Clinico-radiological, surgical and pathological findings at initial diagnosis (33 patients).
\r\n\tThe WHO classification in 2007; was based on the histogenesis and cell origin of the tumor. In the latest classification made in 2016; to better characterize the tumor and obtain better data on its prognosis; The combination of molecular and genetic biomarkers and histopathological features of the tumor was used. Despite all current treatment approaches, the median survival time is around 12 months in most GBM patients. Compared with the situation of some types of successfully treated cancers; the survival time of GBM patients is not at an acceptable level today. In the treatment of CNS tumors; surgery, chemotherapy, and radiation treatments (x-rays, gamma rays, electron and proton beams) are used. The therapeutic potential of chemotherapy; New strategies are needed to increase drug concentration at the diseased site, as this largely depends on the ability of the chemotherapeutic agent to achieve effective concentrations at tumor localization. Based on our better understanding of the genetic and molecular characteristics of CNS tumors; Targeted therapies, including vaccines, and treatment protocols such as immunotherapy are promising developments.
\r\n\r\n\tThis book supposes to be written by many authors who have an internationally honored place in their field to share their ideas about the treatment of CNS tumors. Surgery, Radiotherapy, Chemotherapy and Antiangiogenic Therapy Protocols, Immunotherapy, Molecular Therapy, Specific target-agents therapy with Nanoparticles and Gene Therapy for CNS tumors among the book chapters.
\r\n\tIn these sections; there are many practical pieces of information that can help the students who graduated from the Medicine Faculty and specialist doctors who are interested in Neurosurgery.
Soybean (
Among the important phytochemicals in soybeans for human health, phytoestrogens, mainly, isoflavones (genistein and daidzein) and lignans, are the most widely studied. Nevertheless, saponins and phytosterols have also been the subject of research on soybeans. This chapter will discuss these phytochemicals compounds, their chemical structures, and their relationship with the major biological functions, scientifically proved, and their health benefits.
Phytoestrogens are non-steroidal compounds found in plants. They demonstrate estrogenic and/or antiestrogenic activity and constitute a diverse group of compounds that have similar chemical structures and biological activity of estrogens.
The phytoestrogens can be divided into four main classes: isoflavonoids, flavonoids, coumestrol and lignans. Nearly all food vegetables have phytoestrogens although the amount and concentration of the compounds vary significantly. Some vegetables are high in phytoestrogens content such as flaxseed, which are a rich source of lignans; soybeans and chickpeas have high concentrations of isoflavones. Lignans can also be found in cereals, vegetables, and fruits (Kuhnle et al., 2009), whereas isoflavone-containing foods
Phytoestrogens are intrinsic plant compounds and their contents depend on a number of factors including the cultivar, place of production, planting or harvesting season, or growth-related factors.
Among the phytoestrogens, isoflavones are found mostly in plants, especially in the glycosides forms and are biologically inactive. Soybeans are a main source of phytoestrogens in the human diet. Flavonoids are widely distributed throughout the plant kingdom and are found in many vegetables, grains, herbs, and green tea. As for the coumestrol, its only sources are alfalfa sprouts and a variety of bean seeds. Chemical structures of the four classes of phytoestrogens are shown in Figure 1.
Chemical structure of the major classes of phytoestrogens.
The contents of isoflavones in soybean and soy products have been extensively analyzed and studied. Those studies have demonstrated that the concentration and composition of isoflavones vary considerably, which can be explained by environmental and geographical conditions as well as by the level of industrial transformation. Daidzein, genistein, and glycitein are the most abundant isoflavones found in soy.
Isoflavones are naturally occurring compounds in foods as glycosides conjugated highly polar conjugated or non-conjugated form. For example, the textured soy protein and tofu have high contents of conjugated isoflavones such as daidzein and genistein, while fermented soy products such as miso, have approximately 90% of the isoflavones in non-conjugated form, mainly daidzein and genistein (Coward et al., 1993). Those chemical structures and their similarity with equol and estradiol (human estrogen) can be seen in Figure 2.
When ingested, phytoestrogens are metabolized by intestinal bacteria to equol (Cassidy, 1996; Setchell et al., 1984). The metabolism of phytoestrogens in humans is probably facilitated and modulated by bacterial colonies; therefore, the colonic ecology might be associated with increased efficiency in conversion of dietary soy isoflavones to their bioactive form (Teas et al., 2009). After absorption, isoflavones undergo enterohepatic circulation and are primarily conjugated with glucuronic acid in the liver and then excreted in urine.
Numerous studies have shown that a number of factors influence the bioavailability of soy isoflavones. Xu et al. (1994) evaluated the bioavailability of daidzein and genistein from soymilk and observed that daidzein was more bioavailable in adult women. The efficiency of absorption of soymilk isoflavones varies from 13% to 35% depending on individual gut microflora (Xu et al., 1995). Lampe et al., (1998) suggested that dietary fiber and other compounds in a diet rich in fibers might promote the growth and/or activity of bacterial colonies favorable to the conversion of daidzein to one of its catabolic products, equol, for a further absorption in the colon. Fermentation can reduce the isoflavones content in food products but increasing its bioavailability (Hutchins et al., 1995). Recently, it has been demonstrated in postmenopausal Japanese women that the bioavailability of isoflavones in fermented soy products rich in aglycones is much greater compared to the consumption of glucoside-rich non-fermented soybeans (Okabe et al., 2011).
Chemical structure of the major isoflavones found in soy and their similarity to equol and estradiol.
In recent years, it has been demonstrated that the phytoestrogens have multiple mechanisms of action. Such growing scientific evidence suggests that isoflavones are responsible for many of health benefits, which include the prevention and treatment of cardiovascular diseases, cancer, osteoporosis, and also for the relief of unpleasant pre- and post-menstrual symptoms.
Coronary heart diseases are the leading cause of death especially in industrialized countries. High levels of total and LDL cholesterol are considered risk factors for these diseases. In humans, the consumption of 25g of soy protein per day may reduce the levels of total and LDL cholesterol
Preliminary results suggest that isoflavones, such as estrogens, may produce a cardioprotector effect directly on blood vessel walls and on other processes involved in the etiology of coronary heart diseases although the results are sometimes incompatible. Soy isoflavones act as potent antioxidants able to reduce the oxidation of LDL cholesterol and to induce vascular reactivity. The presence of modified LDL cholesterol in the blood vessel walls contribute to the formation of atherosclerotic plaques and, according to studies in humans, soy isoflavones improve endothelial function and arterial relaxation.
Nagarajan (2010) suggested that soy isoflavones may inhibit the effect of endothelial cell activation associated to chronicle diseases such as atherosclerosis by blocking the activation of inflammatory cells and the adhesion to the vascular endothelium. This author concluded that the atherosclerotic protection of soy isoflavones is mediated through the regulation of monocyte activation (Figure 3). Another mechanism associated with soy isoflavones regarding cardiovascular health has been demonstrated by the reduction of vascular contraction through inhibition of the RhoA/Rho-kinase signaling pathway, which has a major role in muscle contraction (Seok et al., 2008).
I) Inflammatory process associated with atherosclerosis. (II) Soy/isoflavone diet blocks endothelial and monocytes activation (Adapted from
A prospective study carried out in Japan showed that the high consumption of isoflavones was associated with reduced risk of cerebral and myocardial infarctions in women, mainly in postmenopausal women, suggesting that the consumption of dietary isoflavones may be beneficial for the prevention of cardiovascular diseases (Kokubo et al., 2007).
Isoflavones may have inhibitory effects on the adipose tissue that could help prevent obesity-associated diseases by improving the plasma lipid profile. Nevertheless,
Cardiovascular health benefits of soy isoflavones are controversial. It has been suggested that a genistein supplemented diet (Villa et al., 2009) improves the glycemic and vascular reactivity indexes in postmenopausal women compared to the control. Nonetheless, discrepancies in clinical studies may be associated with the differences in intestinal bacterial flora of subjects and, therefore, with the bioavailability of soy isoflavones metabolites, differences in dose-response effects, duration of isoflavones supplementation, and the limited number and metabolic status of subjects included in supplementation trials (Siow & Mann, 2010)
Most of the evidences of the phytoestrogens effects on humans are epidemiological and are based on the differences in the consumption of soy products in different areas of the world, considering soy products as the major source of isoflavones. A recent publication of a meta-analysis of a prospective study suggested that the consumption of isoflavones is associated with a reduced risk of breast cancer incidence in Asian populations (Dong & Qin, 2011). Accordingly, anticancer effects of soy isoflavones have been reported on prostate and colon cancer. The mechanisms that define the anticancer effects of isoflavones have also been reported in several studies that suggest various cellular pathways of the functional role as an anticancer agent.
Studies have demonstrated that isoflavones prevent the growth of a variety of cells including those that are not hormone-dependent, these effects are based on the capacity of isoflavones to inhibit the activity of enzymes that control cell growth. Recently, it has been proved that dietary genistein may reduce breast cancer progression via transcriptional regulation of Rho GTPases and PAK (Martínez-Montemayor et al., 2010). Genistein acts as an inhibitor of the tyrosine-kinase activity, essential enzyme in the biological control of cell growth and differentiation.
Another mechanism proposed for the anticancer activity of isoflavones was demonstrated by the inhibition of angiogenesis. Guo et al. (2007) found that soy isoflavones may inhibit prostate tumor angiogenesis through the suppression of vascular endothelial growth factor signaling pathways between tumor cells and vascular endothelial cells. Similar results were found by Su et al., (2005) in human bladder cancer cells lines. These authors demonstrated that isoflavones did not exhibit toxicity to normal bladder cells due to their angiogenic inhibitor effects.
In prostate cancer cell lines has been observed that genistein significantly decreased reactive oxygen species levels and induce the expression of antioxidant enzymes such as manganese, superoxide dismutase and catalase through AMP-activated protein kinase (AMPK) activation and increase PTEN expression (phosphatase and tensin homolog deleted from chromosome 10) (Park et al., 2010).
Based on
Experimental and epidemiological evidences support the hypothesis that phytoestrogens have estrogenic and antiestrogenic effects in women. The biological effect varies according to the woman’s biological phase. Hence in premenopausal women, the phytoestrogens act as antiestrogens when the estrogen levels are high, and they act as estrogen in postmenopausal women when the estrogen levels are low (Messina, 2000).
Studies of controlled intervention in premenopausal women suggest that phytoestrogens diet may produce estrogenic effects (Cassidy et al., 1994, 1995). The interest in soy’s hormonal effects on premenopausal women is based on potential antiestrogenic benefits evidenced in hormone-dependent cancers, such as breast cancer. Hence, frequent assays measure the plasma concentration of reproductive hormones and the menstrual cycle. A reduced risk of breast cancer is associated to a longer menstrual cycle, reduced estrogens, increase in sex hormone-binding globulin, and increase urinary excretion ratio of 2- to 16α-hidroxy estrogens (Kurzer, 2002). In a randomized study with 40 premenopausal women was demonstrated that a soy diet slightly increased menstrual cycle length by 1.8±0.7 days and significantly increased urinary isoflavonoid excretion compared to women fed a control diet (Brown et al., 2002). In similar study, Hooper et al. (2009) found that the consumption of isoflavone-rich soy products significantly reduced concentrations of FSH and LH hormones that regulate the development, growth, puberty maturation, and reproduction processes in premenopausal women. Menstrual cycle length was increased by 1.05 days.
A recently published study, carried out in 73,223 premenopausal Chinese women demonstrated that the consumption of soy protein or isoflavones was inversely associated with the risk of breast cancer, and the association was highly statistically significant (
A daily intake of soy textured protein containing 45mg of isoflavones alters the menstrual cycle in healthy premenopausal women by prolonging its length, especially in the follicular phase. This effect was not observed with soy protein free of isoflavones, supporting the evidence that soy phytoestrogens act as an endocrine regulator. Similar effects of phytoestrogens on the menstrual cycle have been reported in other studies; nonetheless Phipps et al (1993) reported an increase in the length of the luteal phase. This result is not so easy to explain since changes in the luteal phase length are associated almost exclusively with changes in the follicular phase. The luteal phase is extremely constant and difficult to modify (Ferin et al., 1993).
Epidemiological and clinical data indicate that postmenopausal estrogen therapy provides protection against cardiovascular diseases, reduces osteoporosis, improves the cognitive function, and relieves the menopausal symptoms related to the major loss of ovarian estrogen (Col et al., 1997). Alternative sources of exogenous estrogen have been extensively investigated due to a possible increased risk of breast cancer associated with hormonal replacement therapy (Breckwoldt et al., 1995). Various studies have focused on verifying the potential of soy isoflavones as a source of exogenous estrogen.
During menopause, the ovarian production of estrogens decreases. A reduction of estrogen levels in the blood leads a series of characteristic symptoms of menopause, such as hot flashes, insomnia, excessive sweating, headaches, mood swings, nervous tension, irritability, depression and vaginal dryness and pain. A group of 145 postmenopausal women was fed a diet rich in phytoestrogens (soy and flaxseed) and a control diet for 12 weeks. The subgroup of women fed a phytoestrogen diet presented a significant lower incidence of hot flashes and vaginal dryness and an increase in the serial phytoestrogen concentrations (Brzezinski et al., 1997).
A study involving 51 perimenopausal women who were fed a rich diet supplemented with isoflavones presented menopausal symptoms relief, reduction in the blood pressure, and improvements in the lipoprotein profile (Washburn et al., 1999). Similarly, a double-blind study involving 40 women who received daily doses of 100mg of isoflavones reported a decrease in menopausal symptoms and in the plasma levels of total and LDL cholesterol, which are risk factors for cardiovascular diseases (Han et al., 2002). Similar results were found in a study involving 58 postmenopausal women who consumed 45g of soy flour or 45g of wheat flour. Those who consumed the soy flour presented a significant reduction of hot flash (Warren et al., 2002).
By the time a woman reaches menopause, her bone density (peak bone density is reached at approximately 30 years of age) decreases rapidly along with a reduction in estrogen in the plasma. If the estrogen replacement treatment starts before the onset of menopause, it is possible to prevent bone density loss as well as the risk of cardiovascular diseases in postmenopausal women. However, estrogen hormone replacement can also cause an increase in the risk of endometrial and breast cancer.
The possibility that soy phytoestrogens may offer a natural alternative to the conventional hormone therapy for the prevention of bone loss has fostered research in animals and humans. Animal studies have used ovariectomized rats, although this is not an ideal model that simulates the influence of ovarian hormones on the reproductive physiology and bone loss in postmenopausal women; the findings are encouraging in terms of the protective effects of phytoestrogens. The consumption of soy isoflavone has demonstrated a significantly decreased in the number of osteoclasts and an inhibition of bone resorption after ovariectomy in this type of animals (Uchida et al., 2010). Analogously, it has been observed in ovariectomized rats, a reduction of urinary excretion levels of deoxypyridinoline, a specific biomarker of bone resorption, after the consumption of isoflavones with supplemental calcium (Breitman et al., 2003). Another study in rats demonstrated that genistein and moderate physical exercises prevented body weight gain and bone loss (Wu et al., 2004).
Epidemiologic studies have showed a lower incidence of osteoporosis in populations consuming diets high in soy, such as Asians, when compared to western populations. Hip fracture is 50-60% less frequent among Asian compared to western women although this benefit gradually disappears as Asians adapt a western lifestyle (Adlercreutz & Mazur, 1997; Roos et al., 1991, as cited in Lagari & Levis, 2010).
In addition to the usual investigations on isoflavones as one of the main soy bioactive compounds, there has been a growing interest for investigating the functionality of soy saponins and their health benefits.
Saponins (from the Latin “
Saponins are usually located in the seed, hulls, leaves, stems, and roots of plants (Carlson, 2009), and many of those compounds occur naturally even within a single vegetable species. Among the legumes, soy is one the main sources of saponins in the human diet (Lin & Wang, 2004).
Saponins have an antifungal activity and a major role in defenses against predators in plants. This function has been traditionally associated with an anti-nutritional factor in foods containing saponins, besides having limited their application due to their bitter taste. However, recent studies have demonstrated the role of these compounds in the prevention and control of chronic degenerative diseases.
Saponins are compounds that have amphiphilic structure, i.e. having polar and non-polar fractions. The polar fraction is represented by one or more hydrophilic sugars chains linked to hydrophobic aglycon, triterpen or steroidal called sapogenin.
Sapogenins are composed of carbon atoms in the form of fused rings. The sugars are in the form of oligosaccharides, linear or branched chains, although monosaccharides can also occur, such as the case of glucose and galactose. Both polar and non-polar groups are responsible for the beneficial biological effects.
The structure of saponins from different plant sources varies depending on the types and amount of sugars as well as the composition of the steroid ring (Rao & Sung, 1995). In vegetables, steroidal saponins are mainly found in monocotyledons, and triterpene saponins are predominately present in dicotyledons such as leguminous plants, in which soy is considered as one of their major food sources (Güçlü-Üstündağ & Mazza, 2007). Galactose, arabinose, rhamnose, glucose, glucuronic acid, and fructose are the most common sugars in saponin structures, and five sapogenins have been identified in soybeans (Figure 4). Soy saponins are usually classified into three groups: A, B, and E (Lin & Wang, 2004) suggesting that saponins group E are formed from group B saponins during extraction and analysis when the 22-hydroxyl group is oxidized to a ketone (Berhow et al., 2006).
As in most vegetables, the concentration of soy saponins depends on many factors, including the cultivar, age, physiological stage, geographical location, processing, and storage. Similarly, there are qualitative and quantitative variation also exists between plant parts (Oleszek, 2000).
The contents of saponins in soybeans can vary among the different genotypes. In a study conducted in the USA, 21 lines of soybean grown in five different environments were evaluated. The contents of saponins found were between 2209 and 5830 µg.g-1 among the different lines and locations (MacDonald et al., 2005). The saponin content in the grain varies, and the highest amount is found in the hypocotyl, where there is a 4-fold accumulation compared to that of cotyledon and pod shell (Shimoyamada et al., 1990).
Saponins are thermal sensitive, and several studies have evaluated the characteristics and stability of saponins in a number of soy products. During processing and storage of soybeans, chemical modification of saponins can occur resulting in a change in the total content, composition, and properties/biological activity and properties, which may or may not be desirable (Güçlü-Üstündağ & Mazza, 2007).
The cooking process of legumes as soybean reduces the amount of saponins by 7-53% (Shi et al., 2004). Soy-based foods have different amounts of saponins; usually low values compared to those of raw soybeans. Soybean flour, soy protein isolate, lecithin, and tofu present reduced content of saponins, 50, 25, 73, and 37%, respectively, compared to that of the whole soybeans (Fenwick & Oakenfull, 1981). Soy-based foods obtained by ethanol processes, such as concentrated proteins, for example, present low content of saponins due to their solubility in alcohol (Murphy et al., 2008).
Structures of five types of sapogenins identified in soybeans (Adapted from de
Due to recent advances in analysis and purification techniques of saponins, several studies have evaluated the functionality of these compounds influenced by the genetic polymorphism of their different structures (Tsukamoto & Yoshiki, 2006). Hence, saponins have been reported to possess a wide range of biological activities (Güçlü-Üstündağ and Mazza, 2007), mainly anticancer, antioxidant, hypocholesterolemic, and antiviral effects.
The biological oxidation caused by reactive oxygen species (ROSs) and free radicals is involved in biological processes such as aging and degenerative diseases such as cancer. The etiology and pathogenesis of cancer are multifactorial and involve multiple steps that culminate into complex disarray of cell signaling.
Today, there are no clinical studies evaluating the activity of saponins as an anticancer or antioxidant agent, and even considering the scanty experimental research in animals, information is still insufficient to provide pertinent conclusions. Most studies in the literature are limited to
Schematic representation of plausible mechanism of action(s) of diosgenin (saponin) at the cellular level as a cancer chemopreventive agent (Adapted from
Soy saponins help preventing the development and reducing the number of tumors in rats (Konoshima & Takasaki, 2000). More recently, the effect of soy saponins on human colon cancer cells was evaluated leading to the conclusion that these compounds may be effective in preventing colon cancer by affecting cell morphology, cell growth, and cell proliferation enzymes. In this study, the saponins affected the cell growth in two different ways; by increasing the alkaline phosphatase activity while reducing protein kinase C activity to induce cell differentiation, or by inducing type II autophagic death (Tsai et al., 2010).
The antioxidant activity of saponins is also related to their capacity to bind to cholesterol and prevent cholesterol oxidation. Group B saponins, abundant in soy, linked with 2, 3-dihydro-2,5-dihydroxy-6-methyl-4H-pyran-4-one (DDMP) group, are responsible for preventing lipid peroxidation or degeneration of DNA and protecting proteins from free radical attack (Ruiz et al., 1996; Shi et al., 2004; Yoshiki et al., 1994).
In addition to preventing cholesterol oxidation by the action of free radicals, group A and B saponins have antioxidant effects on rat liver microsome through the inhibition of lipid peroxidation (Nishida et al., 1993). Recently, a group of researchers isolated type I soy saponins, one of the main groups occurring in soybeans, showing that it presents a free radical scavenging activity comparable to that of α-tocopherol inhibiting lipid peroxidation. In this study was also demonstrated that the treatment with soy saponins increases the superoxide dismutase and catalase activity, essential for the control of free radicals (Lee et al., 2010). Similarly, mice fed a soy extract rich in saponins exhibited a better profile of the antioxidants system with significant increase of superoxide dismutase, glutathione peroxidase
Saponins may have a synergistic antioxidative effect in the presence of hydrogen donors such as phenol compounds. Iron and copper ions generate hydroxyl radicals through the Fenton reaction to facilitate biological oxidation. Saponins may also have a preventive antioxidant that prevents active oxygen from being generated during the chelation of these metal ions (Tsukamoto and Yoshiki, 2006).
The amphiphilic nature of saponins can explain the hypocholesterolemic activity of these compounds. This activity has been attributed to saponins for years (Sautier et al., 1979; Sidhu & Oakenfull, 1986), and, in general, is associated with their ability to interfere with cholesterol absorption through possible mechanisms of action such as the formation of insoluble complexes with cholesterol, affectation micelle formation, interference with bile acid metabolism, and/or the perturbation the unstirred water layer or brush border membrane characteristics of enterocytes due to their detergent-like properties (Cohn et al., 2010).
Afrose et al. (2010) demonstrated the hypocholesterolemic effects of saponins in laying hens suggesting that the reductions in the levels of serum and egg cholesterol are caused by the suppression of cholesterol synthesis and the promotion of cholesterol catabolism in the liver. In another study, Zhao et al., (2008) proved these effects in hamsters fed a diet supplemented with saponins, but they attributed the results to the substantial increase in fecal cholesterol loss and not to the reduction of cholesterol absorption or synthesis.
A glycoside saponin, glycyrrhizin, found in some roots, exhibited suppressive effects on the replication
Soybean saponins have been evaluated for their antiviral activity against
Group B saponins with arabinose as the second sugar has an inhibitory effect on human cytomegalovirus (HCMV), influenza A virus, and human immunodeficiency virus type 1. The antivirus effect of soy saponins is not limited to inhibit cell permeability and protein synthesis but also exhibit virus inactivation activity (Tsukamoto and Yoshiki, 2006).
Phytosterols are compounds found in plants that have important functions, especially in the structure of cell membranes and in cellulose biosynthesis. Studies have suggested that due to structural and functional analogy of phytosterols and phytostanols with cholesterol, they have properties to compete for incorporation into micelles inhibiting cholesterol absorption in the intestine and enhancing its elimination in the feces.
Phytosterols, also called plant sterols, are found naturally in plants (Schneider et al., 2009; Harrabi, 2008) in small quantities. Their hypocholesterolemic properties come from their structural similarity to cholesterol (Kaloustian et al., 2008).
Since the 1950s, beneficial effects of plant sterols have been observed due to decreases in the plasma cholesterol levels and a significant reduction in the incidence of atherosclerosis in chick fed a soybean diet; therefore, it is possible that some soy sterols interfere with cholesterol absorption in the intestine (Peterson et al., 1952). Since that time, there have been studies in animals and humans demonstrating the effects of these compounds on the reduction of plasma cholesterol.
Phytosterols are steroid alcohols derived from plants with resemblance to cholesterol, the predominant sterol found in animals, and also are similar in functions to cholesterol, especially in terms of structure and functions of cell membranes. These compounds are members of the triterpen family and, unlike cholesterol, include a methyl or ethyl group at carbon 24 (AbuMweis & Jones, 2008; Palou et al., 2005, Piironen et al., 2000).
Phytostanols are formed from the saturation of the double bond at carbon-5, and they do not occur very frequently in nature. The term plant sterols is usually used to refer to phytosterols and phytostanols. A phytosterol can be converted to its similar phytostanol by enzyme activity in plants,
More than 200 phytosterols have been identified in the plant kingdom, and many are found in edible foodstuffs (Bradford & Awad, 2007). Their nomenclature is rather confusing due to the partial approval of international norms defined by the International Union of Pure and Applied Chemistry (IUPAC) and the International Union of Biochemistry (IUB) (Moreau et al., 2002).
The most common and widely studied phytosterols are sitosterol or
In addition to the free form, phytosterols can be found as conjugated or esterified compounds, in which the 3β-hidroxyl group is esterified to fatty acids, glycosides, or phenolic compounds with different chemical, technological, and nutritional properties (Figure 7). The occurrence of these classes varies between the foods and parts of these foods (Palou et al., 2005; Piironen & Lampi, 2004). Vegetable oils are, in general, rich in free phytosterols and their fatty acid esters (Piironen & Lampi, 2004) although there is a great variability in the contents of free and esterified phytosterols in many types of oils and fats (Phillips et al., 2002). Nuts also contain high amounts of phytosterols (Piironen & Lampi, 2004). Due to the wide variety of soy-based food products for human consumption, it is considered an important dietary source of phytosterol, and it can contribute significantly to the consumption of those products. A study involving 510 soybean cultivars showed that the content of phytosterols ranged from 202 and 843 µg.g-1. The highest amounts are found in soybeans with high lipid content. β-sitosterol, campesterol, and estigmasterol were the main phytosterols found in the grain at the proportions of 43-67%, 17-34%, and 10-30%, respectively (Yamaya et al., 2007). Germinated soybeans have higher levels of phytosterols,
Chemical structures of cholesterol, phytosterols and their saturated derivatives (Adapted from
Modification of 3β-OH group in phytosterols (Adapted from de
finding that has been corroborated recently in a study involving soybeans with 7 days of germination with phytosterol contents of 1004 and 1987 µg.g-1; the predominant phytosterol found was β-sitosterol (Shi et al., 2010).
Soy germ is rich in phytosterols. Therefore, the soybean oil produced is an important source of these compounds in countries where it is highly consumed. Studies cited by Piironen et al., (2000) indicated that the contents of phytosterols in raw soybean oil vary between 2,290 and 4,490 µg.g-1 and between 2,210 and 3,280 µg.g-1 in refined soybean oil. This type of oil showed lower loss of phytosterols in a continuous frying system compared with corn and sunflower oils (Winkler et al., 2007).
The intake of free phytosterols, especially β-sitosterol and the esterified sources, has demonstrated properties of reducing serum cholesterol in animals and humans studies.
According to the World Health Organization criteria, this biological function is fairly convincing, but further studies are necessary to demonstrate that this reduction is associated to the prevention of cardiovascular diseases. Other biological activities have also been attributed to the action of phytosterols such as antioxidant activity, cancer prevention, and immune system improvement. Nevertheless, those studies are considered insufficient to corroborate these hypotheses (de Jong et al., 2008).
The functions of phytosterol in plants are similar to those of cholesterol in animals. They have an important role in the structure of the vegetable cell membranes acting as regulators of membrane fluidity and permeability by affecting the proteins associated to membranes (Alignan et al., 2009; Piironen et al., 2000; Roche et al., 2008). In addition to this structural function, phytosterols also act as precursors of a group of factors related to the growth of the plant. They act in the biosynthesis of cellulose and as substrates for secondary vegetable products such as alkaloids, cardenolides, and saponins (Palou et al., 2005; Peng et al., 2002; Piironen et al., 2000; Read & Bacic, 2002;). Phytosterols can also act as biogenetic precursors of a number of metabolites including plant steroid hormones, such as brassinosteroids and are involved in embryogenesis (Alignan et al., 2009; Breinhölder et al., 2002; Schaller, 2003).
Scientific evidences demonstrate that phytosterols interfere in the reduction of cholesterol absorption stimulating a subsequent synthesis of the endogenous cholesterol. This leads a reduction in the plasma cholesterol levels and an increase elimination of cholesterol in the feces. The way by which phytosterols reduce cholesterol absorption has not been defined yet; however, there are evidences that indicate that the phytosterols compete with cholesterol for the micelles of absorption in the intestine.
Studies have demonstrated serum cholesterol-lowering effect of phytosterols when consumed at levels of 1.5-2 g per day (Piironen & Lampi, 2004). An increase in the rate of endogenous cholesterol synthesis caused by the action of phytosterols leads to an increase LDL-receptor activity in the liver and an increase of the number of LDL receptors in order to capture the cholesterol from these lipoproteins for the bile acid synthesis thus increasing elimination of LDL from circulation. Finally, the levels of LDL cholesterol, and therefore, total cholesterol in humans decrease without affecting the levels of HDL cholesterol and triglycerides (Palou et al., 2005).
The contents of phytosterols in soy and its products are relatively too low to cause relevant effects in the reduction of cholesterol levels, which has attracted the interest of industries in the development and improvement of soy-based products.
A clinical study on the consumption of a soy drink enriched with 2.6 g of phytosterol was conducted in 50 subjects (19 men and 31 women) for eight weeks, aged between 19 and 65 years with moderate hypercholesterolemia. The study found that the regular consumption of 200 ml of soy drink enriched with plant sterols reduces significantly the level of LDL cholesterol by approximately 0.29 mmol.L-1 or 7% compared to baseline. The reduction in the levels of total, LDL and non-HDL cholesterol were significant greater than in the placebo group. Nevertheless, HDL cholesterol and triglycerides were not affected by the consumption of the drink, which was sensorally accepted by the subjects (Weidner et al., 2008).
Accordingly, many studies have demonstrated and corroborated the effectiveness of phytosterols enriching various foods; margarine (AbuMweis et al., 2008), juices (Devaraj et al., 2003), milk (Plana et al., 2008; Hansel et al., 2007), and yogurt (Plat et al., 2009), evaluating cholesterol-lowering effect when consumed in the recommended dose.
Recently, a meta-analysis of 84 clinical trials was conducted evaluating the effect of the enrichment of foods with phytosterols on subjects with hypercholesterolemia. The combined results of all studies grouped indicated that the reductions in the levels of LDL cholesterol were of 0.34 mmol.L-1 or 8.8% compared with control, for a mean daily dose of 2.15 g phytosterol. This study evaluated the impacts of subject baseline characteristics of the grouped studies through regression analysis suggesting that groups higher baseline LDL cholesterol resulted in greater absolute LDL cholesterol reductions, which could indicate the effectiveness of those foods in subjects with hypercholesterolemia (Demonty et al., 2009). Figure 8 shows the dose/response relationship in the reduction of LDL cholesterol levels in the grouped studies.
Dose-response relationship for the absolute (A) and relative (B) LDL cholesterol-lowering effect of phytosterols (Adapted from
Soy-based products have high potential for phytosterols enrichment. Soy is considered a very important food due to its countless benefits, and its phytosterols and high quality protein can produce a synergic effect, which also has proved to reduce the levels of LDL and total cholesterol.
Some studies suggest the hypothesis that phytosterols have antioxidant activity and may help the prevention of certain types of cancer (Awad et al., 2001; Normén & Andersson, 2004; Wang et al., 2002). Nonetheless, the information available is still insufficient to corroborate those findings.
In a study in mice was founded that phytosterols modulated and reduced the growth of tumors in ovariectomized female athymic (Ju et al., 2004). On the other hand, oxidant effects of phytosterols on biomarkers, such as DNA or lipid peroxidation, were not found in clinical studies (de Jong et al., 2008). The discrepancies between the results are frequently found in the literature.
Emerging evidence supports the inhibitory actions of phytosterols on lung, stomach, ovarian and breast cancer, through multiple mechanisms of action, including inhibition of carcinogen production, cancer-cell growth, angiogenesis, invasion, metastasis and apoptosis. Phytosterol consumption may also increase the activity of antioxidant enzymes and thereby reduce oxidative stress (Woyengo et al., 2009).
Soy is considered a rich source of proteins and lipids and contains other bioactive compounds such as isoflavones, saponins, and phytosterols. Such diversity in compounds makes it difficult to attribute an exclusive beneficial biological function to a single compound after consuming soy-based food products. For example, cholesterol-lowering effects are associated to the consumption of soy protein, but are also associated to phytosterols, isoflavones, and even saponins. Highlight the synergistic multicomponent effects of soy on biological functions would be a recommendation for further studies, as well as studies of the mechanism of action and new biomarkers for to prove the effectiveness of soy bioactive compounds in preventing and treating several symptoms and/or pathologies.
The recurrence’s rate of intracranial meningiomas ranges from 10–32% at 10 years [1, 2, 3] .The main risk factors include the WHO grade [4, 5, 6, 7], the extent of resection according to Simpson [8, 9, 10], the proliferation index Ki67-MIB1 [11, 12, 13, 14] and mitotic index [15] and the postoperative adjuvant treatments [1, 16, 17]. Other factors have also been suggested, such as patient age and sex [4, 18], tumor size [19, 20, 21], location [22, 23] and morphology [19, 22, 24], brain invasion [10, 14], progesterone receptor (PR) expression [25, 26, 27].
Meningiomas may recur with different patterns of growth, from more localized to more extensive and sometimes diffuse forms. This carries several diagnostic and therapeutic implications. However, all published studies consider the overall recurrences, with no focusing on their topography and extension, which were first discussed only in our recent report [28].
According to their topography on the post-contrast magnetic resonance imaging (MRI) and surgical findings, the recurrences of meningiomas may be classified in 4 types [28]:
type 1, local, at the previous dural site;
type 2, peripheral, at the surrounding dura, contiguous to the previous site;
type 3, multicentric, with multiple nodules both at the dural site and distant, with seemly normal interposed dura mater;
type 4, diffuse, with multiple nodules with interposed dural infiltration, or diffuse dural and extradural infiltration.
Local type 1 is the most frequent regrowth pattern. It may occur after resection of Simpson grades 2 to 4; the tumor may growth both intradurally and at the bone. The recurrence may involve from a variable portion to the whole initial dural attachment and may extend to the contiguous previously normal dura.
Peripheral type 2 recurrences may be observed after initial resection of grade 1, but also of grade II when the dural attachment was carefully and extensively coagulated. The recurrence may involve a variable dural portion contiguous to the initial attachment and may often extend to it. In cases with larger recurrences the site of regrowth (local versus peripheral) is difficult to be defined.
Multicentric type 3 recurrences are characterized by tumor nodules or mass both at initial dural attachment or contiguous dura and in distal dural regions where no tumor nodules nor dural enhancement were visible on the magnetic resonance imaging at initial surgery. In this type the dura mater between local-peripheral and distal recurrent nodules seems to be normal.
Diffuse type 4 recurrences show multiple nodules of tumor regrowth even in very distal regions, with variable infiltration of the interposed dura and bone.
The above discussed patterns of recurrence suggest that multicentric and diffuse recurrences are two phases of the same pathological conditions.
The pathological mechanisms responsible for meningioma recurrence in distal dural regions are not well defined and deserve to be discussed.
The concept of regional multicentricity of meningiomas is known since about 35 years. Borovich and Doron [29] demonstrated in convexity meningiomas small tumor nodules as well as intradural clusters of tumor cells in the dural specimens taken up to 3 cm from the tumor. Qi et al. [30] found tumor invasion in 88% of dura adjacent to convexity meningioma up to 2,5 cm from the tumor origin. These observations may explain some “unexpected relapses” after an apparent complete resection (Simpson grade 1) of convexity meningiomas [29] and the frequent peripheral recurrences at the dura surrounding the initial attachment after resection od Simpson grades 1 and 2 in all locations.
These pathological findings support the concept of a wide dural excision 2-3 cm beyond the tumor base (grade zero resection), which was suggested for convexity [31] and falx meningiomas [32].
Mooney et al. [32] suggest that in the falcine meningiomas the tumor cells may spread from the site of origin to other falx regions between the two dural leaflets of the falx. However, this pattern of diffusion of the tumor cells cannot explain the very distant recurrences from other locations. For multiple meningiomas some studies [33, 34] have suggested that they may arise from a single progenitor cell and could then spread through the subarachnoid space. A similar mechanism may also be advocated for distant recurrences.
However, it is more like that multicentric-diffuse recurrences represent the progressive growth of multiple distant dural nodules with different growth potential. In this way the meningioma may be considered, at least in several cases, a diffuse disease of the meninges than a localized tumor.
Thirty-three patients with multicentric-diffuse recurrences of meningiomas are included in our series [28] (Tables 1–3 and Figures 1–3). They are 22 females (67%) and 11 males (33%), with a median age of 52 years. The findings at initial surgery were as follows (Table 1). The most frequent location was non skull-base (55%), followed by lateral (36%) and medial skull-base (9%). The tumor was mostly flat-shaped (76%) and less frequently round (24%). Complete resection (Simpson grades 1 and 2) at initial surgery was obtained in 23 among 33 patients (70%).
Covariates | Number of cases (rate) |
---|---|
Age (mean) | 52 y |
Sex | F 22 (67%) M 11 (33%) |
Tumor location | |
medial skull base | 3 (9%) |
lateral skull base | 12 (36%) |
non skull base | 18 (55%) |
Tumor shape | |
flat | 25 (76%) |
round | 8 (24%) |
Brain-tumor interface | |
preserved | 15 (45%) |
unclear- lost | 18 (55%) |
Extent of resection (Simpson grade) | |
I | 9 (28%) |
II | 14 (42%) |
III | 10 (30%) |
Interval between initial surgery and recurrence (median) | 4.7 y |
WHO grade | |
I | 17 (52%) |
II | 16 (48%) |
Ki67 Li | |
< 4% | 7 (20%) |
≥ 4% | 26 (80%) |
P.R. expression | |
≤ 15% | 11 (33%) |
16–50% 51–79% | 16 (49%) 3 (9%) |
≥ 80% | 3 (9%) |
Clinico-radiological, surgical and pathological findings at initial diagnosis (33 patients).
Covariates | Number of cases (rate) |
---|---|
| 25(76%) |
| |
One reoperation | 12 (48%) |
Two or three reoperations | 13 (52%) |
| |
Gross total | 5 (20%) |
Subtotal | 20 (80%) |
| |
Similar to the first surgery | 15 (60%) |
Progression from I to II | 7 (28%) |
| 3 (12%) |
| 1 (4%) |
| 20 (60%) |
| 9 (27%) |
| 5 (15%) |
Management of 33 patients with multicentric-diffuse recurrences.
Covariates | Group 1-Surgery (24 pts) | Group 2-No-surgery(8 pts) | Statistical significance (Group 1 Vs Group 2) |
---|---|---|---|
Local control | 11 (46%) | — | p = 0.029 |
Tumor progression | 6 (25%) | 2 (25%) | n.s. |
Death during the follow-up | 7 (29%) | 6 (75%) | p = 0.038 |
Outcome of 33 patients with multicentric-diffuse meningioma recurrence.
58 years old woman with history of previous resection of a WHO I grade meningioma of the left frontal convexity in 1991. (a) Postoperative CT after the initial surgery: no residual tumor; (b) Post-contrast MRI 21 years later: local multicentric recurrence at the previous dural site and distal recurrence at the left parietal region; (c) Postoperative MRI showing resection of both nodules (WHO grade I) and interposed dura.
68 years old man who underwent resection of an anterior parasagittal WHO grade II meningioma in 2010. (a-d) Post-contrast MRI, T1 axial (a, d) and coronal (b, c) sequences: diffuse recurrences of the parasagittal and both convexity regions with significant tumor masses, at the left parasagittal and convexity and at the anterior temporal convexity. Two-stage resection of the masses and irradiation.
(a-b) 72 years old man with history of a left spheno-orbital WHO grade II meningioma: a) preoperative T1 axial post-contrast MRI and (b) postoperative CT scan: complete resection. (c-d) Post-contrast T1 axial (c) and coronal (d) MRI sequences seven years after the initial surgery: large tumor recurrence involving the left orbital cavity and extending diffusely in the intracranial compartment at the suprasellar, left parasellar region and temporal fossa. Management by external radiotherapy.
The pathological findings at initial diagnosis (Table 1) showed 52% of WHO [35] grade I and 48% of grade II tumors; the Ki67-Li was <4% in 20% and ≥ 4%in 80%. The PR expression was ≤50% in 82% of specimens and > 50% in 9%.
When compared to the findings of meningiomas which showed localized-peripheral recurrences, only the higher rates of flat-shaped tumors (p = 0.0008) and tumors with Ki67-Li ≥4% (p = 0.037) were significant [28].
The management and outcome of the recurrences were as follows (Table 2). Twenty-five out of 33 patients (76%) were reoperated on and underwent one (48%) or two or three reoperations (52%) (Figures 1 and 2). The complete resection (Simpson grades I and II) was possible only in 5 among the 25 patients (20%). The histological WHO grade at first reoperation was similar to that of the initial surgery in 15 out of 25 patients (60%); progression to a higher grade was observed in 10 cases (40%).
Adjuvant treatments included external radiotherapy in 20 patients, stereotactic radiosurgery in 9 and chemotherapy in 5.
When compared to patients with localized-peripheral recurrences, those with multicentric-diffuse recurrences showed significantly higher number of reoperations (p = 0.0034), lower rate of gross total resection (p = 0.00001) and higher but not significant rate of cases with progression of the WHO grade (p = 0.09) [28].
The actual follow-up ranges from 2 to 25 years. One patient died postoperatively for respiratory failure. Among the other 24 patients operated on, eleven (34%) are alive with local tumor control versus none out of eight patients who did not undergo surgery (p = 0.029). Six (25%) show slow tumor progression with no symptoms in spite the surgery. Seven patients of the surgical group (29%) died during the follow-up (5 for tumor progression) versus 6 (for tumor progression) out of 8 (75%) of the non-surgical group (p = 0.038). Thus, among 25 patients reoperated on 17 (68%) are alive after one or more reoperations versus only 2 out of 8 (25%) who did not undergo surgery.
Several pathological, neuroradiological and surgical findings at initial diagnosis are correlated to the meningioma recurrence. However, which factors may be considered at risk of multicentric-diffuse recurrence are not defined.
The meningioma location is a significant risk factor of recurrence. Medial skull-base meningiomas include locations, such as olfactory groove, tuberculum sellae, anterior clinoid, foramen magnum, with low recurrence rates (0–15%) [36, 37, 38]. Besides, the low recurrence rate of spinal meningiomas is well known (0–10% in 15 among 19 reviewed series in our recent study [39]). On the other hand, the reported recurrence rates are higher for lateral skull-base (35–40% for lateral sphenoid wing and mainly spheno-orbital [38, 39, 40]) and for non-skull base meningiomas (16 to 24% for parasagittal and falcine) [23, 41].
However, when the rates of multicentric-diffuse recurrences are considered, the differences for intracranial tumor locations are not relevant. Although in our study [28] spheno-orbital and parasagittal meningiomas show higher rates of multicentric and diffuse recurrences, this finding does not reach significance. Our series does not include diffuse recurrences of spinal meningiomas; this agrees with the well known better biological behavior of this location.
Thus, the meningioma location is correlated with the rate but not with the growth pattern of the recurrences.
The shape of meningiomas may be variable. According to the rate height/base on magnetic resonance imaging, the meningiomas may be classified as round (rate > 1) and flat-shaped (rate ≤ 1). Flat-shaped meningiomas are characterized by prevalent and often extensive dural involvement as compared to round-shaped ones. Thus, it has been shown that flat-shaped meningiomas are more likely to recur than round ones [22, 24].
The flat-shaped morphology at initial diagnosis was the only radiological finding at significantly higher risk of multicentric diffuse recurrence as compared to local-peripheral recurrence in our study (p = 0.0008) [28]. Thus, it is like that flat-shaped meningiomas are associated to various degree of even distant microscopic dural infiltration.
The change of the peritumoral dura mater depicted on the postcontrast magnetic resonance studies and defined as “dural tail” is known since its description in 1989 [42]. It may correspond to various histopathological patterns, including increased loose connective tissue, angiogenesis, dilated vessels, reactive hyperplasia, tumor invasion [42, 43]. Qi et al. [30], in a large series of convexity meningiomas, described several types of dural tail with different histological aspects: smooth (uniformly extended) with tumor extension up to 1,5 cm; nodular, with nodular hyperplasia corresponding to tumor nodules and tumor extension to the distal dura up to 2,5 cm; mixed, with nodular enhancement proximal to the dural attachment and distal smooth enhancement. In spite of the presence of tumor cells nodules, the finding of dural tail was found to be not correlated to the meningioma recurrence in most studies [9, 19, 22]. We did not investigate this finding in our series of multicentric-diffuse recurrences; however, we suggest that further studies will define this aspect.
The brain-tumor interface, more often well preserved during meningioma surgery, may be unclear or lost, often with variable pial invasion, as in WHO grade II tumors. In such cases the tumor resection may be incomplete, with residual nodules mainly in critical regions. This may increase the risk of recurrence at the initial site or at the surrounding region [10, 14, 22]. On the other hand, the presence of the residual cell nests at the brain-tumor interface does not explain the recurrences in distal dural regions and the diffuse regrowths.
The entity of the resection at initial surgery is mostly considered a major risk factor for recurrence [23, 44, 45]. However, the clinical usefulness of the Simpson grading in general has been questioned, at least for benign meningiomas. Some studies found no statistically significant differences in progression-free survival between Simpson grades 1 to 4 [46] and 1 to 3 [13, 47] resections for WHO I grade meningiomas. This discrepancy may reflect the technical surgical improvement and the smaller tumor remnants in incomplete resections. In a recent report Haddad et al. [48]. found that patients with WHO grade I meningiomas and Ki67-MIB1 > 4,5% treated by gross total resection had similar risk of recurrence as those patients with subtotal resection. In this study, early recurrences were more significantly impacted by extent of resection, whereas the Ki67-MIB1 was more significant for later recurrences.
In our study on multicentric-diffuse recurrences [28], their rate is not impacted by the extent of resection at initial surgery.
Multiple meningiomas account for 2 to 8% of all meningiomas [49]. They may be diagnosed either initially or during the neuroradiological follow-up.
In a large metanalysis of the literature on multiple meningiomas, Pereira et al. [49] found recurrence rate of 8.07% and no higher with respect to single ones. On the other hand, in the study by Gousias et al. [45] multiple meningiomas showed higher recurrence rate and significantly lower progression-free survival than single ones.
Multiple meningiomas likely develop from multicentric dural tumor foci according to the Borovich [29] theory. A similar mechanism is suggested for multicentric recurrences. In our study on multicentric-diffuse recurrences two patients had multiple meningiomas (two lesions) at initial diagnosis, with no significant differences with local-peripheral ones. We think that further studies on the long-term follow-up of patients operated on for multiple meningiomas will defined the recurrence rates and patterns of these cases.
In our study [28] meningiomas with values of Ki67 Li ≥ 4% are related to major risk of multicentric-diffuse recurrence, while the WHO grade (I versus II) is not significant. Several reports [7, 25, 26, 27] confirmed the relationship between higher Ki67-Li values and lower PR expression, and higher recurrence risk for intracranial meningiomas. However, in this study the PR expression is not correlated with the pattern of diffuse regrowth. Both these findings have not previously been reported.
The higher initial values of Ki67 Li of meningiomas recurring as diffuse forms suggest that even small dural tumor foci, even distant from the primary tumor site, may diffusely regrow.
Several studies have found that different genetic profiles and chromosomal abnormalities correspond to different meningioma subtypes with different aggressiveness and recurrence’s rate [50, 51, 52, 53, 54], making speculate the existence of characteristic biomolecular profiles for meningiomas which recur in multicentric-diffuse pattern.
The management of multicentric-diffuse recurrences of intracranial meningiomas is often difficult to be defined; there are not studies defining the guidelines. The management options include a second surgery, external radiotherapy, stereotactic radiosurgery, medical therapy.
The decision is based on several factors, including tumor location (non-skull base versus skull base; critical versus not critical), significant intradural mass versus prevalent dural infiltration (Figures 4 and 5), entity of bone extension, time to recurrence, WHO grade of the initial tumor, patient age and KPS, neurological symptoms and signs.
Post-contrast MRI of a 58 years old man with history of previous surgery (5 years before) of gross-total resection of a bilateral meningioma of the anterior third of the falx (WHO grade II). Sagittal (a-b) and coronal (c-d) T1 sequences: distant and diffuse recurrence at the right fronto-temporal bone and suprasellar regions, with no recurrence at the initial tumor site. Reoperation and resection of the recurrent tumor (WHO grade II). Postoperative death for respiratory failure.
Post-contrast MRI of a 70 years old woman with history of previous (7 year before) surgical resection (Simpson 3) of a WHO grade II meningioma of the posterior parasagittal region: sagittal (a) and coronal (b-c) sequences: diffuse recurrence with extensive dural and superior sagittal sinus involvement and tumor nodules at the posterior fossa. No reoperation was decided.
The indication to reoperation is mainly posed for younger and middle-aged patients with symptomatic recurrences. According to the location and pattern of regrowth, surgery should be reserved to cases with prevalent intradural tumor growth, tumor nodules ≥3 cm and not extensive dural infiltration (Figures 1). Non skull-base meningiomas, mainly if limited to the brain convexity, are usually more favorable to surgery, because of the chance of more wide resection of the involved dura mater. For skull-base meningiomas a more wide resection is possible at the anterior cranial fossa and external sphenoid wing; on the other hand, diffuse recurrences at the suprasellar, parasellar and spheno-orbital regions (Figure 3), as well as clival and petroclival regions, are difficult to treat, because of the involvement of the cranial nerves and vessels; for such locations a second surgery is only justified for the resection of a large symptomatic intradural mass.
Elderly patients with comorbidities, particularly if with no or trivial neurological symptoms, must be treated conservatively with periodical radiological follow-up.
The WHO grade at initial diagnosis is obviously important. Only WHO grades I and II meningiomas are suitable for reoperation. On the other hand, anaplastic WHO grade III tumors at initial diagnosis must not be reoperated on.
In selected patients according to the above discussed criteria the reoperation results is satisfactory resection of the intradural tumor and involved dura. However, a really complete resection with no residual contrast enhancement on MRI (Simpson grades 1 and 2) is obtained only in some cases (20% in our series versus 76% of local-peripheral recurrences) [28].
Further recurrences may be reoperated on following the same criteria, if they occur after several years and if the tumor does not progress to anaplastic WHO III form.
All studies focusing on the irradiation of recurrent meningiomas include all recurrences; thus guidelines of radiotherapy management of diffuse recurrences are not available.
The external radiotherapy of multicentric-diffuse recurrences of meningiomas is in our opinion mandatory, independently from the entity of resection and the WHO grade, but mainly in subtotally or partially resected WHO grade II recurrences [55, 56].
The stereotactic radiosurgery is scarcely indicated, because of the extensive and diffuse tumor growth. It may sometimes be performed in association to the external radiotherapy to increase the control of smaller nodules and to treat the not infrequent second recurrences outside the radiotherapic field [57]. Besides, re-radiosurgery for recurrent meningiomas is advisable if the previous radiosurgical treatment was unsatisfactory [58].
The medical therapy is reserved to recurrent meningiomas which show growth progression after surgery and irradiation and to malignant WHO III forms. Many clinical trials have studied the effects of cytotoxic chemotherapy [59, 60], hormone-directed therapy [61, 62], other targeted therapies [63, 64, 65] and molecular therapies [66]. Targeted and molecular therapies defined on the basis of the biomolecular profile of the meningioma may be useful in diffuse-multicentric recurrences showing progression after surgery and radiotherapy.
Meningiomas may sometimes recur as multicentric-diffuse forms, with dural infiltration and recurrent tumor mass distal to the initial site. These may result from the progressive growth of multiple tumor nodules with different growth potential.
Flat-shaped radiological aspect and Ki67 Li ≥4% at initial diagnosis are related to higher risk of recurrence in multicentric-diffuse pattern.
Patients with not anaplastic intracranial meningioma with prevalent intradural component and not extensive dural infiltration may undergone multiple surgical operations during years experimenting good postoperative quality of life.
Further studies will investigate whether the different patterns of regrowth and recurrence correspond to different biomolecular and genetic expression of the meningioma. This will aid to predict the tumor behavior and to detect the most appropriate molecular therapies.
The authors declare no conflict of interest.
World Health Organization Magnetic Resonance Imaging
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After progenitor cells form osteoblastic lines, they proceed with three stages of development of cell differentiation, called proliferation, maturation of matrix, and mineralization. Based on its embryological origin, there are two types of ossification, called intramembranous ossification that occurs in mesenchymal cells that differentiate into osteoblast in the ossification center directly without prior cartilage formation and endochondral ossification in which bone tissue mineralization is formed through cartilage formation first. In intramembranous ossification, bone development occurs directly. In this process, mesenchymal cells proliferate into areas that have high vascularization in embryonic connective tissue in the formation of cell condensation or primary ossification centers. This cell will synthesize bone matrix in the periphery and the mesenchymal cells continue to differentiate into osteoblasts. After that, the bone will be reshaped and replaced by mature lamellar bone. 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He received his Ph.D. in Molecular Biology with his thesis “Genetic variability of the tick-borne encephalitis virus in natural foci of Novosibirsk city and its suburbs.” His primary field is molecular virology with research emphasis on vector-borne viruses, especially tick-borne encephalitis virus, Kemerovo virus and Omsk hemorrhagic fever virus, rabies virus, molecular genetics, biology, and epidemiology of virus pathogens.",institutionString:"Russian Academy of Sciences",institution:{name:"Russian Academy of Sciences",country:{name:"Russia"}}},{id:"310962",title:"Dr.",name:"Amlan",middleName:"Kumar",surname:"Patra",slug:"amlan-patra",fullName:"Amlan Patra",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/310962/images/system/310962.jpg",biography:"Amlan K. Patra, FRSB, obtained a Ph.D. in Animal Nutrition from Indian Veterinary Research Institute, India, in 2002. He is currently an associate professor at West Bengal University of Animal and Fishery Sciences. He has more than twenty years of research and teaching experience. He held previous positions at the American Institute for Goat Research, The Ohio State University, Columbus, USA, and Free University of Berlin, Germany. His research focuses on animal nutrition, particularly ruminants and poultry nutrition, gastrointestinal electrophysiology, meta-analysis and modeling in nutrition, and livestock–environment interaction. He has authored around 175 articles in journals, book chapters, and proceedings. Dr. Patra serves on the editorial boards of several reputed journals.",institutionString:null,institution:{name:"West Bengal University of Animal and Fishery Sciences",country:{name:"India"}}},{id:"53998",title:"Prof.",name:"László",middleName:null,surname:"Babinszky",slug:"laszlo-babinszky",fullName:"László Babinszky",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/53998/images/system/53998.png",biography:"László Babinszky is Professor Emeritus, Department of Animal Nutrition Physiology, University of Debrecen, Hungary. He has also worked in the Department of Animal Nutrition, University of Wageningen, Netherlands; the Institute for Livestock Feeding and Nutrition (IVVO), Lelystad, Netherlands; the Agricultural University of Vienna (BOKU); the Institute for Animal Breeding and Nutrition, Austria; and the Oscar Kellner Research Institute for Animal Nutrition, Rostock, Germany. In 1992, Dr. Babinszky obtained a Ph.D. in Animal Nutrition from the University of Wageningen. His main research areas are swine and poultry nutrition. He has authored more than 300 publications (papers, book chapters) and edited four books and fourteen international conference proceedings.",institutionString:"University of Debrecen",institution:{name:"University of Debrecen",country:{name:"Hungary"}}},{id:"201830",title:"Dr.",name:"Fernando",middleName:"Sanchez",surname:"Davila",slug:"fernando-davila",fullName:"Fernando Davila",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/201830/images/5017_n.jpg",biography:"I am a professor at UANL since 1988. My research lines are the development of reproductive techniques in small ruminants. We also conducted research on sexual and social behavior in males.\nI am Mexican and study my professional career as an engineer in agriculture and animal science at UANL. Then take a masters degree in science in Germany (Animal breeding). Take a doctorate in animal science at the UANL.",institutionString:null,institution:{name:"Universidad Autónoma de Nuevo León",country:{name:"Mexico"}}},{id:"309250",title:"Dr.",name:"Miguel",middleName:null,surname:"Quaresma",slug:"miguel-quaresma",fullName:"Miguel Quaresma",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/309250/images/9059_n.jpg",biography:"Miguel Nuno Pinheiro Quaresma was born on May 26, 1974 in Dili, Timor Island. He is married with two children: a boy and a girl, and he is a resident in Vila Real, Portugal. He graduated in Veterinary Medicine in August 1998 and obtained his Ph.D. degree in Veterinary Sciences -Clinical Area in February 2015, both from the University of Trás-os-Montes e Alto Douro. He is currently enrolled in the Alternative Residency of the European College of Animal Reproduction. He works as a Senior Clinician at the Veterinary Teaching Hospital of UTAD (HVUTAD) with a role in clinical activity in the area of livestock and equine species as well as to support teaching and research in related areas. He teaches as an Invited Professor in Reproduction Medicine I and II of the Master\\'s in Veterinary Medicine degree at UTAD. Currently, he holds the position of Chairman of the Portuguese Buiatrics Association. He is a member of the Consultive Group on Production Animals of the OMV. He has 19 publications in indexed international journals (ISIS), as well as over 60 publications and oral presentations in both Portuguese and international journals and congresses.",institutionString:"University of Trás-os-Montes and Alto Douro",institution:{name:"University of Trás-os-Montes and Alto Douro",country:{name:"Portugal"}}},{id:"38652",title:"Dr.",name:"Rita",middleName:null,surname:"Payan-Carreira",slug:"rita-payan-carreira",fullName:"Rita Payan-Carreira",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRiFPQA0/Profile_Picture_1614601496313",biography:"Rita Payan Carreira earned her Veterinary Degree from the Faculty of Veterinary Medicine in Lisbon, Portugal, in 1985. She obtained her Ph.D. in Veterinary Sciences from the University of Trás-os-Montes e Alto Douro, Portugal. After almost 32 years of teaching at the University of Trás-os-Montes and Alto Douro, she recently moved to the University of Évora, Department of Veterinary Medicine, where she teaches in the field of Animal Reproduction and Clinics. Her primary research areas include the molecular markers of the endometrial cycle and the embryo–maternal interaction, including oxidative stress and the reproductive physiology and disorders of sexual development, besides the molecular determinants of male and female fertility. She often supervises students preparing their master's or doctoral theses. She is also a frequent referee for various journals.",institutionString:null,institution:{name:"University of Évora",country:{name:"Portugal"}}},{id:"283019",title:"Dr.",name:"Oudessa",middleName:null,surname:"Kerro Dego",slug:"oudessa-kerro-dego",fullName:"Oudessa Kerro Dego",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/283019/images/system/283019.png",biography:"Dr. Kerro Dego is a veterinary microbiologist with training in veterinary medicine, microbiology, and anatomic pathology. Dr. Kerro Dego is an assistant professor of dairy health in the department of animal science, the University of Tennessee, Institute of Agriculture, Knoxville, Tennessee. He received his D.V.M. (1997), M.S. (2002), and Ph.D. (2008) degrees in Veterinary Medicine, Animal Pathology and Veterinary Microbiology from College of Veterinary Medicine, Addis Ababa University, Ethiopia; College of Veterinary Medicine, Utrecht University, the Netherlands and Western College of Veterinary Medicine, University of Saskatchewan, Canada respectively. He did his Postdoctoral training in microbial pathogenesis (2009 - 2015) in the Department of Animal Science, the University of Tennessee, Institute of Agriculture, Knoxville, Tennessee. Dr. Kerro Dego’s research focuses on the prevention and control of infectious diseases of farm animals, particularly mastitis, improving dairy food safety, and mitigation of antimicrobial resistance. Dr. Kerro Dego has extensive experience in studying the pathogenesis of bacterial infections, identification of virulence factors, and vaccine development and efficacy testing against major bacterial mastitis pathogens. Dr. Kerro Dego conducted numerous controlled experimental and field vaccine efficacy studies, vaccination, and evaluation of immunological responses in several species of animals, including rodents (mice) and large animals (bovine and ovine).",institutionString:"University of Tennessee at Knoxville",institution:{name:"University of Tennessee at Knoxville",country:{name:"United States of America"}}},{id:"251314",title:"Dr.",name:"Juan Carlos",middleName:null,surname:"Gardón",slug:"juan-carlos-gardon",fullName:"Juan Carlos Gardón",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/251314/images/system/251314.jpeg",biography:"Juan Carlos Gardón Poggi received University degree from the Faculty of Agrarian Science in Argentina, in 1983. Also he received Masters Degree and PhD from Córdoba University, Spain. He is currently a Professor at the Catholic University of Valencia San Vicente Mártir, at the Department of Medicine and Animal Surgery. He teaches diverse courses in the field of Animal Reproduction and he is the Director of the Veterinary Farm. He also participates in academic postgraduate activities at the Veterinary Faculty of Murcia University, Spain. His research areas include animal physiology, physiology and biotechnology of reproduction either in males or females, the study of gametes under in vitro conditions and the use of ultrasound as a complement to physiological studies and development of applied biotechnologies. Routinely, he supervises students preparing their doctoral, master thesis or final degree projects.",institutionString:"Catholic University of Valencia San Vicente Mártir, Spain",institution:null},{id:"125292",title:"Dr.",name:"Katy",middleName:null,surname:"Satué Ambrojo",slug:"katy-satue-ambrojo",fullName:"Katy Satué Ambrojo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/125292/images/system/125292.jpeg",biography:"Katy Satué Ambrojo received her Veterinary Medicine degree, Master degree in Equine Technology and doctorate in Veterinary Medicine from the Faculty of Veterinary, CEU-Cardenal Herrera University in Valencia, Spain. She is a Full Professor at the Department of Medicine and Animal Surgery at the same University. She developed her research activity in the field of Endocrinology, Hematology, Biochemistry and Immunology of horses. She is a scientific reviewer of several international journals : American Journal of Obstetrics and Gynecology, Comparative Clinical Pathology, Veterinary Clinical Pathology, Journal of Equine Veterinary Science, Reproduction in Domestic Animals, Research Veterinary Science, Brazilian Journal of Medical and Biological Research, Livestock Production Science and Theriogenology. Since 2014, she has been the Head of the Clinical Analysis Laboratory of the Hospital Clínico Veterinario from the Faculty of Veterinary, CEU-Cardenal Herrera University.",institutionString:"CEU-Cardenal Herrera University",institution:{name:"CEU Cardinal Herrera University",country:{name:"Spain"}}},{id:"309529",title:"Dr.",name:"Albert",middleName:null,surname:"Rizvanov",slug:"albert-rizvanov",fullName:"Albert Rizvanov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/309529/images/9189_n.jpg",biography:'Albert A. Rizvanov is a Professor and Director of the Center for Precision and Regenerative Medicine at the Institute of Fundamental Medicine and Biology, Kazan Federal University (KFU), Russia. He is the Head of the Center of Excellence “Regenerative Medicine” and Vice-Director of Strategic Academic Unit \\"Translational 7P Medicine\\". Albert completed his Ph.D. at the University of Nevada, Reno, USA and Dr.Sci. at KFU. He is a corresponding member of the Tatarstan Academy of Sciences, Russian Federation. Albert is an author of more than 300 peer-reviewed journal articles and 22 patents. He has supervised 11 Ph.D. and 2 Dr.Sci. dissertations. Albert is the Head of the Dissertation Committee on Biochemistry, Microbiology, and Genetics at KFU.\nORCID https://orcid.org/0000-0002-9427-5739\nWebsite https://kpfu.ru/Albert.Rizvanov?p_lang=2',institutionString:"Kazan Federal University",institution:{name:"Kazan Federal University",country:{name:"Russia"}}},{id:"210551",title:"Dr.",name:"Arbab",middleName:null,surname:"Sikandar",slug:"arbab-sikandar",fullName:"Arbab Sikandar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210551/images/system/210551.jpg",biography:"Dr. Arbab Sikandar, PhD, M. Phil, DVM was born on April 05, 1981. He is currently working at the College of Veterinary & Animal Sciences as an Assistant Professor. He previously worked as a lecturer at the same University. \nHe is a Member/Secretory of Ethics committee (No. CVAS-9377 dated 18-04-18), Member of the QEC committee CVAS, Jhang (Regr/Gen/69/873, dated 26-10-2017), Member, Board of studies of Department of Basic Sciences (No. CVAS. 2851 Dated. 12-04-13, and No. CVAS, 9024 dated 20/11/17), Member of Academic Committee, CVAS, Jhang (No. CVAS/2004, Dated, 25-08-12), Member of the technical committee (No. CVAS/ 4085, dated 20,03, 2010 till 2016).\n\nDr. Arbab Sikandar contributed in five days hands-on-training on Histopathology at the Department of Pathology, UVAS from 12-16 June 2017. He received a Certificate of appreciation for contributions for Popularization of Science and Technology in the Society on 17-11-15. He was the resource person in the lecture series- ‘scientific writing’ at the Department of Anatomy and Histology, UVAS, Lahore on 29th October 2015. He won a full fellowship as a principal candidate for the year 2015 in the field of Agriculture, EICA, Egypt with ref. to the Notification No. 12(11) ACS/Egypt/2014 from 10 July 2015 to 25th September 2015.; he received a grant of Rs. 55000/- as research incentives from Director, Advanced Studies and Research, UVAS, Lahore upon publications of research papers in IF Journals (DR/215, dated 19-5-2014.. He obtained his PhD by winning a HEC Pakistan indigenous Scholarship, ‘Ph.D. fellowship for 5000 scholars – Phase II’ (2av1-147), 17-6/HEC/HRD/IS-II/12, November 15, 2012. \n\nDr. Sikandar is a member of numerous societies: Registered Veterinary Medical Practitioner (life member) and Registered Veterinary Medical Faculty of Pakistan Veterinary Medical Council. The Registration code of PVMC is RVMP/4298 and RVMF/ 0102.; Life member of the University of Veterinary and Animal Sciences, Lahore, Alumni Association with S# 664, dated: 6-4-12. ; Member 'Vets Care Organization Pakistan” with Reference No. VCO-605-149, dated 05-04-06. :Member 'Vet Crescent” (Society of Animal Health and Production), UVAS, Lahore.",institutionString:"University of Veterinary & Animal Science",institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}},{id:"311663",title:"Dr.",name:"Prasanna",middleName:null,surname:"Pal",slug:"prasanna-pal",fullName:"Prasanna Pal",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311663/images/13261_n.jpg",biography:null,institutionString:null,institution:{name:"National Dairy Research Institute",country:{name:"India"}}},{id:"202192",title:"Dr.",name:"Catrin",middleName:null,surname:"Rutland",slug:"catrin-rutland",fullName:"Catrin Rutland",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",biography:"Catrin Rutland is an Associate Professor of Anatomy and Developmental Genetics at the University of Nottingham, UK. She obtained a BSc from the University of Derby, England, a master’s degree from Technische Universität München, Germany, and a Ph.D. from the University of Nottingham. She undertook a post-doctoral research fellowship in the School of Medicine before accepting tenure in Veterinary Medicine and Science. Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. Dr. Rutland has also written popular science books for the public. https://orcid.org/0000-0002-2009-4898. www.nottingham.ac.uk/vet/people/catrin.rutland",institutionString:null,institution:{name:"University of Nottingham",country:{name:"United Kingdom"}}},{id:"283315",title:"Prof.",name:"Samir",middleName:null,surname:"El-Gendy",slug:"samir-el-gendy",fullName:"Samir El-Gendy",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRduYQAS/Profile_Picture_1606215849748",biography:"Samir El-Gendy is a Professor of anatomy and embryology at the faculty of veterinary medicine, Alexandria University, Egypt. Samir obtained his PhD in veterinary science in 2007 from the faculty of veterinary medicine, Alexandria University and has been a professor since 2017. Samir is an author on 24 articles at Scopus and 12 articles within local journals and 2 books/book chapters. His research focuses on applied anatomy, imaging techniques and computed tomography. Samir worked as a member of different local projects on E-learning and he is a board member of the African Association of Veterinary Anatomists and of anatomy societies and as an associated author at local and international journals. Orcid: https://orcid.org/0000-0002-6180-389X",institutionString:null,institution:{name:"Alexandria University",country:{name:"Egypt"}}},{id:"246149",title:"Dr.",name:"Valentina",middleName:null,surname:"Kubale",slug:"valentina-kubale",fullName:"Valentina Kubale",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/246149/images/system/246149.jpg",biography:"Valentina Kubale is Associate Professor of Veterinary Medicine at the Veterinary Faculty, University of Ljubljana, Slovenia. Since graduating from the Veterinary faculty she obtained her PhD in 2007, performed collaboration with the Department of Pharmacology, University of Copenhagen, Denmark. She continued as a post-doctoral fellow at the University of Copenhagen with a Lundbeck foundation fellowship. She is the editor of three books and author/coauthor of 23 articles in peer-reviewed scientific journals, 16 book chapters, and 68 communications at scientific congresses. Since 2008 she has been the Editor Assistant for the Slovenian Veterinary Research journal. She is a member of Slovenian Biochemical Society, The Endocrine Society, European Association of Veterinary Anatomists and Society for Laboratory Animals, where she is board member.",institutionString:"University of Ljubljana",institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"258334",title:"Dr.",name:"Carlos Eduardo",middleName:null,surname:"Fonseca-Alves",slug:"carlos-eduardo-fonseca-alves",fullName:"Carlos Eduardo Fonseca-Alves",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/258334/images/system/258334.jpg",biography:"Dr. Fonseca-Alves earned his DVM from Federal University of Goias – UFG in 2008. He completed an internship in small animal internal medicine at UPIS university in 2011, earned his MSc in 2013 and PhD in 2015 both in Veterinary Medicine at Sao Paulo State University – UNESP. Dr. Fonseca-Alves currently serves as an Assistant Professor at Paulista University – UNIP teaching small animal internal medicine.",institutionString:null,institution:{name:"Universidade Paulista",country:{name:"Brazil"}}},{id:"245306",title:"Dr.",name:"María Luz",middleName:null,surname:"Garcia Pardo",slug:"maria-luz-garcia-pardo",fullName:"María Luz Garcia Pardo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/245306/images/system/245306.png",biography:"María de la Luz García Pardo is an agricultural engineer from Universitat Politècnica de València, Spain. She has a Ph.D. in Animal Genetics. Currently, she is a lecturer at the Agrofood Technology Department of Miguel Hernández University, Spain. Her research is focused on genetics and reproduction in rabbits. The major goal of her research is the genetics of litter size through novel methods such as selection by the environmental sensibility of litter size, with forays into the field of animal welfare by analysing the impact on the susceptibility to diseases and stress of the does. Details of her publications can be found at https://orcid.org/0000-0001-9504-8290.",institutionString:null,institution:{name:"Miguel Hernandez University",country:{name:"Spain"}}},{id:"41319",title:"Prof.",name:"Lung-Kwang",middleName:null,surname:"Pan",slug:"lung-kwang-pan",fullName:"Lung-Kwang Pan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41319/images/84_n.jpg",biography:null,institutionString:null,institution:null},{id:"201721",title:"Dr.",name:"Beatrice",middleName:null,surname:"Funiciello",slug:"beatrice-funiciello",fullName:"Beatrice Funiciello",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/201721/images/11089_n.jpg",biography:"Graduated from the University of Milan in 2011, my post-graduate education included CertAVP modules mainly on equines (dermatology and internal medicine) and a few on small animal (dermatology and anaesthesia) at the University of Liverpool. After a general CertAVP (2015) I gained the designated Certificate in Veterinary Dermatology (2017) after taking the synoptic examination and then applied for the RCVS ADvanced Practitioner status. After that, I completed the Postgraduate Diploma in Veterinary Professional Studies at the University of Liverpool (2018). My main area of work is cross-species veterinary dermatology.",institutionString:null,institution:null},{id:"291226",title:"Dr.",name:"Monica",middleName:null,surname:"Cassel",slug:"monica-cassel",fullName:"Monica Cassel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/291226/images/8232_n.jpg",biography:'Degree in Biological Sciences at the Federal University of Mato Grosso with scholarship for Scientific Initiation by FAPEMAT (2008/1) and CNPq (2008/2-2009/2): Project \\"Histological evidence of reproductive activity in lizards of the Manso region, Chapada dos Guimarães, Mato Grosso, Brazil\\". Master\\\'s degree in Ecology and Biodiversity Conservation at Federal University of Mato Grosso with a scholarship by CAPES/REUNI program: Project \\"Reproductive biology of Melanorivulus punctatus\\". PhD\\\'s degree in Science (Cell and Tissue Biology Area) \n at University of Sao Paulo with scholarship granted by FAPESP; Project \\"Development of morphofunctional changes in ovary of Astyanax altiparanae Garutti & Britski, 2000 (Teleostei, Characidae)\\". She has experience in Reproduction of vertebrates and Morphology, with emphasis in Cellular Biology and Histology. She is currently a teacher in the medium / technical level courses at IFMT-Alta Floresta, as well as in the Bachelor\\\'s degree in Animal Science and in the Bachelor\\\'s degree in Business.',institutionString:null,institution:null},{id:"442807",title:"Dr.",name:"Busani",middleName:null,surname:"Moyo",slug:"busani-moyo",fullName:"Busani Moyo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Gwanda State University",country:{name:"Zimbabwe"}}},{id:"423023",title:"Dr.",name:"Yosra",middleName:null,surname:"Soltan",slug:"yosra-soltan",fullName:"Yosra Soltan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Alexandria University",country:{name:"Egypt"}}},{id:"349788",title:"Dr.",name:"Florencia Nery",middleName:null,surname:"Sompie",slug:"florencia-nery-sompie",fullName:"Florencia Nery Sompie",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sam Ratulangi University",country:{name:"Indonesia"}}},{id:"345713",title:"Dr.",name:"Csaba",middleName:null,surname:"Szabó",slug:"csaba-szabo",fullName:"Csaba Szabó",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Debrecen",country:{name:"Hungary"}}},{id:"345719",title:"Mrs.",name:"Márta",middleName:null,surname:"Horváth",slug:"marta-horvath",fullName:"Márta Horváth",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Debrecen",country:{name:"Hungary"}}},{id:"420151",title:"Prof.",name:"Novirman",middleName:null,surname:"Jamarun",slug:"novirman-jamarun",fullName:"Novirman Jamarun",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Andalas University",country:{name:"Indonesia"}}},{id:"420149",title:"Dr.",name:"Rusmana",middleName:"Wijaya Setia",surname:"Wijaya Setia Ningrat",slug:"rusmana-wijaya-setia-ningrat",fullName:"Rusmana Wijaya Setia Ningrat",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Andalas University",country:{name:"Indonesia"}}},{id:"339759",title:"Mr.",name:"Abu",middleName:null,surname:"Macavoray",slug:"abu-macavoray",fullName:"Abu Macavoray",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Njala University",country:{name:"Sierra Leone"}}},{id:"339758",title:"Prof.",name:"Benjamin",middleName:null,surname:"Emikpe",slug:"benjamin-emikpe",fullName:"Benjamin Emikpe",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Ibadan",country:{name:"Nigeria"}}},{id:"339760",title:"Mr.",name:"Moinina Nelphson",middleName:null,surname:"Kallon",slug:"moinina-nelphson-kallon",fullName:"Moinina Nelphson Kallon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Njala University",country:{name:"Sierra Leone"}}}]}},subseries:{item:{id:"25",type:"subseries",title:"Evolutionary Computation",keywords:"Genetic Algorithms, Genetic Programming, Evolutionary Programming, Evolution Strategies, Hybrid Algorithms, Bioinspired Metaheuristics, Ant Colony Optimization, Evolutionary Learning, Hyperparameter Optimization",scope:"Evolutionary computing is a paradigm that has grown dramatically in recent years. This group of bio-inspired metaheuristics solves multiple optimization problems by applying the metaphor of natural selection. It so far has solved problems such as resource allocation, routing, schedule planning, and engineering design. Moreover, in the field of machine learning, evolutionary computation has carved out a significant niche both in the generation of learning models and in the automatic design and optimization of hyperparameters in deep learning models. This collection aims to include quality volumes on various topics related to evolutionary algorithms and, alternatively, other metaheuristics of interest inspired by nature. For example, some of the issues of interest could be the following: Advances in evolutionary computation (Genetic algorithms, Genetic programming, Bio-inspired metaheuristics, Hybrid metaheuristics, Parallel ECs); Applications of evolutionary algorithms (Machine learning and Data Mining with EAs, Search-Based Software Engineering, Scheduling, and Planning Applications, Smart Transport Applications, Applications to Games, Image Analysis, Signal Processing and Pattern Recognition, Applications to Sustainability).",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",hasOnlineFirst:!1,hasPublishedBooks:!0,annualVolume:11421,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. Dr Ventura also holds the positions of Affiliated Professor at Virginia Commonwealth University (Richmond, USA) and Distinguished Adjunct Professor at King Abdulaziz University (Jeddah, Saudi Arabia). Additionally, he is deputy director of the Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI) and heads the Knowledge Discovery and Intelligent Systems Research Laboratory. He has published more than ten books and over 300 articles in journals and scientific conferences. Currently, his work has received over 18,000 citations according to Google Scholar, including more than 2200 citations in 2020. 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