / Ke Sai(Sun Yat-sen University, China) 54 Clinical application analyses of IDH1 genetic testing combined CD-DST drug sensitivity test to guide the adjuvant chemotherapy in gliomas 56 / Zhang Ye(China Medical University, China) Introduction of endoscopic transorbital approach for orbit, middle fossa, and Meckel's cave lesions / 공두식 ( 성균관대 ) 58 Developing an endoscopic neurosurgical training model with 3-D printing technologies / 노태훈 ( 아주대 ) 60 9

10 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Scientific Session III 좌장 : 이창훈 ( 한국원자력의학원 ) / 이기택 ( 가천대 ) Cerebellopontine angle tumors causing hemifacial spasm / 박봉진 ( 경희대 ) 64 Comparison between retrosigmoid and translabyrinthine approaches for large vestibular schwannomas / 설호준 ( 성균관대 ) 65 Homogeneous transcriptomic profile of glioblastoma: comparison of gene expression patterns among IDH1-wildtype glioblastoma tumor tissue, tumorsphere, and normal brain 66 tissue / 윤선진 ( 연세대 ) Chemo-photothermal therapy by temozolomide-loaded iron oxide nanoparticles in U87-MG glioma cells / 조원호 ( 부산대 ) 67 Radiosensitivity enhancement by radiation-guided JNK inhibitor delivery in a Lewis lung carcinoma bearing brain tumor mouse model / 임사회 ( 전남대 ) 68 Association of mir-146ac>g, mir-149c>t, mir-196a2c>t, and mir-499a>g polymorphisms 69 with brain tumors / 임재준 ( 차의과학대 ) 간호사세션 : 뇌종양환자에서전문간호사의역할 좌장 : 장성현 ( 칠곡경북대병원 ) / 최민선 ( 서울아산병원 ) Infection control after craniotomy / 이도운 ( 화순전남대병원 ) 72 Role of PA in the comprehensive care / 배진영 ( 분당서울대병원 ) 73 PA as a neurosurgeon's partner / 장용준 ( 연세대세브란스병원 ) 74 Scientific Session IV (Meningioma) 좌장 : 김영규 ( 충북대 ) / 김정훈 ( 울산대 ) Keynote Lecture: Approach selection in surgery for cerebellopontine angle and skull base meningiomas / Michihiro Kohno (Tokyo Medical University, Japan) 76 Endoscopic transorbital surgery for middle cranial fossa tumors / 이상헌 ( 연세대 ) 77 Clinical and radiological features of malignant transformed meningioma: 10 case reports / 정지호 ( 전남대 ) 78 New classification of tentorial meningioma and clinical outcomes / 김주성 ( 연세대 ) 79 Usefulness of indocyanine green videoangiography to assess venous collaterals in meningioma surgery / 김주휘 ( 전남대 ) 80 Scientific Session V (Pituitary adenoma & Craniopharyngioma) 좌장 : 차승헌 ( 부산대 ) / 권정택 ( 중앙대 ) Keynote Lecture: Aggressive surgery based on an anatomical subclassification of craniopharyngiomas / Kenji Ohata (Osaka City University, Japan) 80 Clipping technique for the repair of the intraoperative CSF leakage during transsphenoidal pituitary tumor surgery / 김의현 ( 연세대 ) 83 The outcomes of pituitary adenomas treated with transsphenoidal surgery: a single institution s experience/ 서영범 ( 영남대 ) 84 Natural history of asymptomatic nonfunctioning pituitary adenomas with optic compression on MRI / 박현주 ( 서울대 ) 85 Long-term efficacy and tolerability of gamma knife radiosurgery for growth hormonesecreting adenoma: a retrospective multi-center study / 김경환 ( 성균관대 ) 86 Poster Session Selection of surgical approach for trigonal meningiomas in consideration of visual outcome / 김주휘 ( 전남대 ) 88 Adult onset sellar and suprasellar ATRT: a case report / 남민우 ( 한양대 ) 89 Brain abscess caused by Klebsiella pneumoniae misdiagnosed for a brain tumor: a case report / 문하용 ( 중앙대 ) 90 Effect of glioblastoma-cultured medium on neural differentiation of induced pluripotent stem cell / 박영석 ( 충북대 ) 91 Comparison of 3 and 7 Tesla magnetic resonance imaging of obstructive hydrocephalus caused by tectal glioma / 박영석 ( 충북대 ) 92 Procarbazine and CCNU chemotherapy for recurrent glioblastoma with MGMT promoter methylation / 양승호 ( 가톨릭대 ) 93 Recurrent glioma with lineage conversion from oligodendroglioma to astrocytoma / 정민호 ( 전남대 ) 94 Subfrontal falco-olfactory approach for midline anterior skull base meningiomas / 천영준 ( 전남대 ) 95 The inhibition of tumor growth through flagellin B secreted by engineered salmonella typhimurium with radiation in mouse glioma model / 최진명 ( 전남대 ) 96 10

11 등록안내 사전등록현장등록연회비합계 ( 라인 / 현장 ) 자문위원 무료 정회원 ( 전문의 ) 50,000 원 70,000 원 30,000 원 80,000 원 /100,000 원 준회원 ( 전공의 ) 30,000 원 50,000 원 - 30,000 원 /50,000 원 간호사, 기사, 학생, 연구원 10,000 원 20,000 원 - 10,000 원 /20,000 원 등록비에는정회원의경우, 연회비 30,000 원이포함되어있으며, 점심식사및초록집을제공합니다. 대한뇌종양학회정회원의경우는학회주최모든학술대회에우선적으로참여할기회가부여되고, 학회발행유인물 ( 연 2 회의 Newsletter, 학회지등을포함 ) 을제공받습니다. 전임회장, 초청연자의등록비는면제입니다. 11

12 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 좌장및연자주의사항 좌장주의사항 1) 구연발표의시간을엄격히지켜주십시오. 발표시간은토론시간을포함하여자유연제는 10분 (7분발표, 3분토론 ) 입니다. 2) 토론 일부사람에게독점되지않도록해주십시오. 토론이없는경우를대비하여좋은토론내용을준비해주십시오. 주제를벗어난부적절한발언이나토론내용은즉시제지시켜주십시오. 3) 발표시작전에휴대폰의전원을끄거나진동으로해주십시오. 연자유의사항 1) 연제제출은늦어도발표 30분전까지완료하여주십시오. 연제는 Preview room에서접수받습니다. ( 위치 : 등록대옆 ) 문제가발생될경우, 해결하기어려운의문사항및모든문제점은반드시 Preview room의 Staff와상의하십시오. 정시진행을위해개인노트북은사용하실수없습니다. 2) 연제제출시 USB를이용하시어슬라이드를제출해주십시오. 3) 구연슬라이드파일에비디오가포함된경우, 비디오파일은 wmv 파일로변환하여반드시파워포인트파일과동일한폴더에저장하여제출하여주십시오. 4) 시간을엄수하여주시기바랍니다. 발표시간은토론시간을포함하여자유연제는 10분 (7분발표, 3분토론 ) 입니다. 12

13 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Scientific Session I (Glioma) 좌장 : 이선일 ( 인제대 ), 김세혁 ( 아주대 ) The preclinical efficacy study of MSCs expressing TRAIL and CD for glioblastoma 안스데반 ( 가톨릭대 ) Supratentorial extraventricular ependymoma (STEE): retrospective analysis of 15 patients at a single institution 변준호 ( 울산대 ) ADC value as a predictive biomarker for survival in patients with treatment-naïve glioblastoma using quantitative 김병섭 ( 고신대 ) Proteomics analysis of LGR5 knockdown in neuroblastoma cells 한명훈 ( 한양대 ) Efficacy and safety of low dose temozolomide plus metformin as combination chemotherapy compared with low dose temozolomide plus placebo in patient with recurrent or refractory glioblastoma: a randomized, prospective, multi-center, double-blind, controlled, phaseⅡ trial - an interim report 양승호 ( 가톨릭대 ) Altered expression of the T-cell regulators on the glioblastoma cells can be epigenetically modulated by the histone methylase or demethylase and influence on the prognosis of the glioblastoma patients 김영준 ( 성균관대 )

14 SS(I)-1 Scientific Session I The preclinical efficacy study of MSCs expressing TRAIL and CD for glioblastoma Stephen Ahn, Sin-Soo Jeun Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic of Korea Objective: Our previous study using mesenchymal stem cells (MSCs) as delivery vehicles for tumor necrosis factor-related apoptosis inducing ligand (TRAIL) showed an anti-tumor effect in vitro and in vivo for glioblastoma. However, because most malignant glioma cells exhibit TRAIL resistance, we need to find new strategies to overcome it. We developed MSCs expressing both TRAIL and cytosine deaminase (CD) which convert the prodrug 5-fluorocytosine (5-FC) to the cytotoxic agent 5-fluorouracil (5- FU). We also immortalized these MSCs and introduced a doxycycline-dependent gene-inducible system to maintain the quality control. Lastly, we enhanced tumor tropism by overexpression of CCR2 and CXCR4. In this study, we investigated the anti-tumor efficacy of our novel MSCs (BM-03) with a 5-FC in vitro and in vivo orthotopic xenograft glioblastoma model. Methods: Human bone marrow-derived MSCs were isolated and cultured as described previously after approval by our institutional review board. The multiple genes mentioned above were transfected into the MSCs using a lentivirus vector system. Using a U87 human glioma cell line and male athymic nude mice, we developed an orthotopic glioblastoma xenograft model. We injected BM-03 in a dose-dependent manner (control; low dose, 2.0X104 cells; intermediate dose, 1.0X105 cells, and high dose, 5.0X105 cells) intratumorally with the intraperitoneal injection of 5-FC (500 mg/kg). Additionally, with in vivo bioluminescence imaging, we assessed the tumor volume. Results: First, we confirmed the doxycycline-dependent inducible gene expression system of BM-03 and showed the high expression of TRAIL, CCR2, and CXCR4 using FACS analysis. The synergistic anti-tumor efficacy of BM-03 with 5-FC was shown compared with BM-03 alone, in vitro. Moreover, we revealed the enhanced tumor tropism of BM-03 using in vivo bioluminescence imaging. After BM-03 injection of the contralateral side of the tumor, we could see that our MSCs moved toward the inoculated tumor lesion located on the contralateral side. Finally, when treated with BM-03 and 5-FC, we showed an increased antitumor efficacy in terms of both the median survival rate (control, 44 days; low dose, 46 days; intermediate, 57 days, and high dose, 69 days) and the tumor volume in a dose-dependent manner compared with the control and BM-03 only in the orthotopic xenograft glioblastoma mouse model. Conclusion: Our novel immortalized and inducible MSCs expressing TRAIL and CD showed an enhanced antitumor efficacy in an orthotopic xenograft glioblastoma model. This successful preclinical result will serve as a foundation for IND approval and a phase I clinical trial using our novel MSCs (BM-03). Key Words: MSC, Glioma, TRAIL 14

15 SS(I)-2 Scientific Session I Supratentorial extraventricular ependymoma (STEE): retrospective analysis of 15 patients at a single institution Joonho Byun, Jeong Hoon Kim Department of Neurosurgery, Asan Medical Center Objective: Supratentorial extraventricular ependymoma (STEE) is an extremely rare central nervous system (CNS) neoplasm, the clinical characteristics and optimal treatment for which are as yet unknown. We retrospectively analyzed the clinical characteristics and treatment outcomes of 15 patients with STEE. Methods: Fifteen patients with STEE were identified and their clinical, radiological, and surgical records were reviewed. Results: There were six (40%) male and nine (60%) female patients (median age, 15 years). Gross total resection (GTR), near-total resection (NTR), subtotal resection (STR), and biopsy were performed in nine (60%), three (20%), two (13.3%), and one (6.7%) patient, respectively. Eight and three patients received adjuvant radiotherapy (RT) and adjuvant chemotherapy, respectively. The five-year overall survival (OS) rates of World Health Organization (WHO) grades II and III STEE were 100% and 30%, respectively; the corresponding two-year progression-free survival (PFS) rates were 77.8% and 20%, respectively. The differences in OS and PFS rates between WHO grades II and III STEE were statistically significant (p <0.01 and 0.02, respectively). Anaplastic histology (WHO grade III) was a poor prognostic factor for PFS (p = 0.04). The recurrence pattern was local recurrence in all patients; all cases were primarily treated by redo surgery. Three patients with recurrent WHO grade II STEE were alive more than 64, 52, and 44 months after redo surgery. Conclusion: STEE is an extremely rare CNS neoplasm. The histologic grade of STEE is an important prognostic factor. Microsurgical resection might play a major role in both initial treatment and treatment of recurrent tumors. Key Words: supratentorial extraventricular ependymoma, surgical resection, anaplastic histology, recurrence 15

16 SS(I)-3 Scientific Session I ADC value as a predictive biomarker for survival in patients with treatment-naïve glioblastoma using quantitative multiparametric MR profiling Byung Sup Kim, Sung Tae Kim, Joon Hyung Kim, Ho Jun Seol, Do-Hyun Nam, Hyung Jin Shin, Jung-Il Lee, Doo-Sik Kong Department of Neurosurgery, Kosin University Gospel Hospital, Kosin University College of Medicine Objective: The purpose of this study was to investigate whether quantitative radiomic profiles extracted from multiparametric MR profiles can represent clinical outcome in patients with newly diagnosed glioblastoma (GBM) prior to therapy. Methods: MR images from 93 treatment-naïve patients with newly diagnosed GBM were analyzed. Through tumor segmentation, we selected 36 radiomic features. Based on the unsupervised clustering method, we classified our patients into two groups and investigated their overall survival (OS) using Kaplan-Meier analyses. Results: Among 36 radiomic features, ADC histogram parameters demonstrated a significant association with OS (P <.05). To validate this finding, unsupervised clustering analysis revealed three clusters with similar radiomic expression patterns. Clusters 1 and 2 showed a significant correlation with radiomic features representing tumor volumes, and cluster 2 additionally showed a significant correlation with relative cerebral blood volume values. In contrast, cluster 3 showed an inverse relationship with cluster 2, mainly representing the radiomic features indicating ADC and mean transit time. Although there was no statistically significant difference in OS between cluster 1+2 and cluster 3, cluster 3 showed a trend of longer survival than cluster 1+2 (P =.067). After stratification by methylation status and radiomic feature clustering, patients with methylated O6-methylguanine DNA-methyltransferase (MGMT) and those included in cluster 3 showed significantly longer survival (P =.029). Conclusion: ADC histogram parameters are feasible prognostic biomarkers to predict the survival. Quantitative MR profiles can represent clinical outcomes in GBM patients prior to therapy. Key Words: Radiomics, ADC, glioblastoma, survival, oncology 16

17 SS(I)-4 Scientific Session I Proteomics analysis of LGR5 knockdown in neuroblastoma cells Myung-Hoon Han 1, Mina Hwang 2, Seong-Ho Koh 2, Choong Hyun Kim 1, Jae Min Kim 1, Jin Hwan Cheong 1, Yong Ko 1 Department of Neurosurgery 1 and Neurology 2, Hanyang University Guri Hospital Objective: Leucine-rich repeat-containing G-protein coupled receptor 5 (LGR5) has been reported to play a critical role in the proliferation of neuroblastoma cells. However, the specific intracellular signaling proteins directly associated with LGR5 remain unknown in neuroblastoma. To identify the signaling pathways downstream of LGR5, we performed smallinterfering RNA (sirna)-mediated knockdowns of LGR5 in the SH-SY5Y neuroblastoma cell line. Methods: Proteomics analysis of neuroblastoma cell line was performed with 2D-polyacrylamide gel electrophoresis (PAGE) and multiple landmarks were selected for the classification of protein spots that exhibited at least a two-fold change in expression level compared to control samples. Based on the landmarks, 12 protein spots were selected and subsequently identified by peptide mass fingerprinting. Results: Among the 12 proteins identified, the expression of four proteins was increased while the expression of eight proteins was decreased in neuroblastoma cells with LGR5 knockdown. The proteins with increased expression comprised tubulin-beta, heat shock protein (HSP) 90-beta, 78 kda glucose-regulated protein precursor (GRP78), and internexin neuronal intermediate filament protein-alpha (α-internexin). On the contrary, proteins with decreased expression comprised alphatubulin, beta-actin, prohibitin, heterogeneous nuclear ribonucleoproteins A2/B1 (hnrnpa2b1), elongation factor Tu (EF-Tu), heterogeneous nuclear ribonucleoprotein H3 (hnrnph3), peroxiredoxin 3, and protein disulfide isomerase family A, member 3 (PDIA3). Conclusion: Taken together, our findings may be helpful for enhancing our understanding of LGR5 and its role in neuroblastoma, as well as for developing new drugs targeting neuroblastomas based on LGR5 and its related proteins. Key Words: heterogeneous nuclear ribonucleoprotein, LGR5, neuroblastoma, smallinterfering RNA 17

18 SS(I)-5 Scientific Session I Efficacy and safety of low dose temozolomide plus metformin as combination chemotherapy compared with low dose temozolomide plus placebo in patient with recurrent or refractory glioblastoma: a randomized, prospective, multi-center, double-blind, controlled, phaseⅡ trial - an interim report Seung Ho Yang 1, Dong Sup Chung 2, Heon Yoo 3, Young Cho Ko 4, Yoo Jung Kim 5, Do Hyun Nam 6, Dae Seok Heo 7, Jung Hoon Kim 8, Se-Hyuk Kim 9, Jong Hee Chang 10, Shin Jung 11, Se Hoon Kim 12, Youn Soo Lee 13, Yong Gil Hong 14 1 Department of Neurosurgery, The Catholic University of Korea, St. Vincent's Hospital, 2 Department of Neurosurgery, The Catholic University of Korea, Incheon St. Mary s Hospital, 3 Neuro-Oncology Clinic, National Cancer Center, 4 Department of Neurosurgery, Konkuk University Medical Center, 5 Department of Medical Oncology, Bundang Seoul National University Hospital, 6 Department of Neurosurgery, Samsung Medical Center, 7 Department of Medical Oncology, Seoul National University Hospital, 8 Department of Neurosurgery, Asan Medical Center, 9 Department of Neurosurgery, Ajou University Hospital, 10 Department of Neurosurgery, Severance Hospital, 11 Department of Neurosurgery, Chonnam National University Hwasun Hospital, 12 Department of Neurosurgery, Korea University Ansan Hospital, 13 Department of Clinical Pathology, and 14 Neurosurgery, The Catholic University of Korea, Seoul St. Mary s Hospital 18

19 Scientific Session I Objective: Recently, a combined chemotherapy with metformin, which is known to be a treatment for diabetes mellitus, has been attempted in various cancers. In several laboratories, the feasibility of the combination therapy of temozolomide and metfomin has been investigated for malignant gliomas. This study is an interim report of a multi-center clinical study to confirm the efficacy and safety of the combination of low-dose temozolomide and metfomin for the treatment of recurrent and treatment-resistant glioblastoma. Methods: Patients with pathologically or radiologically confirmed recurrent glioblastoma were enrolled. Patients with leptomeningeal seeding or diabetes mellitus were excluded. Double blind allocation was performed for the study. The test group was treated with temozolomide (50mg/m2) and metfomin (1,000 to 2,000mg), daily. If there was no progression of the disease, it was carried out for 6 months. The control group was treated with temozolomide (50mg/m2) and placebo, daily. Forty eight patients were assigned to each group, considering 10% dropout rate. Results: Forty patients (37%) out of 108 patients participated in the clinical study until now. Ten patients are under follow-up after completion of the planned 6-cycle treatment. Four patients are taking medication. Seventeen patients had disease progression after the start of the clinical study. Three patients dropped out due to serious adverse effects. Conclusion: This study is expected to reevaluate the efficacy of low-dose temozolomide and provide valuable information on the usefulness of the combination therapy of metformin for recurrent glioblastoma. Key Words: Recurrent, metformin, glioblastoma 19

20 SS(I)-6 Scientific Session I Altered expression of the T-cell regulators on the glioblastoma cells can be epigenetically modulated by the histone methylase or demethylase and influence on the prognosis of the glioblastoma patients Young Zoon Kim, Mee-Seon Kim Department of Neurosurgery, Sungkyunkwan University Samsung Changwon Hospital Objective: The primary aim of this study is to investigate the expression of the T cell stimulators and inhibitors as well as histone modifying enzymes in the glioblastoma cells. Based on the expression of these proteins, authors estimate the prognostic role in glioblastoma patients and also validate the known prognostic factors. Methods: The medical records of 88 patients having a new diagnosis of histologically ascertained glioblastoma in the period of January 2002 to December 2016 at the authors institution were retrospectively reviewed. Immunohistochemical staining for T cell stimulators (CD 27, CD 28, CD 137, ICOS, 4-1BB), inhibitors (CTLA-4, PD-1, PD-L1, BTLA, KIR), histone 3 lysine methylase (MLL4, ROZ, EZH1, NDS2), and histone 3 lysine demethylase (KDM5c, JMJD2a, UTX, JMJD5). Clinical factors including age, gender, KPS, extent of resection, RPA class, and postoperative therapeutic modality were also reviewed as well as methylation status of MGMT promoter. Results: Median values of the immunohistochemical staining for T cell stimulators and inhibitors were 34.3% of CD27, 27.5% of CD28, 12.7% of CD137, 19.5% of ICOS, 17.4% of 4-1BB, 11.0% of CTLA-4, 27.4% of PD-1, 35.7% of PD-L1, 18.9% of BTLA, and 12.8% of KIR. Median overall survivals of glioblastoma patients according to the increased expression of the T cell stimulators or inhibitors were 27.6 months in CD28, 22.8 months in ICOS, 25.0 months in 4-1BB, 24.6 months in CD27, 23.1 months in CD137, 13.9 months in CTLA-4, 14.7 months in PD-1, 14.2 months in PD-L1, 18.9 months, and 16.4 months in KIR. In multivariate analysis, increased expression of CD27, CD28, and decreased expression of CTLA-4, PD-1 in glioblastoma cells were independently associated with longer overall survival as well as known prognostic factors such as young age, high KPS, wide extent of resection, PRA class, and methylated MGMT promoter. Conclusion: The result of presenting study suggest that the regulators of cytotoxic T cell can be considered as independent prognostic factors in glioblastoma patients regardless the type of therapeutic modality. Key Words: Glioblastoma, T cell, Immunity, Methylation, Epigenome, Prognosis 20

21 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Scientific Session II (Brain Tumor, Others) 좌장 : 이채혁 ( 인제대 ), 유헌 ( 국립암센터 ) Gamma knife radiosurgery and systemic chemotherapy for synchronous brain metastasis from non-small cell lung cancer 정민호 ( 전남대 ) The clinical usefulness of postoperative diffusion weighted magnetic resonance image (DWI) for brain tumor surgery 김영일 ( 가톨릭대 ) Analysis of the difference in accuracy of navigation MRI according to the position of MRI for posterior fossa lesions 도윤식 ( 서울대 ) Follow-up and treatment of the patients with coexisting brain tumor and intracranial aneurysms 이희승 ( 울산대 ) Machine learning-based automatic detection and segmentation of meningioma and pituitary adenoma for gamma knife radiosurgery 윤상열 ( 경북대 ) Avoidance of complications in frameless navigation guided biopsy of the brain 이채혁 ( 인제대 )

22 SS(II)-1 Scientific Session II Gamma knife radiosurgery and systemic chemotherapy for synchronous brain metastasis from non-small cell lung cancer Min Ho Jung, In Young Kim Department of Neurosurgery, Chonnam National University Hwasun Hospital Objective: For synchronous brain metastasis from non-small cell lung cancer (NSCLC) patients, both local brain control for brain metastasis and systemic management for the primary cancer are simultaneously needed. Therefore, the local control of the brain metastasis in these patients could be affected by the systemic chemotherapy without mentioning the local brain management such as gamma knife radiosurgery (GKRS). We managed those patients with GKRS and systemic chemotherapy, and investigated clinical and radiological outcomes. One of our main objectives was if the systemic chemotherapy could enhance the tumor control when it was simultaneously applied with stereotactic radiosurgery for the brain metastasis. Methods: Between June 2004 and 2016, total 159 NSCLC patients underwent GKRS for synchronous metastatic brain tumors from NSCLC. The systemic chemotherapy was indicated in 118 patients (73%) within 2 months before or after the GKRS. Results: The clinical and radiologic follow-up was done in 121 patients with 464 tumors. The tumor control rate was 78.6% and the median progression-free survival was 6.7 months. The significant favorable prognostic factors related to the tumor control were prescription radiation dose more than 18 Gy (p=0.005) and tumor volume less than 5cc (p= 0.010). On the combination of chemotherapy, both simultaneous chemotherapy with GKRS (p= 0.001) and with intravenous agents (p=0.026) were significantly related to the tumor control after GKRS. Conclusion: The combination of GKRS and systemic chemotherapy performed at peri-gkrs periods can have positive effect on not only to the patient s survival but also to the tumor control itself. Key Words: synchronous, brain metastasis, chemotherapy, gamma knife radiosurgery 22

23 SS(II)-2 Scientific Session II The clinical usefulness of postoperative diffusion weighted magnetic resonance image (DWI) for brain tumor surgery Young-Il Kim Department of Neurosurgery, The Catholic University of Korea, St. Vincent's Hospital Objective: Conventional MRI has been performed to evaluate the extent of tumor removal after brain tumor surgery. In our hospital, we performed DWI as well as conventional MRI in order to evaluate the neurologic status of the patient and to help in proper management immediately after brain tumor surgery since The purpose of this study is to investigate the clinical usefulness of postoperative DWI after brain tumor surgery. Methods: Between March 2016 and December 2017, we retrospectively analyzed 107 patients who underwent brain tumor surgery and performed DWI within 48 hours after surgery. Patients with accidental intraoperative arterial injury were excluded from this analysis. Cardiovascular disease and stroke history, administration of antiplatelet agent or anticoagulant, pre and postoperative neurological status, operative time and pathology. Pre and postoperative MRI images were analyzed to determine tumor location, size, and extent of peri-tumoral edema, extent of resection (partial resection / subtotal resection / gross total resection). Gross total resection was defined as a case in which the remaining tumor was not clearly seen on MRI immediately after surgery. In postoperative DWI, a high signal intensity that was thinly seen at the border of the resection cavity regarded as a postoperative change and considered as a positive finding when there was a signal change extending outward from the resection cavity. Results: The median age was 59 years (range 5 84). The ratio of male to female was 52 to 55. There was no significant blood loss or hypoxemia during surgery. Of the 107 patients, 17 had immediate postoperative DWI positive finding (17/107, 15.9%), and 10 of them had aggravated or newly developed neurologic deficits (10/17, 59%). In all of these patients, there were no abnormal intraoperative monitoring findings. For these patients, postoperative blood pressure was maintained 10 to 20 mmhg higher than the other patients and Nimodipine was administered until postoperative seven days. There were no major complications related to these treatments. Of the 10 patients, 6 recovered to preoperative neurologic status up to postoperative 7 days, and the 4 did not recovered despite of these treatment. Conclusion: We suggest that DWI together with conventional MRI immediately after brain tumor surgery may be helpful in the accurate assessment of the patient's neurological status and may help to prevent neurological deterioration by appropriate treatment. 23

24 SS(II)-3 Scientific Session II Analysis of the difference in accuracy of navigation MRI according to the position of MRI for posterior fossa lesions Yun-Sik Dho, Jin Wook Kim, Yong Hwy Kim, Chul-Kee Park, Dong Gyu Kim Department of Neurosurgery, Seoul National University Hospital Objective: The aims of this study is to analyze the differences in accuracy in accordance with position of preoperative navigation Magnetic resonance image (MRI) for posterior fossa lesions Methods: This study was planned as a prospective study. From June 2017 to April 2018, 10 patients with posterior fossa tumors requiring surgery at prone position were enrolled. All patients underwent preoperative navigation MRI in both supine and prone positions. Navigation MRIs obtained at supine and prone positions were defined as supine/prone MRI, respectively. We used three methods to identify discrepancies in supine and prone MRIs when they were matched. The first is to visually confirm the deformation of the one anatomical point the when supine/prone MRIs are registered simultaneously at the prone surgical position when the surgery was performed. The second method is to analyze the distance between two MRIs statistically when the same anatomical landmark is defined after MRI matching using in-house developed ROI software. The third is to visualize the area of slice distortion and identify the trend according to the direction of the MRI slices when matching two MRIs by each slice. Results: All patients who underwent surgery at prone position were more accurate with prone MRIs (P=0.02) and supine MRIs showed discrepancy at the specified locations. The distance of deformation between prone MRI and supine MRI at the same anatomical landmark was statistically significant (P < 0.001). Deformation area-total area ratio shows a tendency to become bigger at post fossa, midline location. Conclusion: This study demonstrated that performing surgery in prone position with prone MRI shows higher accuracy than performing surgery in prone position with supine MRI. This suggests that the positioning of the navigation MRI should be determined according to the surgical position. Key Words: posterior fossa, navigation MRI, prone position, prone MRI 24

25 SS(II)-4 Scientific Session II Follow-up and treatment of the patients with coexisting brain tumor and intracranial aneurysms Heui Seung Lee, Jeong Hoon Kim Department of Neurosurgery, Asan Medical Center, Ulsan University College Of Medicine Objective: The association of primary brain tumor with coexisting unruptured intracranial aneurysm (UIA) has been debated and treatment strategy is not established. This study aimed to evaluate the association between brain tumors and coexisting UIA and the follow-up of brain tumor patients who did not have the treatment of coexisting UIA. Methods: Patients with coexisting UIAs and brain tumors who underwent surgical tumor resection were retrospectively analyzed to evaluate incidence of UIAs according to the type of tumors, association of arterial feeder vessels and coexisting UIAs and the occurrence of subarachnoid hemorrhage (SAH) during follow-up in the patients who did not have treatment of UIAs. Results: Among 54 patients, 21(38.9%) patients had treatment of UIAs whereas, 33(61.1%) had regular follow-up without treatment of intracranial aneurysms. There were 2 cases (6.1%) of SAH in 33 patients who did not have treatment of UIAs. Association of coexisting UIAs with brain tumors significantly higher in astrocytic or oligodendroglial tumors compared with meningiomas (90% vs 51.5%, P=0.03) Conclusion: Incidence of UIAs among patients with primary brain tumors seems higher than that of general population. Considering the association of brain tumors and intracranial aneurysms and occurrence rate of SAH during follow-up, we recommend simultaneous or perioperative treatment of intracranial aneurysms in addition to tumor resection. Key Words: Brain tumor, Intracranial unruptured aneurysm, Meningioma, Astrocytoma, Oligodendroglioma, Glioblastoma, Subarachnoid hemorrhage 25

26 SS(II)-5 Scientific Session II Machine learning-based automatic detection and segmentation of meningioma and pituitary adenoma for gamma knife radiosurgery Sang-Youl Yoon, Ki-Su Park Department of Neurosurgery, Kyungpook National University Hospital Objective: Gamma knife radiosurgery is today a useful therapeutic strategy for meningioma and pituitary adenoma. Accurate target delineation is a key step for efficient and effective stereotactic GKRS treatment planning. However, after MR imaging, the target delineation is still often manually performed, which is timeconsuming and prone to observer variability. To tackle this issue, we investigated to apply machine learning-based automatic detection and segmentation strategy for intracranial primary tumors, especially meningioma and pituitary adenoma. Methods: The proposed method consists of three steps. First, the training set and test set, which are segmentations by clinical experts. Second, the information of skull at MRI slices was removed using statistical tumor size. Third, the region of interest is extracted by tumor feature and average of tumors size. The detection of tumor is progressed using proposed and threshold method. Finally, in order to compare the accuracy of proposed method, we compared the delineation by the clinical expert and results of proposed method. Results: In the meningioma and pituitary adenoma data, validation yield relatively accurate DICE coefficients an area under the receiver operating characteristics curve, as compared with the clinical experts. Conclusion: Based on the present study, the machine learning-based automatic detection and segmentation of meningioma and pituitary adenoma for gamma knife radiosurgery may be similar to the delineation by the clinical experts. And, this strategy may be expected to be applied to the autoplanning of GKRS in future. Key Words: automatic, delineation, segmentation, radiosurgery 26

27 SS(II)-6 Scientific Session II Avoidance of complications in frameless navigation guided biopsy of the brain Chae Heuck Lee, Chan Young Choi Department of Neurosurgery, Novalis Radiosurgery Center, Ilsan Paik Hospital Objective: Cerebral biopsy has changed from frame-based stereotactic biopsy to frameless navigation guided procedure, nowadays. We reviewed the surgical experiences of one surgeon to evaluate the effectiveness and frequency of complications associated with frameless navigation guided procedure in our institution and considered how to avoid these complications. Methods: We studied 18 patients (11 men and 7 women) who underwent navigation guided biopsy procedures during recent 2 years. Procedures for Ommaya reservoir placement, navigation guided craniotomy for flap localization, or navigation guided cyst aspiration. We analyzed clinical factors associated with complications. Results: There was no mortality. However, morbidity rates were 22% (4/18). Three patients were symptomatic hemorrhage (intracerebral hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage) and one patient developed focal symptomatic infarct. All 4 patients has deep-seated, periventricular lesions. Conclusion: Complication rates were relatively high than previous reports. The patients with deep-seated, periventricular, and probable malignant histology may have an increased risk of complication or morbidity. Frameless navigation guided biopsy procedure might be comfortable to the patients but relatively high complication rate than frame based stereotactic biopsy. Key Words: Biopsy, Navigation-guided, Complication, Frame-based, Frameless 27

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29 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Honored Lecture 좌장 : 정신 ( 전남대 ) From startup to scaleup neuro-oncology 홍용길 ( 전남대 )

30 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Yong-Kil Hong Professor, Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine EDUCATION The Catholic University of Korea College of Medicine, B.S. (Medicine) The Catholic University of Korea Postgraduate School, M.S. (Medicine) The Catholic University of Korea Postgraduate School, Ph.D. (Medicine) POSTGRADUATE TRAINING Intern in Neurosurgery, St. Mary's Hospital, Seoul Resident in Neurosurgery, Gangnam St. Mary's Hospital, Seoul Postdoctoral Neuro-oncology Fellowship in MD Anderson Cancer Center, Houston, TX ACADEMIC AND HOSPITAL APPOINTMENT Director, Brain Tumor Center, Seoul St. Mary s Hospital, The Catholic University of Korea College of Medicine Director, Department of Neurosurgery, Seoul St. Mary s Hospital, The Catholic University of Korea College of Medicine Director, Catholic Cancer Center, Kangnam St. Mary s Hospital, The Catholic University of Korea College of Medicine Director, Catholic Cancer Research Institute, The Catholic University of Korea College of Medicine 1988 Instructor, Department of Neurosurgery, The Catholic University of Korea College of Medicine PROFESSIONAL & OTHER ACTIVITIES President, World Federation of Neuro-oncology Societies (WFNOS) Current President, Organizing Committee of 6th Quadrennial Meeting of World Federation of Neuro-oncology Societies in Seoul (WFNOS 2021) President, The Korean Society for Neuro-oncology (KSNO) President, The Korean Brain Tumor Society (KBTS) Chair of Plan & Design Committee, The Korean Neurosurgical Society Steering Committee of Cilengitide Clinical Trial (CENTRIC) Chair of Scientific Committee of 7th Meeting of ASNO in Seoul, Current Executive Committee of Korean Photodynamic Association Current Executive Committee of Korean Cancer Association Current Executive Committee Member of Korean Brain Tumor Society (Secretary in General, Chair of Brain Tumor Registration Committee) Current Editorial Board (Past and Present): J Korean Neurosurg Soc, Neuro-oncology, Chinese Journal of Contemporary Neurology and Neurosurgery Current Reviewer (Past and Present): Cancer Letter, Cancer Immunology Immunotherapy, Vaccine, Cancer Res Treat, J Korean Neurosurg Soc, J Korean Med Sci, Child s Nerve Syst CLINICAL and RESEARCH INTERESTS 1. Brain tumor microscopic/ endoscopic surgery, Chemotherapy, Clinical trials 2. Basic and translational researches of brain tumors 1) Gene therapy, Immunotherapy 2) Antiangiogenesis 3) Drug resistance, repurposing 30

31 Honored Lecture From startup to scaleup neuro-oncology Yong-Kil Hong Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine 31

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33 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Symposium: Tumors in Challenge 좌장 : 김오룡 ( 영남대 ), 고용 ( 한양대 ) Petroclival meningiomas resected via a combined transpetrosal approach: surgical outcomes in 60 cases and a new scoring system for clinical evaluation Kenji Ohata (Osaka City University, Japan) Facial nerve preservation in surgery for large vestibular schwannomas Michihiro Kohno (Tokyo Medical University, Japan)

34 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Kenji Ohata Dean, Graduate School of Medicine, Osaka City University, Professor and Chairman, Department of Neurosurgery Certification of Special License 1980 M.D., Japan 1987 Neurosurgeon, Japan EDUCATION UNDERGRADUATE: Faculty of Medicine Osaka City University, Japan, GRADUATE: Graduate School of Medicine Osaka City University, Japan PROFESSIONAL TRAINING AND EMPLOYMENT Resident; Junior, Senior and Chief Resident, Department of Neurosurgery, Osaka City University, Japan 1987 Japanese Board of Neurosurgeon awarded (#1950) Lecturer, Department of Neurosurgery Osaka City University, Japan Research Associate, Department of Neurosurgery, Medical College of Virginia, USA Clinical Fellow, Department of ENT, Fluda Municipal Hospital, Germany Director: Prof. Dr. med. Wolfgang Draf 1991 Clinical Instructor, Department of Neurosurgery Osaka City University, Osaka, Japan Assistant Professor, Department of Neurosurgery Osaka City University, Osaka, Japan 1999 Visiting Professor, Department of Neurosurgery Verona University, Italy Associate Professor, Department of Neurosurgery Osaka City University, Osaka, Japan Honorary Visiting Consultant for Life, Department of Neurosurgery Seth G.S. Medical Collage, King Edward Memorial Hospital, India Professor and Chairman, Department of Neurosurgery Osaka City University, Japan Parallel Professor, Department of Neurosurgery Tokyo Medical University, Japan Associate dean, Faculty of Medicine Osaka City University 2015 Visiting Professor, Department of Neurosurgery AIIMS, India Dean, Graduate School of Medicine & Faculty of Medicine, Osaka City University Visiting Professor, Harvard Medical School, USA ACADEMIC INTEREST Skull base, Brain tumor, Spinal surgery 34

35 Symposium: Tumors in Challenge Petroclival meningiomas resected via a combined transpetrosal approach: surgical outcomes in 60 cases and a new scoring system for clinical evaluation Ohata K, Morisako H, Nanakishi Y, Tanoue Y, Goto T Department of Neurosurgery, Osaka City University, Japan Objective: Petroclival meningiomas are among the most challenging intracranial tumors to treat surgically. Many skull base approaches have been described to improve resection and decrease patient morbidity. The authors undertook this study to evaluate the results of their treatment of petroclival meningiomas using objective measurements of tumor volume and a new impairment scoring system to assess neurological symptoms that severely affect the patient's quality of life, such as impairment of swallowing and speaking, motor function, and consciousness and communication. Methods: For the last 20 years, the authors used a combined transpetrosal approach to treat 60 patients with benign (WHO Grade I) petroclival meningiomas. In this retrospective study, all 60 cases were analyzed in detail with regard to tumor volume, extent of resection (EOR), long-term tumor control, neurological outcome, and the patient condition. In addition, patients were divided into 2 groups according to the period during which the surgery was performed: the early group in the first 10 years and the late group in the second 10 years. A new scoring system, the petroclival meningioma impairment scale (PCMIS), was created for quantitative assessment of 8 categories of neurological functions, with scores assigned in each category according to the level of disability and its impact on the patient. The PCMIS was used preoperatively, at 3 months after surgery, and at the time of the last follow-up examination, and the results for the 2 groups were compared. Results: There were 24 cases in the early group, and the mean duration of followup was months. The mean EOR was 96.1%, and good long-term tumor control was obtained in 22 patients (91.7%). One of patients died because of a postoperative complication in the perioperative period. The PCMIS improved in 3 patients (12.5%), remained stable in 1 (4.2%), and worsened in 20 (83.3%). There were 36 cases in the late group, and the mean duration of follow-up was 77.9 months. The mean EOR was 92.7%, and good long-term tumor control was obtained in 34 patients (94.4%). The PCMIS score improved in 23 patients (63.9%), remained stable in 5 (13.9%), and worsened in 8 (22.2%). Conclusions: The combined transpetrosal approach has provided satisfactory functional improvements and excellent tumor control for patients with petroclival meningiomas. The PCMIS provides a specific tool for quantitative assessment of the patient's state. 35

36 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Michihiro Kohno Professor & Chairman of Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan Employment History June 1987 December 1987 Department of Neurosurgery, National Hospital Medical Center December 1987 September 1988 Department of Neurosurgery, University of Tokyo Hospital October 1988 August 1991 Department of Neurosurgery, Ibaraki Prefectural Central Hospital September 1991 August 1992 Department of Neurosurgery, University of Tokyo Hospital September 1992 December 1992 Department of Neurosurgery, Fuji Brain Institute & Hospital January 1993 March 1995 Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital April 1995 May 2004 Director of Department of Neurosurgery, Fuji Brain Institute & Hospital June March 2013 Director of Neurosurgery, Tokyo Metropolitan Police Hospital January March 2013 Deputy director of Tokyo Metropolitan Police Hospital April Professor & Chairman of Department of Neurosurgery, Tokyo Medical University May Director of Stroke Center of Tokyo Medical University Hospital Graduate March,1987 Hamamatsu University School of Medicine Degrees and Certificates May License, Medical Board of Japan July Certified, Japanese Board of Neurosurgery July PhD Degree (University of Tokyo) March Certified, The Japan Stroke Society June Certified, The Japanese Society of Spinal Surgery July Board of the Japanese Society for Skull Base Surgery April Visiting assistant professor of University of Tokyo. Best Doctors in Japan University, Osaka, Japan Speciality Surgery for Cerebellopontine angle tumors (Acoustic neuroma), benign skull base tumors Surgery for Cerebrovascular diseases (bypass, clipping) Spinal surgery 36

37 Symposium: Tumors in Challenge Facial nerve preservation in surgery for large vestibular schwannomas Michihiro Kohno Professor & Chairman, Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan Purpose: Surgery for large vestibular schwannomas is very difficult to obtain good surgical results, and it requires tips and devices to achieve both high resection rate and high preservation ratio of facial and/or hearing function. Materials And Methods: My personal surgical experience of large vestibular schwannomas (Koos 4) is 884 out of all 1235 patients (Koos 1-4). I have been using intraoperative continuous facial nerve monitoring with direct electrical stimulation on the root exit zone since 1997 in vestibular schwannoma surgery, which is a method for checking facial EMGs during tumor excision in real time. We performed three types of intraoperative facial nerve monitoring: free-running spontaneous EMG, evoked facial nerve EMG with occasional and continuous electrical stimulation, as well as two types of moritoring for hearing function (ABR and CNAP: cochlear nerve action potentials).. Results And Discussion: Overall functional preservation rate of the facial nerve (House and Brackmann grade 1 or 2 at 1 year after surgery) was 97.1% and hearing preservation ratio was 36.5% with a 96.5% mean resection rate for the tumor in Koos 4 group. Conclusion: Using a intraoperative continuous facial nerve monitoring with direct electrical stimulation is useful to increase the tumor excision rate while avoiding severe postoperative facial nerve palsy in vestibular schwannoma surgery. 37

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39 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Luncheon Seminar: Peri-operative Medical Issues 좌장 : 박봉진 ( 경희대 ), 곽호신 ( 국립암센터 ) Anticoagulation 나상훈 ( 서울대내과 ) Delirium 김정란 ( 충남대정신건강의학과 ) Nutritional Support Team(NST) 정미란 ( 전남대외과 )

40 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 나상훈서울대병원내과 학력및경력 년 서울의대졸업 년 내과전문의, 2005년순환기내과분과전문의 년 ~2008년 동국대학교일산병원순환기내과교수 년 ~ 서울대학교병원권역응급의료센터 / 순환기내과교수 - 현재서울대학교병원내과학교실 / 순환기내과부교수 학회및협회활동 - 대한심장학회, 부정맥학회, 중재시술학회및한국심초음파정회원 - 학회한국혈전지혈학회학술및총무간사역임 40

41 Luncheon Seminar Anticoagulation -Anti-thrombotics at a Glance- Sang-Hoon Na Seoul National University, Internal Medicine/Cardiology 서론 : 항혈전제를복용하는도중수술을하거나, 급성뇌출혈등의출혈성합병증이생기는경우에는출혈이생길수있어, 최근에사용하고있는항응고제및항혈소판제제들의종류및특성을이해하는것은중요할것이다. 특히, 뇌종양수술등 Intracranial Surgery의경우에는항응고제나항혈소판제제등의항혈전제의수술전중단및재사용이치명적일수있는출혈합병증인뇌출혈의예방을위하여중요할것이다. 혈전 (thrombosis; blood clot) 은우리몸에상처가생겼을때지혈을하게되는중요한생리적인현상이다. 만약혈전이생기지않는다면, 조그만상처에도대량출혈로죽을수도있다. 동맥경화등에의하여혈관내부에병적으로혈전이생기는경우를혈전증이라하는데, 동맥혈전증 ( 허혈성심질환, 뇌졸중, 등 ) 이나정맥혈전증 ( 폐색전증, 심부정맥혈전증 ) 은치명적일수있다. 혈전증의치료에핵심이되는약물이항혈전제 (antithrombotics) 인데작용기전에따라항응고제 (anticoagulants) 와항혈소판제 (anti-platelet agents) 로나눌수있다. 본원고에서는오래전부터사용을하던전통적인항응고제인와파린과헤파린 ( 저분자량헤파린포함 ), 항혈소판제인아스피린, 클로피도그렐 (clopidogrel) 을포함하여, 그외에도최근에새롭게사용되고있는항응고제인 NOAC(New Oral Anti-Coagulants) 과새로운항혈소판제제들의종류및특성과이들약제의수술전중단및재사용에대하여알아보겠다. 2. 본론 (1) 항응고제 (anti-coagulants) 1950년대에개발된와파린이 2010년경까지 60여년간유일한경구항응고제였다. 비타민 K를억제하여응고인자의생성을억제하는효과를가지고있으며, 응고인자 2,7,9 그리고 10번을주로간접적으로억제하며, 응고인자의반감기에따라항응고효과를나타내므로, 와파린을장기간복용하는경우중단을하고 3-4일이상, 약 1주일이지나야항응고효과가없어진다. PT INR 수치로약의항응고효과를모니터할수있으며, 비타민 K 를길항제로사용할수있다. 와파린의경우많은약제와의상호작용및개인간의약효의차이가심하고, 음식과의상호작용도심하여, 이의단점을극복하고자하는노력은지속적으로있었으며, 2010년대이후직접적으로마지막응고인자인 2번 (thrombin) 이나 10번 (factor Xa) 을억제하는새로운항응고제인 NOAC(New or Novel Oral Anti- Coagulants) 가이미와파린용법의대부분을대체하고있는실정이다. 트롬빈억제제인다비가트란 ( 프라닥사 ) 과 10번인자억제제인리바록사반 ( 자렐토 ), 아픽사반 ( 엘리퀴스 ), 에독사반 ( 릭시아나 ) 3가지를합쳐총 4가지의 NOAC이이미임상에서많이사용되고있다. 4가지의 NOAC은정도의차이는있지만신장배설이주된기전이므로, Cr clearance 가 30 미만인경우에는사용을할수가없다. 기존에와파린을사용하던적응증의약 50% 이상이현재 NOAC으로대체되었으며, CrCL 30미만의신장기능저하가있는경우와인공판막을가진경우에만와파린을사용하고있으며, 이외대부분의항응고제임상적응증은 NOAC의사용으로이미변경되고있는시점이다. NOAC의경우반감기가 12시간정도로짧으므로, 반감기의 2배인하루를중단하면항응고효과의약 75% 가없어지며, 2일간중단을하면대부분의항응고효과가없어지므로, 시술전출혈위험에따라와파린처럼 3-4일에서 1주일이아니라, 하루나이틀만중단을하면된다. 41

42 Luncheon Seminar 드물지만경구가아닌주사제제인 LMWH( 클렉산, 프라그민등 ) 도암환자나임산부에서의항응고요법이필요한경우하루한번이나두번지속적으로피하주사를하는경우도있으므로, 주사제제로사용하는항응고제도내시경등의관혈적치료전확인이필요하겠다. 뇌종양수술전후항옹고제의중단기간및재사용에대한일반적인방법은아래그림 1~3으로요약할수있다. 42

43 Peri-operative Medical Issues: Anticoagulation -Anti-thrombotics at a Glance- (2) 항혈소판제 (anti-platelet agents) 정맥혈전증이나심방세동환자에서의혈전예방에는항응고제를항혈전제로사용하지만, 뇌졸중, 허혈성심질환이나, 말초동맥허혈등의동맥혈전증의치료에는항혈소판제를우선적을사용하고있다. 항응고제의경우어떤경우에도총 5가지 ( 와파린 +4가지 NOAC) 중한가지만사용을해야하지만, 항혈소판제제의경우, 최근관상동맥스텐트시술이후에최소 3내지 1년간사용이필요한이중항혈소판제제 (DAPT; dual antiplatelet agents) 로아스피린과클로피도그렐의사용이흔하게이루어지고있으며, 클로피도그렐의경우효과의유전적저항성이알려져있어최근에는새로운항혈소판제제인프라수그렐 ( 에피언트 ) 나티카그렐러 ( 브릴란타 ) 의사용도증가하고있다. 클로피도그렐의이전약제인티클로피딘도아직사용이되고있는상태이다. 중증의허혈성심질환이나반복적인뇌졸중이있는경우에는총 3가지의항혈소판제제나, 항혈전제 ( 항응고제 1가지 + 두가지항혈소판제제 ) 의사용도흔하게이루어지고있다. 항혈소판제제의경우기존에사용하고있는아스피린, 클로피도그렐, 티카그렐러, 프라수그렐, 이외에도아주다양한기전의많은항혈소판효과가있는약제들이, 혈류개선, 증상조절 목적으로사용되고있는실정이며, 흔하게사용하고있는약제로는실로스타졸, 사포그릴레이트, 트리플루살, 트렌탈, 은행옆엑기스, 니서골린, 나푸로닐, 각종프로스타글란딘제제, 등등무수히많은약제가있고, 여기에다대부분의 NSAIDs 항염증 / 진통제및각종생약제제등까지보면, 5~6가지의항혈소판제제의중복복용을하고있는경우도있으므로뇌종양수술전처방전의자세한확인이매우중요하겠다. 대부분의항혈소판제제는 5-7일간중단을하게되면항혈소판효과가없어진다. 3. 결론최근 10여년동안전통적으로사용하고있던항혈전제인와파린, 아스피린, 클로피도그렐이외에매우다양한항응고제및항혈소판제제가사용되고있으므로, 뇌종양수술전신중하게현재복용중인처방약제의확인을하는것은매우중요하겠다. 항응고제의경우기존에유일한경구용항응고제였던와파린의경우신장기능이상이있거나, 인공심장판막의경우를제외하고는보다사용이간편한다비카트란, 리바록사반, 아픽사반, 에독사반의 4가지 NOAC으로많은경우사용이변경된상태로, NOAC을사용하고있는혈전증환자의경우이전와파린과는다르게수술전중단이필요한경우 일주일간의중단 이아니라, 하루나이틀간만중단을하면항응고효과가없어지므로, 너무이른중단으로인한혈전증의악화가생기지않도록용법을숙지하고있어야하겠다. 항혈소판제제의경우도전통적으로흔히사용하던아스피린과클로피도그렐, 티클로피딘이외에다양한기전의항혈소판제제가사용되고있다는점을알고있어야하며, 특히협심증이나심근경색등의허혈성심질환의치료로관상동맥스텐트시술을한경우에는시술후 3개월에서 1년간은필수적으로아스피린과클로피도그렐, 혹은아스피린과프라수그렐이나티카그렐러중의하나를사용하는이중항혈소판제제 (DAPT: dual antiplatelet agents) 의사용이필수적이므로, 치료내시경시술전특히관상동맥스텐트시술을하였는지의병력과정확한시행날짜는반드시확인하여야하는병력이다. 복용중이던항혈전제 ( 항응고제 and/or 항혈소판제 ) 를수술전출혈위험으로중단이필요한경우에는일반적으로는중단시의혈전증의악화가능성과약제유지시의시술전후출혈위험성을저울질하여중단여부나중단시점및기간의결정을해야하겠지만, 뇌종양수술의경우출혈고위험군에해당하므로, 수술전충분한기간동안중단을하고수술진행을하는것이권고되며. 수술후재사용시점의경우는기존항응고제 / 항혈소판제제를사용하는적응증에따라뇌종양수술후출혈위험과중단기간이길어질경우의혈전악화가능성을같이검토하여재사용시기의결정을하는것이필요하겠다. 현재사용중인항응고제나흔한항혈소판제의목록은아래표1~ 표4를참조하기바란다. 43

44 44 Luncheon Seminar

45 Peri-operative Medical Issues: Anticoagulation -Anti-thrombotics at a Glance- 45

46 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 김정란충남대학교의학전문대학원, 충남대학교병원정신건강의학과충남대학교의과대학정신과학교실주임교수 & 충남대학교병원정신건강의학과장 학력 충남대학교의과대학졸업 정신과전문의취득 충남대학교대학원의학박사 International Fellow, Western IRB International Fellow, Department of Psychiatry, Duke Medical School, North Carolina, USA 학회활동대한신경정신의학회감사노인정신의학회평이사생물치료정신의학회평이사 노인및치매관련활동국가치매관리위원세종특별자치시광역치매센터장, 세종특별자치시치매안심센터장한국치매협회대전충남지부회장 46

47 Luncheon Seminar 섬망 김정란충남대학교병원정신건강의학과 섬망은급성의학적상태와연관되어있으며의식을포함한뇌의전반적기능장애로나타나는임상증후군이다. 섬망은사고, 기억, 그리고지각과같은인지과정의갑작스러운장애가특징이며, 환경과자신에대한인식 (awareness) 감소와주의력장애가핵심증상이다. 섬망의증상은보통갑작스럽게발생하고, 일시적이며, 증상의변동이있으며야간에그증상이뚜렷하다. 보통섬망은환자의정신적, 신체적취약성 (vulnerability) 과신체적손상 (physical insult) 의심각도가상호작용하여발생한다. 특히노인에서는한가지원인으로섬망이일어나는경우는매우드물다. 두가지이상의원인들이섬망발생에기여하는경우가 25 45% 정도된다. 섬망이뇌의장애인것은분명하지만, 아직까지구체적인신경병리는밝혀지지않았다. 현재까지의결과를종합하면, 최종공통경로 (final common pathway) 인아세틸콜린의결핍과도파민과잉활성이섬망을일으키는것으로보인다. 섬망에서는주의를기울이고유지하고이동하는능력의장애와환경을파악하는명료도가감소하는의식장해 (deficit of awareness) 가핵심적이고필수적인증상이다. 운동활동에따라섬망의아형을저활동형, 과활동형, 혼합형세가지로나눈다. 섬망의진단을위해환자의머리맡에서가장쉽게사용할수있는도구는 CAM이다. CAM은정신과의사가아니어도훈련을받으면사용할수있도록개발된선별도구로검사시간은 10-15분정도걸린다. 섬망의진단에유용한도구로는 CAM 이외에 Delirium Rating Scale revised -98 (DRS-R-98) 이있으며우리나라에서표준화되었다. 섬망의약물치료목표는부작용을최소화하면서증상을효과적으로조절하는것이다. 현재미국식약청 (Food and Drug Administration, FDA) 이섬망의치료로승인한약물은없다. 47

48 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 정미란화순전남대병원외과 학력 2003년전남대학교의과대학의학과졸업, 학사학위취득 2006년전남대학교의과대학대학원석사학위취득 2014년전남대학교의과대학대학원박사학위취득 경력 2003 ~ 2004 전남대학교병원인턴 2004 ~ 2008 전남대학교병원외과전공의수료, 외과전문의자격취득 2008 ~ 2010 화순전남대학교병원위장관외과전임의 2010 ~ 2012 화순전남대학교병원위장관외과임상교수 ~ 화순전남대학교병원위장관외과임상조교수 학회활동대한외과학회대한위암학회대한임상종양학회대한내시경복강경외과학회유럽복강경외과학회대한정맥경장영양학회대한외과대사영양학회대한비만대사외과학회 48

49 Luncheon Seminar Nutritional Support Team(NST) 정미란화순전남대병원외과 뇌종양수술환자들은질환자체및수술로인한대사적스트레스로인해영양불량의위험성이증가하게됩니다 (Fig 1). 하지만실제임상에서는이를간과하거나저평가되는경우가많습니다. 여러연구에서적절한영양지원이환자의예후를향상시킬수있음이밝혀져있으며, 최근에발표된신경외과환자의수술후치료에관한지침서에서도영양지원항목을환자의회복을위한필수적인요소로강조하고있습니다. 적절한영양지원을위해서는의사는물론, 영양사, 간호사, 약사등을포함하는다직제로이루어진전문화된팀의존재가매우중요합니다. 이는수술전영양불량의위험성이있는환자를선별하는것은물론수술후에도지속적인모니터링및재평가를통해환자의상태에따른적절한영양지원을위해필수적입니다. 뇌종양수술환자에게특화된영양검색도구는아직없으며, 타당성이검증되어일반적으로사용되는도구들중각각의기관에적합한것을선택하여사용하게됩니다 (Table 1). 수술전영양불량이동반된환자들에대해유럽정맥경장영양학회 (European society for clinical nutrition and metabolism, ESPEN) 에서는수술후합병증등의발생을줄이기위해수술전 7~14일간영양지원을시행할것을권장하고있습니다. 뇌종양수술후에는신경학 49

50 적손상, 진정제나스테로이드등의약물들의사용과기관삽관등의처치들로인해오심, 위배출지연, 삼킴장애, 흡인, 움직임제한등이빈발하게됩니다. 그로인해경구섭취가제한되는경우가많아경장또는정맥영양형태로의추가적인영양지원이필요한경우가많습니다. 수술전에영양불량상태였거나수술후 5일이상경구섭취를통한충분한영양섭취가어려운경우에는술후 24~48시간내에조기경장영양 (enteral nutrition, EN) 을시작할것을권유하고있습니다. 경장영양형태의영양지원이우선시되나경장영양의금기에해당되거나술후 7일이내에경장영양만으로영양요구량을만족시키기어려운경우에는정맥영양 (parenteral nutrition, PN) 의사용을고려해야합니다. 미국신경외과학회의가이드라인의최신버전 (Guidelines for the management of severe traumatic brain injury, 4th ed. ) 에서는영양지원의방법, 시작시점, 열량, 영양보충제제의필요성, 혈당조절등에관한임상연구들의체계적인고찰을통해다음의 2가지권장사항들을제안하였습니다. 먼저사망률을줄이기위해최소 5일이내, 최대 7일이내에는환자에게필요한기초영양요구량을제공하기위한영양지원이이루어질수있도록조기영양지원을할것을강조하고있습니다. 경장영양을하는경우인공호흡기와관련된폐렴의발생을줄이기위해유문부하방공장관의사용을권하고있습니다. 그밖의사항들에대해서는아직근거가충분치않아권장사항을제안하지는못하였으나, 혈당조절의경우최근의무작위대조연구의결과를바탕으로너무엄격한조절보다는 140~180 mg/dl 정도를목표로할것을제시하고있습니다. 참고문헌 1. Brain Trauma Foundation. American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. Neurosurgery 2017;80: Yannis D, Airs P, Konstantian P, et al. Nutritional Alterations Associated with Neurological and neurosurgical disease. Open Neurol J 2016;10: Gahan B, Astri ML. Postoperative care of neurosurgical patients: general principles. Anesth Intensive Care Med 2017;18(6): Sukhminder JSB, Ashish K. Nutritional issues in neurointensive care. J Med Nut Nutaceu 2015;4: Hatice K, Nuray T, Gulsun OA. Management of Nutrition in Neuro Intensive Care Patients. J Neurol Neurosurg Nur 2017;6: Coester A, Neumann CR, Schmidt MI. Intensive insulin therapy in severe traumatic brain injury: a randomized trial. J Trauma. Apr 2010;68(4):

51 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 12 th Chinese-Korean Brain Tumor Joint Meeting 좌장 : 정용구 ( 고려대 ), Zhixiong Lin (Capital Medical University, China) Hypoxia induce glioma stem-like cells to transdifferentiate into endothelial cells and promote glioma resistance to temozolomide by providing more JAG1 and DLL4(keynote) Zhixiong Lin (Capital Medical University, China) Response assessment in glioma treatment: to be or not to be(keynote) Ke Sai (Sun Yat-sen University, China) Clinical application analyses of IDH1 genetic testing combined CD-DST drug sensitivity test to guide the adjuvant chemotherapy in gliomas Zhang Ye (China Medical University, China) Introduction of endoscopic transorbital approach for orbit, middle fossa, and Meckel's cave lesions 공두식 ( 성균관대 ) Developing an endoscopic neurosurgical training model with 3-D printing technologies 노태훈 ( 아주대 )

52 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Zhixiong Lin Capital Medical University, China Academic Professor and PhD Dissertation Advisor of Capital Medical University Associate Dean of The 11th Clinical School of Capital Medical University Professional Expert awarded with Special Expert Allowance of the State Council since [year] Deputy Director of Beijing Sanbo Brain Hospital and Director of Fujian Sanbo Funeng Brain Hospital Experience Member of the Chinese Medical Doctor Association (CMDA) s Standing Committee of Experts on Glioma and Chairman of the 1st Committee of Experts on Pediatric Glioma Member of the 3rd and 4th Standing Committee of Experts of Chinese Society of Neuro-oncology (CSNO) Deputy Director of the Committee of the 6th Chinese Society for Pediatric Neurosurgery Executive Director of the Beijing Medical Consultation Center on Glioma of CMDA Throughout ~30-years clinical practice, Dr. Lin has developed deep understanding in brain neoplasm, spinal cord tumor and application of minimally invasive surgery in pediatric neurosurgery, with focuses on brain tumors, hydrocephalus, pediatric neurosurgery and individualized comprehensive treatment for consciousness recovery after brain injury. Dr. Lin has published more than 100 academic papers as the author and the corresponding author, 40+ of which were cited by SCI. 52

53 12 th Chinese-Korean Brain Tumor Joint Meeting Hypoxia induce glioma stem-like cells to transdifferentiate into endothelial cells and promote glioma resistance to temozolomide by providing more JAG1 and DLL4(keynote) Zhixiong Lin Capital Medical University, China 53

54 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Ke SAI, M.D., Ph.D. Sun Yat-sen University Cancer Center, Guangzhou, P. R. China POSITION: Associate Professor, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China EDUCATION & TRAINING: Postdoctoral Fellowship, MD Anderson Cancer Center, Houston, TX Ph.D., Medical School of Sun Yat-sen University M.D., Medical School of Sun Yat-sen University HOSPITAL APPOINTMENT present Associate Professor, Department of Neurosurgery, Sun Yat-sen University Cancer Center Attending Neurosurgeon, Department of Neurosurgery, Sun Yat-sen University Cancer Center Resident, Department of Neurosurgery, Sun Yat-sen University Cancer Center PROFESSIONAL & OTHER ACTIVITIES Present Executive Committee, Chinese Society of Neuro-oncology, Chinese Anti- Cancer Association Present Member, Chinese Congress of Neurological Surgeons Present Member, Chinese Society of Neurosurgery, Chinese Medical Association RESEARCH ACTIVITIES Clinical Studies: Coinvestigator for 4 clinical trials on GBM and low-grade gliomas Basic Researches: Principal investigator for 2 projects on glioma stem cells which are supported by National Natural Science Foundation of China CLINICAL SPECIALTY Brain tumor surgery 100 neurosurgical cases of brain tumors per year, including gliomas, meningiomas, pituitary adenomas and acoustic & trigeminal schwannomas. PUBLICATIONS 20 SCI, SCIE papers 54

55 12 th Chinese-Korean Brain Tumor Joint Meeting Response assessment in glioma treatment: to be or not to be(keynote) Ke Sai Sun Yat-sen University, China 55

56 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Zhang Ye Chief Physician, Department of Neurosurgery, China Medical University, China Archiater of Department of Neurosurgery, Liaoning Cancer Hospital &Institute(Cancer Hospital of China Medical University), Master s Degree Young member of Neuron-Oncology Committee of China Anti-Cancer Association Member of Pediatric Glioma Committee of China Physician Association Standing Member of Neurology of Liaoning Anti-Cancer Association Standing Member of Surgical Biological Material Committee of Liaoning Cell Biological Association Cell Research and Treatment Committee of Liaoning Cell Biological Association Member of Neuron-Oncology Comprehensive Treatment Group, Liaoning Cancer Hospital Zhang Ye start his clinical and scientific career since 2000.He participate in 3 Provincial scientific items, and he write 2 major books.he has published more than 10 paper in national journals. Major advantages: (1) He is experienced in diagnosis and treatment of cranial and spinal tumor. (2) He is good at individual comprehensive treatment of glioma particularly. (3) minimal invasive treatment of cranial and spinal tumor. 56

57 12 th Chinese-Korean Brain Tumor Joint Meeting Clinical application analyses of IDH1 genetic testing combined CD-DST drug sensitivity test to guide the adjuvant chemotherapy in gliomas Zhang Ye China Medical University, China 57

58 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 공두식삼성서울병원신경외과 학력및경력 1996 한양대의대졸업 2001 삼성서울병원신경외과수련 2012 스탠포드대학방문교수 학회활동대한뇌종양학회대한두개저외과학회대한내시경뇌수술학회 58

59 12 th Chinese-Korean Brain Tumor Joint Meeting Introduction of endoscopic transorbital approach for orbit, middle fossa, and Meckel's cave lesions Doo-Sik Kong, Kyung Hwan Kim, Ho Jun Seol, Jung-Il Lee, Do-Hyun Nam Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine Objective: The tumors involving the orbit and Meckel\'s cave remain extremely challenging because of the surrounding complex neurovascular structures and which involve the deep orbit, floor of the frontal bone and lesser and greater wing of sphenoid bone. We introduce a new minimal-access technique using the endoscopic transorbital approach (etoa) to cranio-orbital lesions, Meckel's cave and the middle cranial fossa lesions and review the surgical tips and pitfalls of this approach. Methods: Between September 2016 and May 2018, we performed etoa in 30 patients with tumors involving the cranio-orbital areas (21 patients), Meckel\'s cave and middle cranial fossa (9 patients). The lesions included trigeminal schwannoma in 5 patients, a meningioma in 12 patients, others. Details of surgical techniques and clinical outcomes were described. Results: Gross total resection was performed in 15 of 30 patients (50%). Four patients underwent extended etoa (with lateral orbital rim osteotomy). 14 of 30 patients (46.7%) had preoperative proptosis on the ipsilateral side and all of 14 patients had improvement in exophthalmos; mean proptosis reduced from 5.7 ± 2.7 mm to 1.5 ± 1.4 mm. However, some residual proptosis was evident in 9 of the 14 (64%). 10 of 30 patients (33.3%) had preoperative optic neuropathy, and 6 of them (60.0%) had improvement; median best-corrected visual acuity improved from 20/100 to 20/40. Drilling of the trapezoid sphenoid floor, a middle fossa peeling technique and full visualization of the Meckel's cave were applied to approach the lesions. There was no postoperative cerebrospinal fluid leak. To achieve successful removal of the tumor, the emphasis should be placed on the importance of adequately removing the greater sphenoidal wing and vertical crest. However, etoa may still have a limitation in approaching posterior fossa lesions and infratemporal fossa, because of the limited working space. Conclusion: The etoa affords a direct route to access orbit, Meckel's cave and the middle cranial fossa lesions. With experience, this novel approach will be successfully applied to selected skull base lesions. Key Words: endoscopic transorbital approach, cranio-orbital lesion, Meckel's cave, middle fossa approach 59

60 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 노태훈아주대병원신경외과 연세대학교의과대학졸업연세대학교대학원의학과석사, 박사과정연세대학교의과대학신경외과학교실강사연세대학교의과대학신경외과학교실임상연구조교수현아주대학교의과대학신경외과학교실진료조교수 60

61 12 th Chinese-Korean Brain Tumor Joint Meeting Developing an endoscopic neurosurgical training model with 3-D printing technologies 노태훈아주대병원신경외과 61

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63 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Scientific Session III 좌장 : 이창훈 ( 한국원자력의학원 ), 이기택 ( 가천대 ) Cerebellopontine angle tumors causing hemifacial spasm 박봉진 ( 경희대 ) Comparison between retrosigmoid and translabyrinthine approaches for large vestibular schwannomas 설호준 ( 성균관대 ) Homogeneous transcriptomic profile of glioblastoma: comparison of gene expression patterns among IDH1-wildtype glioblastoma tumor tissue, tumorsphere, and normal brain tissue 윤선진 ( 연세대 ) Chemo-photothermal therapy by temozolomide-loaded iron oxide nanoparticles in U87-MG glioma cells 조원호 ( 부산대 ) Radiosensitivity enhancement by radiation-guided JNK inhibitor delivery in a Lewis lung carcinoma bearing brain tumor mouse model 임사회 ( 전남대 ) Association of mir-146ac>g, mir-149c>t, mir-196a2c>t, and mir-499a>g polymorphisms with brain tumors 임재준 ( 차의과학대 )

64 SS(III)-1 Scientific Session III Cerebellopontine angle tumors causing hemifacial spasm Bong Jin Park, Seung Hwan Lee, Young Jin Lim, Bong Arm Rhee Department of Neurosurgery, School of Medicine, Kyung Hee University Objective: Although hemifacial spasm is usually developed by vascular compression around the root exit zone of the facial nerve, it is sometimes caused by a cerebellopontine angle tumor. We reviewed and analyzed data from past experience with hemifacial spasm induced by cerebellopontine angle tumors. Methods: Seventeen patients (0.78%) of a total 2172, who had presented with hemifacial spasms associated with cerebellopontine angle tumors between 2000 and 2017, were reviewed. Results: Six meningiomas, 6 epidermoid tumors, 2 vestibular schwannomas, 2 arachnoid cysts and 1 lipoma were included in this study. With respect to the pathogenesis of hemifacial spasms, offending vessels were found in 12 patients, whereas, there were 5 patients whose cause of HFS was only mass effect from the tumor itself without offending vessel. Hemifacial spasm was resolved in 15 patients, but, in 2 patients with a vestibular schwannoma and an epidermoid tumor, it improved temporarily and then recurred in a month. Conclusion: Each type of tumor had different characteristics with respect to the induction of hemifacial spasm, therefore, it is suggested that neurosurgeons, who are planning surgeries both for the purposes of relieving hemifacial spasm and removal of cerebellopontine angle tumor, should thoroughly prepare appropriate approaches and specific dissecting strategies according to each causative lesion. Key Words: CPA tumor, hemifacial spasm 64

65 SS(III)-2 Scientific Session III Comparison between retrosigmoid and translabyrinthine approaches for large vestibular schwannomas Kyung Hwan Kim, Jung Won Choi, Doo-Sik Kong, Do-Hyun Nam, Jung-Il Lee, Ho Jun Seol Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine Objective: Although both retrosigmoid(rs) and translabyrinthine(tl) approaches are prime ways to resect large vestibular schwannoma (VS), direct comparison between two approaches has been seldom reported. The aim of this study is to compare the surgical and functional outcomes after removal of large VS via two surgical approaches and to investigate cerebellar injury due to surgical factors. It is hypothesized that TL approach causes less retraction injury and results in faster recovery from morbidities than RS approach. Methods: Between August 2010 and January 2018, 74 consecutive patients with large VS who underwent surgical resection through RS or TL approach were reviewed. Surgical and functional outcomes, operative time, volume of perioperative cerebellar edema, and time period of hospital stay were investigated and compared between two approaches. Results: Forty-eight patients underwent RS approach with a median follow-up period of 43 months. Since 2014, 24 patients underwent microsurgical resection via TL approach, and a median follow-up time was 13 months. Except a follow-up period, all preoperative characteristics including age, sex, tumor size, accompanying hydrocephalus, volume of cerebellar edema, portion of solid VS, hearing class, and facial function were not statistically different in two groups. Hearing preservation, which was available only in RS group, achieved in 5 out of 17 patients (29.4%) with preoperative serviceable hearing function. Other surgical and functional outcomes including extent of resection, tumor recurrence, surgical complications and facial nerve preservation were not shown significant difference between two groups. However, the median amount of change in volume between pre- and post-operative cerebellar edema, presumably caused by retraction injury, was significantly larger in RS group than in TL group (6.4 cc vs. 0.7 cc, p < 0.001) and was related to main operation time between dural opening and closure (p = 0.003), solid VS (p = 0.018), and RS approach (p = 0.001). In addition, patients in RS group showed a marginal trend for receiving in-hospital rehabilitation due to cerebellar dysfunction and/or lower cranial nerve dysfunction (p = 0.052). Conclusion: Both surgical approaches show equivalent tumor control and facial nerve preservation. Though TL approach is hearing destructive and not familiar with neurosurgeon, it provides promising results in terms of avoidance of retraction injury. Therefore, TL is a reasonable surgical option in selected patients. Key Words: large vestibular schwannoma, retrosigmoid, translabyrinthine, surgical approach, retraction injury 65

66 SS(III)-3 Scientific Session III Homogeneous transcriptomic profile of glioblastoma: comparison of gene expression patterns among IDH1-wildtype glioblastoma tumor tissue, tumorsphere, and normal brain tissue Seon-Jin Yoon 1,3, Ji Hyun Lee 1, Hyeyoung Son 2, Junseong Park 1, Ju Hyung Moon 1, Eui-Hyun Kim 1, Sun Ho Kim 1, Sahng Wook Park 3, Yong-Min Huh 2,3, Jong Hee Chang 1, and Seok-Gu Kang 1 1 Department of Neurosurgery, Brain Tumor Center, Severance Hospital, Yonsei University College of Medicine 2 Departments of Radiology, Severance Hospital, Yonsei University College of Medicine 3 Department of Biochemistry and Molecular Biology, Yonsei University College of Medicine Objective: IDH1-wildtype Glioblastoma (GBM) is known as heterogeneous cancer. This type of cancer has multiple aspects, and homogeneous nature of the tumor should not be neglected. Tumorsphere (TS) in GBM is an established tumor-derived spheroid cell and known to have several cellular types based on their transcriptomic profile. However, the homogeneous nature of TS by comparing the transcriptome of it with that of IDH1-wildtype GBM tissue was not reported previously. Methods: Differential gene expression (DEG) of three types of samples (GBM tissue, normal brain tissue, TS) was compared, and consistently robust genes of both GBM tissues and TS from normal brain tissues were derived. Results: Among the tumor overexpressed 644 genes (GBM vs. normal brain), 68 genes were not elevated in TS, suggesting the gene set would have an association with tumor tissue enriched factors. Immune (CD163L1, FCGBP) or extracellular matrix (COL1A1, COL1A2) associated genes were found in this group of genes. On the other hand, 576 genes were found to have relatively a good correlation between GBM tissue and TS and a few genes (including IDH1, BIRC5) were found to have a history of drug development beside cell cycle and organelle organization gene sets (p < ). This in silico observation indicates any GBM or TS study with ECM should consider multiple collagens and ECM modifying enzymes. Conclusion: These homogeneous expression patterns of a set of genes coexist with heterogeneous genes in GBM, and its high expression property would help us find potential targets to overcome GBM and the resistance against treatment. Key Words: Glioblastoma, IDH1-wildtype, tumorsphere, transcriptome, differential gene expression, homogeneous 66

67 SS(III)-4 Scientific Session III Chemo-photothermal therapy by temozolomide-loaded iron oxide nanoparticles in U87-MG glioma cells Won Ho Cho 1, Young Min Kwon 2, Seung Heon Cha 1 1 Department of Neurosurgery, Pusan National University Hospital, 2 Department of Neurosurgery, Dong-a University Hospital Objective: Combination of chemotherapy and photothermal therapy has recently received great attention as promising strategies for cancer treatment because of selective therapeutic effects with minimal complications. The iron oxide nanoparticles have been widely used as an effective drug carrier due to their low toxicity. Especially, Fe3O4 magnetic nanoparticles have been well demonstrated as effective photothermal agents for near-infrared (NIR) light-mediated cancer therapy. In the present study, we examined how drug-loaded Fe3O4 magnetic nanoparticles promoted effective U87-MG brain cancer cell death by the chemo-photothermal therapy. Methods: We prepared temozolomide (TMZ) and indocyanine green (ICG)-loaded multifunctional Fe3O4 magnetic nanoparticles (Fe3O4-TMZ-ICG) for the synergistic brain cancer therapy. Characterizations (size and morphology, phototherma heating effect, TMZ and ICG loading content) were evaluated by various techniques. Also, TMZ-ICG-Fe3O4 effect on U-87 MG cells was evaluated. Morphological changes by photothemal effect, live/dead cell assay, ROS detection, nanoparticle intracellular uptake and mitochodrial disruption and in vitro cell cytotoxic effect were done to evaluate the effect of Temozolamide loaded iron oxied nanoparticles on cancer cells. Results: Successful Temozolamide loaded iron oxide nanoparticles with conjugation of ICG were prepared (TMZ-ICG-Fe3O4 nanoparticles). Average size of TMZ-ICG- Fe3O4 nanoparticles was 152 nm (± 23.05). TMZ-ICG-Fe3O4 nanoparticles also showed excellent photothermal induced thermal response with high stability. Phototheramal effect induced somewhat morphological changes and increased nanoparticles uptakes in U-87-MG cells on optical microscopy. And TMZ-ICG-Fe3O4 nanoparticles with photothermal irradiation group showed the nuclear condensation and cell membrane disruptions. Live/dead cell assay calcein AM/PI double staining under fluorescence microscopy showed the most apoptotic changes in TMZ-ICG- Fe3O4 nanoparticles with photothermal irradiation group. ROS generation was also generated most strongly in TMZ-ICG-Fe3O4 nanoparticles with photothermal irradiation group. TMZ-ICG-Fe3O4 nanoparticles with photothermal irradiation group also showed enhanced intracellular uptakes and mitochondrial disruption which resulted in the increase of cell apoptosis. In vitro cell cytotoxic effect, TMZ-ICG- Fe3O4 nanoparticles with photothermal irradiation group showed the most effective apoptosis compared to other groups. Conclusion: In this study, the synthesized Fe3O4-TMZ-ICG nanoparticles could be utilized as an effective drug carrier to achieve the synergistic effects of the combination of chemo/phototherapy in cancer therapy applications. The experimental results showed that the combined chemo/phototherapy using the Fe3O4-TMZ-ICG nanoparticles induced the synergistic cancer cell death mediated by the enhanced ROS generation and abrupt changes in the mitochondrial membrane, which playing a major role in the apoptotic process. Therefore, these therapeutic results demonstrate the synthesized NIR-light responsive Fe3O4-TMZ-ICG nanoparticles are promising phototherapeutic agents for brain cancer treatment. Key Words: Iron Oxide Nanoparticles, Glioma, temozolomide 67

68 SS(III)-5 Scientific Session III Radiosensitivity enhancement by radiation-guided JNK inhibitor delivery in a Lewis lung carcinoma bearing brain tumor mouse model Sa-Hoe Lim, Chun-Hao Li, Jin-Myoung Choi, Young-Il Jeong, Shin Jung Department of Neurosurgery, Chonnam National University Hwasun Hospital Objective: Jun N-terminal Kinases (JNKs) regulates H2AX phosphorylation, which repairs DNA damage by radiation and its blocking can modulate radiosensitivity for tumor cells. HVGGSSV peptide was found to bind specifically to the tax-interacting protein-1 (TIP-1) receptor expressed in irradiated cancer cells. The aim of this study is to establish radiation-guided drug delivery system in a Lewis lung carcinoma (LLC) bearing brain tumor mouse and to assess the therapeutic effect of JNK inhibitor-incorporated nanoparticle (JIIN). Methods: The LLC-Fluc cell line was transfected with a Lentiviral vector containing the firefly luciferase (Fluc) Gene. The LGEsese block copolymer was synthesized to fabricate SP incorporated nanoparticles. JIIN copolymer was conjugated to the peptide to yield JIIN-HVGGSSV polypeptide. Physicochemical and morphological properties were observed by transmission electron microscope (TEM) photo and particle size. Mouse survival analysis was performed to investigate effects of JIIN- HVGGSSV using optical bioluminescence and magnetic resonance imaging (MRI). Results: Western blot data confirmed that irradiation may induce TIP-1 expression in LLC cells in culture. The blood-brain barrier (BBB) permeability of JIIN-HVGGSSV was estimated. Irradiated tumors were sectioned and stained with TIP-1 antibody. This showed minimal staining of normal tissue and substantially increased staining of tumor cells. Blockade of JNK signaling with JIIN-HVGGSSV polypeptide significantly delayed mouse brain tumor growth and prolonged mouse survival after radiotherapy Conclusion: TIP-1 was identified as a radiation inducible receptor that binds the HVGGSSV peptide. Radiation-guided JIIN delivery enhances the radiosensitivity of brain tumor mouse model bearing LLC. Key Words: Radiation-guided DDS, JNK inhibitor, TIP-1 receptor, HVGGSSV peptide 68

69 SS(III)-6 Scientific Session III Association of mir-146ac>g, mir-149c>t, mir-196a2c>t, and mir-499a>g polymorphisms with brain tumors Jaejoon Lim 1, Jung Oh Kim 2, Han Sung Park 2, JeBeom Hong 1, In Bo Han 1, Kyu Bum Kwack 2, Nam Keun Kim 2, Kyunggi Cho 1 1 Department of Neurosurgery, CHA University, CHA Bundang Medical Center, 2 Department of Biomedical Science, CHA Bundang Medical Center, School of Medicine, CHA University Objective: MicroRNAs (mirnas) are short, noncoding RNAs that are implicated in tumorigenesis, functioning as both tumor suppressors and oncogenes. However, the clinical significance of mirna expression profiles for brain tumors remains unclear. Therefore, we designed a study to investigate the association between microrna genetic variants and brain tumor risk. Methods: We recruited 362 participants; 179 for the healthy subjects and 183 who was brain tumor patients confirmed as having gliomas, meningiomas, or schwannomas. This study investigated the single nucleotide polymorphisms mir- 146aC>G, mir-149t>c, mir-196a2t>c, and mir-499a>g by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Results: We found that the dominant mir-149 and CC genotypes were significantly more frequent in patients with glioma. The odds ratios for the C-C-C-G, C-T-C-G, and G-C-T-G haplotypes (mir-146ac>g-mir-149t>c-mir-196a2t>c-mir-499a>g) were significantly increased in glioma, as was the odds ratio for the GCT haplotype of mir-146ac>g, mir-149t>c, and mir-196a2t>c and for the CCG haplotype of mir- 149T>C, mir-196a2t>c, and mir-499a>g. In meningioma, the odds ratios were increased in the GTCG haplotype of mir-146ac>g, mir-149t>c, mir-196a2t>c, and mir-499a>g. The odds ratios were also increased in the GCG haplotype of mir- 146aC>G, mir-196a2t>c, and mir-499a>g and CCG haplotype of mir-149t>c, mir-1962t>c, and mir-499a>g. The odds ratios for schwannoma were increased in the GCTG haplotype of mir-146ac>g, mir-149t>c, mir-196a2t>c, and mir- 499A>G and the CCG haplotype of mir-149t>c, mir-196a2t>c, and mir-499a>g. Conclusion: Our results suggested that the mir-149 polymorphism might be involved in the development of gliomas, and the CCG haplotype of mir-149t>c, mir-196a2t>c, and mir-499a>g showed increased odds ratios for all types of brain tumors in Koreans. Key Words: microrna, single nucleotide polymorphism, case-control study, brain tumor, glioma, meningioma, schwannoma 69

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71 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting 간호사세션 : 뇌종양환자에서전문간호사의역할 좌장 : 장성현 ( 칠곡경북대병원 ), 최민선 ( 서울아산병원 ) Infection control after craniotomy 이도운 ( 화순전남대병원 ) Role of PA in the comprehensive care 배진영 ( 분당서울대병원 ) PA as a neurosurgeon's partner 장용준 ( 연세대세브란스병원 )

72 간호사세션 : 뇌종양환자에서전문간호사의역할 개두술을시행한환자에서수술부위감염과관련된위험요소와결과 이도운화순전남대병원 Introduction: 개두술과관련된신경외과수술은수술후감염이발생하게되면장기간의항생제치료가필요할뿐만아니라심각한합병증을초래하므로이러한수술부위감염을예방하기위한여러가지노력들이있어왔지만여전히감염은수술후이환율과사망률의주요한원인중하나입니다. Purpose: 개두술을시행한전체환자중수술부위감염환자와비감염환자의특성과임상적예후를비교분석하여이를토대로수술부위감염과관련된다양한인자들을파악하여추후감염을예방하고자본연구를시행하였습니다. Methods: 2017 년 5 월부터 2018 년 5 월동안화순전남대학교병원신경외과에서개두술을받은 151 명의환자중수술부위감염환자와비감염환자를 EMR 을통한후향적연구로비교분석하였습니다. 일반적특성비교는성별, 나이, 비만도, 당뇨, 고혈압, 스테로이드사용여부를분석하였고임상적예후로는 drainage tube maintenance, mentality & motor grade, operative duration, Length of hospital stay 를분석하였습니다. Result: 151 명의환자중수술부위감염이발생한환자는총 6 명으로이는전체의 4% 를차지하였으며성별과나이, 비만도, 고혈압유무에서는감염군과비감염군과의차이는없었습니다. 감염군에서당뇨를갖고있는환자의비중이높았으며특히스테로이드평균사용일수가더많은것으로분석이되었습니다. 임상적예후의결과로는 Hemovac drainage 평균사용기간이감염균에서약간길었으며특히재원일수가감염군에서긴것으로나타났습니다. 또한 6 명의감염환자전원이 OP 시간이 4 시간이상걸린것으로확인되었습니다. Mentality 와 motor grade 에서는크게의미있는차이를나타내지않았습니다. Discussion: 개두술후수술부위감염이발생한환자들중기저질환으로당뇨가있는환자들의비중이높았으며특히 steroid 의평균사용일수가길었던것으로보아당뇨와스테로이드사용기간은수술부위감염과유의한상관관계가있다고생각이됩니다. 다만이전의연구들에서도대부분당뇨나고혈당과수술부위감염과의연관성은뚜렷하게밝혀내지못하였습니다. 재원기간은수술부위감염과상당한연관성이있다고보여지며이는재원기간이길어질수록수술부위감염의위험이커지는것을예상할수있는데아마도재원기간이길어지는동안침습적의료행위가반복시행되거나혹은다른환자나의료인을통한전파감염등각종병원균에대한위험이크게증가되기때문일것으로생각됩니다. 수술부위감염이발생한 6 명의환자의예후를분석한결과흔한징후및증상으로는화농성배액, fluid collection, 발열, 절개부위통증와함께발사후상처가벌어지는상처회복의지연을나타냈습니다. 이번에조사한자료의한계점으로는 EMR 을통한후향적분석이었으며다양한요인을분석하지못함과동시에자료를분석한환자의수가적었다는점입니다. Conclusions: 개두술을시행한환자들에게감염이발생될경우심각한결과를초래하므로감염과관련된다양한요인들을확인하고이를예방할수있는적극적인전략마련이필요하며이런노력을통해환자의치료를개선하고사망률과질병발생률및의료비용의경제적부담을줄이는데도움을줄것입니다. 72

73 간호사세션 : 뇌종양환자에서전문간호사의역할 Role of PA in the Comprehensive Care of malignant brain tumor Patients 배진영분당서울대병원 분당서울대병원뇌종양팀 PA의역할과, 여러가지역할중한가지예로악성신경교종환자치료교육프로그램에대해소개드립니다분당서울대병원뇌종양 PA는환자가병원을찾는첫외래에서부터수술전, 후, 퇴원및임종까지모든과정에서의다리역할을하고있습니다. 수술전, 후, 퇴원, 임종에이르는간호역할과그예시로악성신경교종환자치료교육프로그램인테모졸로마이드복용방법을교육자료를통하여환자및보호자에게각각의치료시기에맞추어개별교육을진행하고있습니다. 이러한뇌종양 PA로서의수술전, 후, 간호및교육, 상담, Terminal care 등은환자의 comprehensive care 를위한간호이며, 이는환자의 Quality of life 향상을위함입니다. 환자의삶의질향상을위한중재프로그램개발이필요합니다. 또한 PA의역할확대를위한방안및제도정립을위한방안이필요할것으로사료됩니다. 73

74 간호사세션 : 뇌종양환자에서전문간호사의역할 PA as a neurosurgeon's partner 장용준연세대세브란스병원뇌종양센터 신촌세브란스병원뇌종양센터수술실전담간호사의역할중수술방안에서의역할에대해서소개해드립니다. 신촌세브란스병원종양파트 7 년간연간수술개수및 C/O & Tumor removal 추이에대해설명한후, 수술방안에서의역할로서종양제거수술시사용되는 4 대의 navigation 의전반적인 setting, 환자 positioning(supine, prone, lateral) 의역할에서중요한부분을담당하고있습니다. 각성수술 (awake surgery) 의수술전환자교육을도맡아실시하여수술진행에대한이해를통한환자의두려움감소, 더나아가수술시협조에대한중요성을알게끔교육함으로써수술진행에큰도움이되는역할을수행하고있습니다. 또한각성수술의준비및 positioning, navigation setting 과더불어종양을제거하는동안에도환자의의식수준, motor 및 language 를다각적으로 assess 하여종양을제거하는와중에도환자 function 에이상이생기지않도록하는행위를수행하고있습니다. TSA 에서는 7 년간의총 TSA 및 endoscopic TSA 의추이를먼저살펴보고, 그중 endoscopic TSA 의 navigation 등록및 preparation 을진행후 Endoscopic TSA 의 first assist 로서의역할을수행하고있습니다. 74

75 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Scientific Session IV (Meningioma) 좌장 : 김영규 ( 충북대 ), 김정훈 ( 울산대 ) Keynote Lecture: Approach selection in surgery for cerebellopontine angle and skull base meningiomas Michihiro Kohno (Tokyo Medical University, Japan) Endoscopic transorbital surgery for middle cranial fossa tumors 이상헌 ( 연세대 ) Clinical and radiological features of malignant transformed meningioma: 10 case reports 정지호 ( 전남대 ) New classification of tentorial meningioma and clinical outcomes 김주성 ( 연세대 ) Usefulness of indocyanine green videoangiography to assess venous collaterals in meningioma surgery 김주휘 ( 전남대 )

76 Keynote Lecture Approach selection in surgery for cerebellopontine angle and skull base meningiomas Michihiro Kohno Department of Neurosurgery, Tokyo Medical University, Japan Selection of an appropriate surgical approach is very important in CPA tumor surgery as well as intraoperative neuro-monitorings. My personal experience of surgery for CP angle tumors is 1700 including 1200 vestibular schwannomas. We report our policy in selecting a surgical approach for CPA and skull base meningiomas. We surgically treated 176 CP angle and skull base meningiomas, using a lateral suboccipital approach in 61%, combined transpetrosal approach in 24%, anterior transpetrosal approach in 12% and simple transmastoid approach in 3%. In our series, 60% of these cases showed intrameatal extension. One of the points of our surgical policy is total removal of the intrameatal part to prevent tumor recurrence and to improve hearing function. To remove the intrameatal tumor, selection of the approach is important not to take the tumor beyond the VII/VIII nerves the internal auditory canal. When the VII/VIII locate rostral, caudal or ventral to the tumor, a lateral suboccipital approach is favorable. When the VII/VIII run dorsal to the small tumor located rostrally, or Meckel's cave extension are the good candidates for anterior transpetrosal approach, we use this approach for small rostrally located meningiomas like these cases. Combined transpetrosal approach is necessary for a large tumor or a petroclival meningioma. In most of all cases, tumor was removed extensively, and functional facial nerve preservation ratio (HB grade 1, 2 at the point of 1year after surgery was 97%, hearing improvement in 34%, and worsening of hearing was 12%. Karnofsky performance status (KPS) was improved in 7 % and worsened in 5%. Choosing a surgical approach not to remove the tumor beyond the VII/VIII, referring the CISS findings of the relationship between the tumor and VII/VIII in the CPA cistern, is considered justifiable. Even in a case in which preoperative hearing function was poor, we should avoid selecting a translabyrinthine approach, with a hope for postoperative hearing improvement. 76

77 SS(IV)-1 Scientific Session IV Endoscopic transorbital surgery for middle cranial fossa tumors Sanghun Lee, Chang-Ki Hong Department of Neurosurgery, Gangnam Severance Hospital Objective: Although endoscopic endonasal approach for the skull base lesion recently has been evolved, it is still difficult to access to the middle cranial fossa including the petrous apex. That reason is why transcranial approaches (TCA) have been used to manage pathologies in these anatomic spaces. Recently, purely endoscopic transorbital surgery (ETOS) has been emerging as an alternative surgical approach for the lateral aspect of the skull base. We aimed to evaluate the feasibility of ETOS and investigated whether ETOS is an alternative procedure to TCA or endoscopic endonasal approach. Methods: We started ETOS in June 2017 and collected data from patients who had undergone ETOS (ETOS group). Magnetic Resonance Images (MRI) of patients who underwent TCA at our hospital since 2010 were reviewed by two neurosurgeon and patients who considered as could be operated with ETOS were selected as TCA group. And gross total rate (GTR), operative time, intraoperative blood loss, hospital stay, surgical morbidities were compared. Results: Nine patients underwent ETOS surgery until June 2018 (ETOS group). One of them was combined with endoscopic endonasal approach. Upper eyelid incision and dissection to orbital margin was performed by a plastic surgeon. There were seven patients with meningioma, one patient with trigeminal schwannoma and one patient with plasma cell tumor. The mean tumor size of ETOS group was 3.2 cm. Among those who have undergone TCA surgery since 2010, 23 patients were compared with ETOS (TCA group). There were 15 patients with meningioma, seven patients with schwannoma and 1 one patient with CNS lymphoma. The mean tumor size of TCA group was 3.9 cm. Compare the two groups, GTR was 6 patients (67%) in ETOS group and 18 patients (78%) in TCA group. Mean operation time was 4 hours 8 minutes in ETOS group and 6 hours 22 minutes in TCA group. Mean intraoperative blood loss was 642 cc in ETOS group and 735cc in TCA group. Mean hospital days was 12 days in ETOS group and 18 days in TCA group. One patient in ETOS group experienced cerebrospinal fluid leakage as surgical morbidity and improved after lumbar puncture. One 6th nerve palsy and two 3rd nerve palsys were observed in TCA group as surgical morbidity. Conclusion: ETOS is considerable options for the lateral aspect of the skull base due to its less destructive, shorter operation time, fewer amount of intraoperative blood loss, faster recovery after surgery and unremarked scar. As the number of ETOS cases increases, the indication of ETOS will be extending. However, there is lack of long term follow up and narrowing surgical field, so careful patient selection is necessary. Key Words: Endoscopic surgery, Skullbase 77

78 SS(IV)-2 Scientific Session IV Clinical and radiological features of malignant transformed meningioma: 10 case reports Ji-Ho Jung, Shin Jung, In-Young Kim, Kyung-Sub Moon, Tae-Young Jung, Woo-Youl Jang Departments of Neurosurgery, Chonnam National University Hwasun Hospital Objective: Most meningiomas have more than 90% benign course and some have borderline to malignant course. In a small number of cases, malignant transformation has occurred after surgery. The purpose of this study is to identify the characteristics of malignant transformed meningioma and to find an alarm factor for follow-up of meningioma patients. Methods: From 2004 to , there were 1078 cases of operation for meningioma at Hwasun Chonnam National University Hospital and malignant transformation of meningioma was found in 10 cases (0.93%). Ten patients were studied by retrograde radiological, histological, and clinically. Results: 8 of 10 patients underwent malignant transformation from Grade I to II, one patient to grade II to III, and one patient to grade I, II to III. The mean time for malignant transformation was 11.5 to 125 months (mean 62.5months), and the mean volume was 63.7cc(3.1cc~91.7cc). 6 of 10 patients had bone invasion. 5 patients had gross total resection, 6 patients had subtotal resection, 7 patients had radiation therapy(gks : 5, IMRT : 1, GKS & IMRT : 1) and 1 patient had got gydroxyurea chemotheraoy. Malignant transformation occurred after an average of 25 months (3months ~ 64month) after radiation therapy. Conclusion: If the patient has long-term dural thickening in the origin dura after surgery and progression is present within 3 years after radiation therapy for recurred mass, the lesion may be suspected of malignant transformation Key Words: meningioma, malignant transformation, radiation therapy 78

79 SS(IV)-3 Scientific Session IV New classification of tentorial meningioma and clinical outcomes Ju-Seong Kim, Sanghun Lee, Chang-Ki Hong Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Objective: Tentorial meningioma is originated from tentorial dura mater. The tentorium is a broad curtain that divides the middle and the posterior cranial fossa. Yasagil classification of tentorial meningioma is divided 8 groups, which classification is too complicated and clinically has no benefit. We report our clinical data about tentorial meningioma, which can occur in a wide range, has different surgical approaches, different degrees of surgical difficulty and outcome along the location of meningioma. Methods: We resected 417 meningiomas from 2011 to 2016 in our Hospital. Retrospective radiological and medical records were reviewed, among them, 64 cases of tentorial meningioma were selected. We analyzed our surgical data including location of meningiomas, surgical approaches, and clinical outcomes in two simplified groups that divided inner group and outer group of tentorial meningioma. Results: A total of 64 patients (8 men and 56 women) were the average age 52.4 at the time of their diagnosis. The T1, 2, and 3 of the Yasagil classification were classified as an inner group, and T 4, 5, 6, 7, and 8 were classified as an outer group, respectively. Each group was able to be classified the tumor according to its location and surgical approach, such as the tentorial incisura (T1,2 n=38, skull base approach), falcotentorial (T3 n=8, occipital transtentorial approach or infratentorial supracerebellar approach), outer lateral (T4,6,7 n=14, cerebellar convexity approach, lateral SOC), outer paramedian (T5,8 n=4, Torcular approach). The tentorial meningioma in our hospital was showing more frequently (15%) than was reported in the literature (3~4%). The overall GTR rate was 67%, most of which remained due to cavernous sinus involve in the tentorial incisural group. (incisural group; 55%, falcotentorial; 56%, lateral/paramedian group; 100% GTR) In addition, the disease control rate was 87%, with 6 patients recurred, 4 patients were performed reoperation and 2 patients were received radiotherapy. Conclusion: The newly proposed classification of tentorial meningioma through origin and surgical approach may help predict surgical risk and patient s outcomes. For surgical treatment of tentorial incisural meningioma, continuous training of skull base approaches is required. Key Words: Tentorial, meningioma, classification, incisural 79

80 SS(IV)-4 Scientific Session IV Usefulness of indocyanine green videoangiography to assess venous collaterals in meningioma surgery Ju-Hwi Kim, Shin Jung Department of Neurosurgery, Chonnam National University Hwasun Hospital Objective: Indocyanine green (ICG) videoangiography has been used in the neurosurgical operations, including vascular and brain tumor field. We applied ICG videoangiography to intracranial meningioma surgery and evaluated the usefulness with attention to collateral venous flow. Methods: Forty-two patients with intracranial meningiomas who underwent microsurgical resection were retrospectively analyzed. For ICG videoangiography, the ICG was injected intravenously with the dose of 5-25 mg before and after tumor resection. Intravascular fluorescence from blood vessels was imaged through a microscope with a special filter and infrared excitation light to illuminate the operating field. We assessed the benefits of ICG videoangiography and analyzed its findings with preoperative and postoperative findings. Results: ICG videoangiography allowed real-time assessment of the patency even in very small peritumoral vessels in all cases. The collateral venous channel due to venous obstruction of tumoral compression was found in ten cases, and if the sacrifice of vein is inevitable, the vein was cut in two cases without consequent venous infarction. However, unexpected venous thrombosis was observed after tumor resection in one case. Interestingly, venous flow diversion was observed promptly after tumor resection in 4 cases. In our analysis, presence of venous collaterals was predictive factor for peritumoral edema formation (p=0.001, HR 0.027, 95% CI ) Conclusion: ICG videoangiography, an excellent method for monitoring blood flow during meningioma resection, provides valuable information for presence of venous collaterals and flow diversion, even in the case with inevitable scarification of drainage vein. In addition, the fact that presence of venous collaterals was related to peritumoral edema may directly support venous theory as the pathogenesis of peritumoral edema formation. Key Words: Indocyanine green (ICG) videoangiography, Meningioma, Peritumoral edema, Venous flow 80

81 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Scientific Session V (Pituitary adenoma & Craniopharyngioma) 좌장 : 차승헌 ( 부산대 ), 권정택 ( 중앙대 ) Keynote Lecture: Aggressive surgery based on an anatomical subclassification of craniopharyngiomas Kenji Ohata (Osaka City University, Japan) Clipping technique for the repair of the intraoperative CSF leakage during transsphenoidal pituitary tumor surgery 김의현 ( 연세대 ) The outcomes of pituitary adenomas treated with transsphenoidal surgery: a single institution s experience 서영범 ( 영남대 ) Natural history of asymptomatic nonfunctioning pituitary adenomas with optic compression on MRI 박현주 ( 서울대 ) Long-term efficacy and tolerability of gamma knife radiosurgery for growth hormone-secreting adenoma: a retrospective multi-center study 김경환 ( 성균관대 )

82 Keynote Lecture Aggressive surgery based on an anatomical subclassification of craniopharyngiomas Ohata K, Morisako H, Nagahama A, Ohata H, Goto T Department of Neurosurgery, Osaka City University, Japan Objective: Craniopharyngiomas remain a particularly formidable challenge in the neurosurgical field. Because these lesions involve the hypothalamus and ophthalmological systems, their resection is associated with either higher rates of mortality and recurrence or a lower rate of radical resection. The authors report the outcomes of aggressive surgeries based on an anatomical subclassification of craniopharyngiomas. Methods: Clinical and ophthalmological examinations, imaging studies, endocrinological studies, neuropsychological function, and surgical complications in all patients who had undergone microsurgical resection for craniopharyngioma at Osaka City University hospital between January 2000 and December 2014 were retrospectively reviewed through the medical records. Radical resections were planned in all of the patients. To help choose the correct surgical approach, craniopharyngiomas were classified based on tumor origin. The 4 possible groups included the intrasellar type, prechiasmatic type, retrochiasmatic type, and intra-third ventricle type. A multistage surgery was planned in some cases. Results: Seventy-two cases of craniopharyngioma were resected. Thirty-two patients (44.4%) had undergone previous surgical procedures at other institutions. Thirtyfive cases (48.6%) were classified as retrochiasmatic, 19 (26.4%) as prechiasmatic, 12 (16.7%) as intra-third ventricle, and 6 (8.3%) as intrasellar. In 26 cases (36.1%), multistage surgery was required to complete the radical resection. Overall, 41 cases involved an orbitozygomatic approach; 21, a transpetrosal approach; 21, an interhemispheric approach; and 14, a transsphenoidal approach. In 3 cases, other approaches were applied. Gross-total resection was achieved in 43 patients (59.7%), near-total resection in 28 (38.9%), and partial resection in only 1 patient (1.4%). The mean follow-up period after resection was 4.7 years. Tumor recurrence or regrowth occurred in 15 (20.8%) of the 72 patients, with 14 of the 15 cases successfully controlled after additional resections and stereotactic radiosurgery. However, 1 patient died of uncontrollable tumor progression, and 2 patients died of unrelated diseases during the follow-up. Overall, disease in 69 (95.8%) of 72 patients was well controlled at the last follow-up. Conclusions: Aggressive tumor resection is the authors' treatment policy for craniopharyngioma. Using an anatomical subclassification of craniopharyngioma to choose the most appropriate surgical approach is helpful in achieving that goal of aggressive resection. 82

83 SS(V)-1 Scientific Session V Clipping technique for the repair of the intraoperative CSF leakage during transsphenoidal pituitary tumor surgery Euihyun Kim, Sun Ho Kim Department of Neurosurgery, Yonsei Severance Hospital Objective: During transsphenoidal surgery (TSS) for a pituitary adenoma with a large suprasellar extension, cerebrospinal fluid (CSF) leakage commonly develops from a defect in the arachnoid recess or the arachnoid membrane. We evaluated the usefulness of a newly developed clipping technique for the repair of intraoperative CSF leakage. Methods: Between September 2012 and November 2016, 698 patients with pituitary adenoma were operated on with TSS. Intraoperative CSF leakage was encountered in 301 patients (43.1%). The clipping technique was used to repair CSF leakage in 144 patients: from the arachnoid recess in 100 patients and from the arachnoid membrane in 44 patients. The clipping technique used titanium clips and a newly designed clip applier. We evaluated anterior pituitary function of the patients whose CSF leakage was closed by clipping, and compared this with function in another patient group treated with different repair techniques. Results: We successfully applied clip technique in 140 out of 144 patients. This clipping technique was faster and easier for repairing CSF leakage than our previously published suture technique. In our early series, 4 patients developed unexpected CSF rhinorrhea after TSS. We found no difference in anterior pituitary function between a clipping group and others. Although titanium clip was identified on postoperative MRI, its metallic scattered artifact was very minimal and did not hinder the detection of possible remnant and recurrent tumors. Conclusion: This clipping technique is a very simple and reliable method for repairing intraoperative CSF leakage when properly applied with caution. Key Words: Arachnoid defect, Arachnoid recess, Cerebrospinal fluid leakage, Clipping, Pituitary adenoma, Transsphenoidal surgery 83

84 SS(V)-2 Scientific Session V The outcomes of pituitary adenomas treated with transsphenoidal surgery: a single institution s experience Youngbeom Seo, Oh-Lyong Kim Department of Neurosurgery, Yeungnam University Hospital Objective: We retrospectively analyzed the outcomes of transsphenoidal surgery for pituitary adenomas treated at a single institute. Methods: A total of 366 consecutive patients undergoing transsphenoidal surgery for a pituitary adenoma from December 1990 through May 2017 were included in this study. The most common tumor type was nonfunctioning pituitary adenoma (NFPA) (63.7%), followed by prolactin-secreting adenoma (20.5%), growth hormonesecreting adenoma (13.4%), adrenocorticotropin-secreting adenoma (2.2%), and thyrotropin-secreting adenoma (0.2%). This cohort study consisted of 164 male and 202 female patients. The median patients age was 48 years. Results: Gross-total resection (GTR) was achieved in 83.7% of patients with a NFPA, 76% of prolactin-secreting adenomas, 71.4% of growth hormone-secreting adenomas, 75% of adrenocorticotropin-secreting adenomas, 100% of thyrotropinsecreting adenomas. There were 326 macroadenomas (69.1%). Surgical outcome was better in patients with microadenomas than in patients with macroadenomas (100% and 77.9%, respectively). Improvement of visual disturbances occurred in 148 (93.7%) of the 158 cases. Hormonal impairment by pituitary adenoma was improved in 105 (87.5%) of the 120 cases. There were 24 (8.2%) cases of recurrence after GTR; 17 patients underwent second surgery, 5 patients received radiotherapy, and the others continued conservative treatment. Conclusion: Transsphenoidal surgery is an effective and safe treatment modality for most patients with pituitary adenoma. Key Words: Pituitary adenoma, Transsphenoidal surgery, Surgical results 84

85 SS(V)-3 Scientific Session V Natural history of asymptomatic nonfunctioning pituitary adenomas with optic compression on MRI Hyun Joo Park, Yong Hwy Kim Department of Neurosurgery, Seoul National University Hospital Objective: The timing of surgical intervention in management of asymptomatic nonfunctioning pituitary adenoma with optic nerve compression is debatable. The objective of this study was to elucidate the necessity of surgery for asymptomatic nonfunctioning pituitary adenomas with optic compression. Methods: We retrospectively reviewed asymptomatic patients with nonfunctioning pituitary adenoma with documented optic nerve compression on MRI. All patients underwent baseline ophthalmological and endocrinologic evaluations. Patients were subjected to visual and hormonal follow-up every 6 months, and MR follow-up was conducted annually for the first two years and then once every 2 years. Visual acuity and visual fields were quantified using Visual Impairment Scale. If visual or hormonal symptoms occurred during follow-up, the tumor was evaluated with MR immediately. Initial and final MRI scans were subjected to volumetric analysis. Primary end-point was a 20% increase in volume, visual deterioration, or surgery. Results: A total of 66 previously untreated asymptomatic patients (mean age 54.8±13.0, range 15-76) with nonfunctioning pituitary adenoma compressing the optic nerve or chiasm were included in this study. Mean follow-up was 64.79±40.0 months (range 2-184). Tumor volume increase 20% was seen in 38 patients (57.6%, 10.7 per 100 personyears [PY]). Tumor regression ( 20%) was observed in 13 cases (19.7%, 3.6 per 100PY). 11 patients underwent surgical resection (16.7%, 3.1 per 100PY). Isolated hormonal deficiencies occurred in 3.0% to 45.5% of patients (ACTH deficiency: 3.4 per 100 PY, TSH deficiency: 1.7 per 100 PY, Gonadotropin deficiency: 8.4 per 100 PY, GH deficiency: 0.5 per 100 PY). Factors that contributed to tumor growth on multivariate analysis was the presence of cavernous sinus invasion (p value = 0.013). Cavernous sinus invasion was also the only contributing factor in determining surgical intervention (p value = 0.006). There was no statistically significant predictor of visual deterioration. The actuarial 3- and 5-year cumulative symptom-free survival was 78±5% and 39±7% for tumor growth, whereas it was 96±3% and 72±8% for surgical intervention, respectively. For visual deterioration, the actuarial 3- and 5-year cumulative symptom-free survival was 95±3% and 66±8% respectively. Kaplan-Meier curves demonstrated a mean progression-free survival (PFS) of 87.5±7.8 months for tumor progression, 141.8±10.6 months for surgical intervention, and 118.6±10.2 months for visual deterioration. There was no difference in variables between the group that had visual deterioration and the group that did not have visual deterioration. All patients who underwent surgery for symptomatic tumor growth recovered without any neurologic or endocrinological deficits postoperatively. Conclusion: The decision for surgical intervention of nonfunctioning pituitary adenoma with optic nerve or chiasm compression should be made by balancing the risks and benefits based on the natural history. The radiological presence of optic nerve abutment by nonfunctioning pituitary adenoma does not indicate a worse prognosis and thus is not an indication for surgical intervention. Key Words: Nonfunctioning, Pituitary Adenoma, Optic nerve compression 85

86 SS(V)-4 Scientific Session V Long-term efficacy and tolerability of gamma knife radiosurgery for growth hormone-secreting adenoma: a retrospective multi-center study Kyung Hwan Kim 1, Doo-Sik Kong 1, Yong Hwy Kim 2, Young-Hoon Kim 3, Do Hoon Kwon 3, Dong-Kyu Kim 2, Jung-Il Lee 1 1 Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 2 Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 3 Department of Neurosurgery, Asan Medical Center, University of Ulsan, College of Medicine Objective: Little is known about the long-term efficacy, prognostic factors and tolerability of gamma knife radiosurgery (GKS) for acromegaly. The aim of this study is to investigate long-term hormonal effects, prognostic factors and tolerability of GKS in patients with GH-secreting adenoma. Methods: Retrospective multi-center study over 25 years with a median follow-up of 85.2 months was performed. A total of 138 patients from three tertiary referral centers in South Korea were included in this study between 1991 and Main outcome measures were endocrine remission, endocrine control under somatostatin analogues, and hypopituitarism. Results: With a mean follow-up period of 85.2 months (range, months), overall median time to the endocrine remission and control under long-acting somatostatin analogues was 138 months and 96 months, respectively. Female sex, normal age-adjusted IGF-I 2 and GKS as an adjuvant treatment were significantly favorable factors for remission (P=0.004, P=0.001, P=0.010, respectively). Early response group had a significantly lower proportion of normal age-adjusted IGF-I level >2 than did late response group (22.2% vs. 51.7%, P=0.035), even though lower radiation dose (24.3 Gy vs Gy, P=0.003). The incidence of GKS-induced hypopituitarism (one or more) was 12 of 138 patients (8.6%) at the last follow-up. Conclusion: In acromegalic patients, women with normal age-adjusted IGF-I 2 and GKS as an adjuvant treatment have a better response to GKS. We should take into account the variability of radiosensitivity of the tumor according to the gender and IGF-I level. Key Words: gamma knife radiosurgery, GH-secreting pituitary adenoma, acromegaly, multi-center 86

87 The 28 th Annual Meeting of The Korean Brain Tumor Society & The 12 th Chinese-Korean Brain Tumor Joint Meeting Poster Session

88 P01 Poster Session Selection of surgical approach for trigonal meningiomas in consideration of visual outcome Ju-Hwi Kim, Shin Jung Department of Neurosurgery, Chonnam National University Hwasun Hospital Objective: We report the surgical outcome of trigonal meningiomas through three different approaches with attention to visual outcomes. Methods: Between 1994 and 2017, twenty-three patients underwent resection of trigonal meningiomas. We performed tumor removal using three different surgical approaches through the superior parietal lobule, middle temporal gyrus (MTG), and modified-mtg. The patients were retrospectively identified and surgical results including visual outcome were analyzed. Results: Twenty-three patients with a mean age of 45 years formed the study group. The most common symptom and sign were headache (N=14, 60.9%) and visual disturbance (N=6, 26.1%). All patients underwent surgical resection, 6 via translateral approach through MTG, 8 via translateral approach through modified MTG, and 9 via transparietal approach through superior parietal lobule (SPL). Gross total resection was achieved in all patients. We found that visual preservation rate was 25% (1/4) in the MTG group, 62.5% (5/8) in the modified MTG group, and 100% (7/7) in the SPL group, respectively (p=0.044). Permanent complication rate was 50% (3/6) in the MTG group, 50% (n=4/8) in the modified MTG group, and 11.1% (n=1/9) in the SPL group. Conclusion: The superior parietal lobule approach is a safe and applicable procedure with a great visual preservation and an acceptable risk of morbidity for trigonal meningiomas, when there is a chance of visual recovery or preservation. Key Words: Meningioma, Superior parietal lobule, Surgical approach, Trigonal, Visual field 88

89 P02 Poster Session Adult onset sellar and suprasellar ATRT: a case report Minu Nahm, Yong Ko Department of Neurosurgery, Hanyang Medical Center Objective: Central nervous system(cns) atypical teratoid/rhabdoid tumor(atrt) is a rare and highly malignant tumor, mainly found in pediatric patients. ATRT in adult patients have been rarely reported. As of 2015, there have been less than 55cases of adult-onset ATRT. Due to extremely rare incidence of this tumor in adult populations, diagnosis is often delayed excluding other more common tumors. In this report, we describe the case of a 56-year-old woman who showed visual disturbance, headache within 2 months period and further accelerated aggravation of symptoms with in next 3 weeks. With this case report we expect more understanding of clinical course of this rare CNS tumor. Methods: Generally healthy 56-years-old female with no underlying disease developed new onset headache and progressive visual field defect with no other neurologic deficits. Gross total tumor removal was done, approached with a transsphenoidal route. In next three weeks, her right visual field got worse and right 3rd nerve incomplete palsy was followed. Her tumor size was grown compared to pre-operation Sellar MR. Second operation was done, approached with a pterional craniotomy and diagnosed ATRT confirmed via biopsy. Results: Our patient had surgery 2 times and present receiving radiosurgery. 2 months clinical follow up time is short for judging treatment outcome, however her condition is slowly improving. Conclusion: ATRT is a very rare disease and fall much lower on the differential diagnosis list than other more statistically common adult brain tumors. In our report, final diagnosis took over 1 month from her initial surgery, to confirm ATRT. And during this period her symptom got rapidly worse. From this case report we can learn the importance of paying attention to post-operative patient s symptom and if symptom is medically relevant (e.g. follow up visual test) follow up MRI should not be hesitated. Key Words: ATRT 89

90 P03 Poster Session Brain abscess caused by Klebsiella pneumoniae misdiagnosed for a brain tumor: a case report Hah Yong Mun, Jeong Taik Kwon Department of Neurosurgery, Chung-Ang University Hospital Objective: A 43-year-old male with dysarthria and right hemiplegia was diagnosed as pontine abscess caused by Klebsiella pneumoniae. Surgical drainage was performed and administered antibiotics. The abscess was resolved and the patient were recovered well. Methods: A 2.5cm-sized round, hypointense and rim-enhanced mass was detected on Gadolinium-enhanced magnetic resonance image. Differential diagnosis between various tumorous conditions was necessary and the neurological deterioration was progressed rapidly. Surgical removal was underwent for treatment and diagnosis. Results: We approached to brainstem by lateral suboccipital craniectomy, and incised pontine under navigator system. High pressure pus-like discharge was gushed out. Klebsiella pneumoniae was identified by culture exam. After surgery and antibiotics treatment, the patient showed excellent neurological recovery. Conclusion: Brainstem abscess may be a fatal disease with severe neurological deficit. However, the differential diagnosis on radiologic imaging was sometimes challenging. When pontine mass was found with acute neurological symptom, we emphasize that brain abscess should be included in the differential diagnosis. Key Words: Brainstem abscess 90

91 P04 Poster Session Effect of glioblastoma-cultured medium on neural differentiation of induced pluripotent stem cell Young Seok Park, Young Gyu Kim Department of Neurosurgery, Chungbuk National University Hospital Objective: Little is known to date about neural development of direct differentiation of pluripotent stem cell to neuronal cell remain elusive. To determine whether soluble factors from GBM promoted the neural differentiation from porcine ipsc, were treated cultured media of GBM cell. Methods: We isolated and established primary GBM cell line. The ceullar morphology of GBM cancer cell line are positive NESTIN, SOX2, VIMENTIN and GFAP using immunoflorescence analysis. G-Banded Karyotype from primary GBM cell line revealed several chromosomal aberrations. Results: GBM-cultured medium treated ipsc-npcs survive well in vitro when supplemented with a combination of growth factors, including EGF and bfgf. The GBM medium treated differentiated cell showed an increase mrna expression level of astrocyte marker, GFAP and the dopaminergic neuron marker, tyrosine hydroxylase(th). However, there was no significant difference in mrna expression of oligodendrocyte marker, MBP. Conclusion: This study showing how GBM cultured media effect on porcine neuronal differentiation. This provide understanding difference of neuronal differentiation between rodents and large animal model(porcine) in vitro. Key Words: glioblastoma, ipscell 91

92 P05 Poster Session Comparison of 3 and 7 Tesla magnetic resonance imaging of obstructive hydrocephalus caused by tectal glioma Young Seok Park, Young Gyu Kim Department of Neurosurgery, Chungbuk National University Hospital Objective: Obstructive hydrocephalus caused by tectal glioma, which relived by neuroendoscopy, have been described using 3.0 Tesla magnetic resonance imaging (3T MRI) so far, we present the results obtained from 3T and 7T MRI in this patient Methods: A 21-year-old woman presented at our hospital with gait disturbance, hormonal insufficiency, and urinary incontinence that began prior to 6 years of age. 3.0T MRI revealed a non-enhancing tectal mass along with obstructive hydrocephalus. We performed 3T and 7T brain MRI, both preoperatively and postoperatively at 1, 6 months. The mass measured approximately cm. An endoscopic third ventriculostomy was performed to relieve the hydrocephalus. We compared hydrocephalus and cerebrospinal fluid (CSF) flow findings from 3T and 7T MRI, both preoperative and postoperative at 1, 6 months. Intraventricular CSF voiding on T2- weighted images obtained with 7T MRI showed greater fluid inversion than those obtained with 3T MRI. Results: An endoscopic third ventriculostomy was performed to relieve the hydrocephalus. We compared hydrocephalus and cerebrospinal fluid (CSF) flow findings from 3T and 7T MRI, both preoperative and postoperative at 1, 6 months. Intraventricular CSF voiding on T2-weighted images obtained with 7T MRI showed greater fluid inversion than those obtained with 3T MRI. Conclusion: This study shows that 7T brain MRI can provide detailed information on hydrocephalus caused by tectal glioma. Further studies are needed to develop refined 7T MRI protocols for better images of hydrocephalus. Key Words: 7T MRI, Tectal glioma 92

93 P06 Poster Session Procarbazine and CCNU chemotherapy for recurrent glioblastoma with MGMT promoter methylation Se Hyuk Kim 1, Heon Yoo 2, Jong Hee Chang 3, Chae-Yong Kim 4, Dong Sup Chung 5, Se Hoon Kim 6, Sung Hae Park 7, Youn Soo Lee 8, and Seung Ho Yang 9 1 Department of Neurosurgery, Ajou University School of Medicine, 2 Department of Neuro-oncology Clinic, National Cancer Center, 3 Department of Neurosurgery, Yonsei Severance Hospital, Yonsei University College of Medicine, 4 Department of Neurosurgery, Bundang Seoul National University Hospital, 5 Department of Neurosurgery, The Catholic University of Korea, Incheon St. Mary s Hospital, 6Department of Neurosurgery, 6 Department of Pathology, Yonsei Severance Hospital, Yonsei University College of Medicine, 7 Department of Pathology, Seoul National University Hospital, 8 Department of Pathology, The Catholic University of Korea, Seoul St. Mary s Hospital, 9 Department of Neurosurgery, The Catholic University of Korea, St. Vincent's Hospital Objective: While procarbazine, CCNU (lomustine) and vincristine (PCV) has been an alternative chemotherapy for malignant gliomas, the question of whether the combination of procarbazine and CCNU is comparable is worth it, as vincristine adds toxicity with uncertain benefit. The purpose of this study was to evaluate the feasibility of procarbazine and CCNU chemotherapy for recurrent glioblastoma multiforme (GBM) with O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation. Methods: Eight patients with recurrent GBM following concurrent chemoradiotherapy and temozolomide (TMZ) adjuvant therapy were enrolled in this trial; they received no other chemotherapeutic agents or target therapy. They received CCNU (75 mg/m2) on day 1 and procarbazine (60 mg/m2) through days 11 and 24 every 4 weeks. The median cycle of CCNU and procarbazine was 3.5 (range: 2 6). Results: One patient achieved stable disease. The median progression-free survival (PFS) with procarbazine and CCNU chemotherapy was eight weeks (range: 5 73), and PFS rates were 25% and 12.5% at 16 and 30 weeks, respectively. The median overall survival (OS) from the initial diagnosis to death was 40 months, and the median OS from the administration of procarbazine and CCNU chemotherapy to death was 9.7 months (95% confidence interval: ). Serious adverse events were found at six visits, and two cases were considered to be grade 3 toxicities. Conclusion: The efficacy of procarbazine and CCNU chemotherapy is not satisfactory. This study suggests the need to develop further treatment strategies for recurrent and TMZrefractory GBM. Key Words: Glioblastoma, Nitrosourea, Recurrent, Procarbazine, CCNU 93

94 P07 Poster Session Recurrent glioma with lineage conversion from oligodendroglioma to astrocytoma Min-Ho Jung, Kyung-Sub Moon Department of Neurosurgery, Chonnam National University Hwasun Hospital and Medical School Objective: Since the advent of molecular classification of gliomas proposed by WHO classification of tumors of the central nervous system in 2016, the entity of oligoastrocytoma has been nearly denied. True oligoastrocytoma with dual genotype is accepted exceptionally. We analyzed two cases of recurrent gliomas that began as oligodendroglioma both histologically and molecularly but transdifferentiated toward astrocytoma over recurrence. Methods: Immunohistochemistry for ATRX, IDH1-R132H and P53 and 1p/19q fluorescence in-situ hybridization (FISH) were performed on formalin-fixed, paraffinembedded tissue. Next generation sequencing (NGS) analysis was also performed on DNA extracted from microdissected tumor tissue of one case. Results: The first case patient started his clinical course with oligodendroglioma. The first recurrent tumor 7 years after the initial surgery was anaplastic oligodendroglioma with 1p/19q-codeletion. The second recurrent one after another seven years showed loss of ATRX expression, strong P53 positivity, and IDH1-R132H preservation but 1p/19q-nondeletion. The original tumor of the second case was diagnosed as anaplastic oligodendroglioma based on histology and 1p/19q codeletion by FISH examination. Then the recurrent mass was composed of highly pleomorphic tumor cells with hyperchromasia and displayed strong P53 positivity, ATRX loss and 1p/19q-nondeletion. NGS analysis performed on the first case confirmed the transition of molecular traits from oligodendroglioma to astrocytoma. IDH mutation of R132H was preserved along with the recurrent episodes but ATRX and TP53 mutations were newly acquired at the recent recurrence. Conclusion: The question in the presented cases is whether the original tumors were true oligodendroglioma and then transdifferentiated into astrocytoma. Another hypothesis would be that the original one was oligoastrocytoma with oligodendroglioma cells outnumbering astrocytoma cells and the astrocytoma cells has grown predominantly over recurrence. Key Words: Cell lineage, Clonal evolution, Genetic heterogeneity, Mixed oligoastrocytoma 94

95 P08 Poster Session Subfrontal falco-olfactory approach for midline anterior skull base meningiomas Young Jun Cheon, Shin Jung Department of Neurosurgery, Chonnam National University Hwasun Hospital and Medical School Objective: Anterior skull base meningiomas such as planum sphenoidale meningioma and olfactory groove meningioma may be symmetric around the midline. Bifrontal frontobasal approach and its variations have long been recommended as standard approach to remove these tumors. In the present report, we describe a subfrontal Falco-olfactory approach to treat these anterior skull base meningiomas. Methods: The subfrontal Falco-olfactory approach was used to treat nine patients with anterior skull base tumor, including six patients who were diagnosed as planum sphenoidale meningioma and three patients with olfactory groove meningioma. Subfrontal craniotomy was performed with minimal dissection of temporalis muscle. Results: In all nine cases, ipsilateral olfactory nerve and tumor base could be visualized in the initial stage of the procedure after retraction of frontal lobe carefully. This allowed for olfactory nerve preservation and early tumors devascularization. Between falx and olfactory nerve (above olfactory nerve), we gained excellent visualization of the tumor. After removal of ipsilateral side tumor, incision of the falx, other side tumor could be exposed easily. Preservation of other side olfactory nerve was also done. All patients had no postoperative complications. Conclusion: Thus, subfrontal transfalcial olfactory approach could be considered as a safe and versatile surgical route for anterior skull base meningiomas. Key Words: subfrontal, anterior skull base, meningioma, Falco-olfactory 95

96 P09 Poster Session The inhibition of tumor growth through flagellin B secreted by engineered salmonella typhimurium with radiation in mouse glioma model Jin Myung Choi, Shin Jung Department of Neurosurgery, Chonnam National University Hwasun Hospital Objective: Glioblastoma (GBM) is presently performed by various therapies such as surgery, radiotherapy, and chemotherapy but show many difficulties due to low cure rate and high recurrence until now. Salmonella typhimurium is used as a potential method for cancer therapy due to moving property to hypoxia environment. Also, the flagellin B (flab) is known as adjuvant for various cancer therapy as well as protectant to radiation. So, to identify flab effect with radiation in GBM, we treated flab-expressing S. typhimurium and identified change of tumor growth in mouse glioma model. Methods: GL261/Fluc cells are transplanted in 6 weeks female C57BL/6 mouse. Mouse divided into four subgroups for treatment; Control, only S. typhimurium (+flab), only radiation, and combination. FlaB-expressing attenuated S. typhimurium (Lux) was injected into the tail veil. Moving and location of S. typhimurium to tumor are identified by bioluminescence imaging (BLI) and immunofluorescence (IF). Secreted flab also showed by IF. MRI and BLI are used for change of tumor growth. Results: The moving of S. typhimurium (+Lux) to tumor was monitored as BLI on brain tumor after tail vein injection of strain. Also, flab induction by L-arabinose and location of S. typhimurium were identified by IF that mainly locate on boundary of between tumor and normal tissue. Furthermore, the combinational effect of S. typhimurium (+flab) and irradiation was identified tendency in which tumor BLI is reduced compare d with nontreatment control. Conclusion: S. typhimurium can move to brain tumor and secreted flab by L-arabinose. Combination of radiation and flab tend to hinder brain tumor growth in mouse glioma model. Taken together, we can infer that flab combination with radiation could be inhibit tumor growth through immunological mechanism. Currently, we are conducting further experiments to verify the effectiveness of flab with radiation in terms of possibility as a potential method for GBM cure. Key Words: Glioblastoma, Salmonella typhimurium, flagellin B, radiation 96

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