Background
The management of craniopharyngiomas is challenging, usually requiring multidisciplinary care. We evaluated the long-term clinical and radiologic outcomes of Gamma Knife radiosurgery ...(GKRS) for craniopharyngiomas.
Methods
This retrospective study involved patients managed with GKRS for a craniopharyngioma during the period of 1989 to 2019. Patient clinical and radiologic data, tumor characteristics, and procedural details were analyzed.
Results
Thirty-eight consecutive patients (24 males; mean patient age at GKRS = 30.82 years SD ± 20.45 years) were treated with GKRS for craniopharyngioma. Overall survival rates at 5 and 10 years were 84.1% and 80.1%, respectively. Progression-free survival at 5 years was 48.1%, and, at 10 years, it was 29.8%. Risk factors for post-GKRS clinical deterioration were increasing number of isocenters used (
p
= 0.04 (HR1.32, CI 1–1.73)), increasing margin dose
p
= 0.02 (HR1.52, CI 1.31–1.84), and maximum dose > 35 Gy
p
= 0.002 (HR1.35, CI 1.11–1.63).
Conclusion
Stereotactic radiosurgery (SRS) appears a safe and effective management option in selected craniopharyngioma patients. Increasing margin dose and maximum dose > 35 Gy are associated with an increased risk for post-SRS neurologic deficit. Further, well-designed studies are necessary to determine the optimal timing and SRS parameters and to identify which patients with craniopharyngioma will benefit the most from SRS.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Objective
The optimal management of asymptomatic, skull-based meningiomas is not well defined. The aim of this study is to compare the imaging and clinical outcomes of patients with asymptomatic, ...skull-based meningiomas managed either with upfront stereotactic radiosurgery (SRS) or active surveillance.
Methods
This retrospective, multicenter study involved patients with asymptomatic, skull-based meningiomas. The study end-points included local tumor control and the development of new neurological deficits attributable to the tumor. Factors associated with tumor progression and neurological morbidity were also analyzed.
Results
The combined unmatched cohort included 417 patients. Following propensity score matching for age, tumor volume, and follow-up 110 patients remained in each cohort. Tumor control was achieved in 98.2% and 61.8% of the SRS and active surveillance cohorts, respectively. SRS was associated with superior local tumor control (p < 0.001, HR = 0.01, 95% CI = 0.002–0.13) compared to active surveillance. Three patients (2.7%) in the SRS cohort and six (5.5%) in the active surveillance cohort exhibited neurological deterioration. One (0.9%) patient in the SRS-treated and 11 (10%) patients in the active surveillance cohort required surgical management of their meningioma during follow-up.
Conclusions
SRS is associated with superior local control of asymptomatic, skull-based meningiomas as compared to active surveillance and does so with low morbidity rates. SRS should be offered as an alternative to active surveillance as the initial management of asymptomatic skull base meningiomas. Active surveillance policies do not currently specify the optimal time to intervention when meningioma growth is noted. Our results indicate that if active surveillance is the initial management of choice, SRS should be recommended when radiologic tumor progression is noted and prior to clinical progression.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The optimal treatment strategy of asymptomatic, convexity meningiomas, remains unclear.
Objective
The purpose of this study was to define the safety and efficacy of stereotactic ...radiosurgery (SRS) in the management of patients with asymptomatic convexity meningiomas.
Methods
Data of SRS-treated patients from 14 participating centers and patients managed conservatively for an asymptomatic, convexity-located meningioma were compared. Local tumor control rate and development of new neurologic deficits were evaluated in the active surveillance and in the SRS-treated cohorts.
Results
In the unmatched cohorts, there were 99 SRS-treated patients and 140 patients managed conservatively for an asymptomatic, convexity meningioma. Following propensity score matching for age, there were 98 patients in each cohort. In the matched cohorts, tumor control was achieved in 99% of SRS-treated, and in 69.4% of conservatively managed patients (p < 0.001). New neurological deficits occurred in 2.0% of patients in each of the matched cohorts (p = 1.00). Increasing age was predictive of tumor growth (OR 1.1; 95% CI (1.04 − 1.2), (p < 0.001).
Conclusion
This is one of the first reports to suggest that SRS is a low risk and effective treatment strategy for asymptomatic incidentally discovered convexity meningiomas. In this study, tumor control was achieved in significantly more patients after radiosurgery compared to those managed with active surveillance. SRS may be offered at diagnosis of an asymptomatic convexity meningioma and should be recommended when meningioma growth is noted on follow-up.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The optimal management of asymptomatic, petroclival meningiomas remains incompletely defined. The purpose of this study was to evaluate the safety and efficacy of upfront stereotactic ...radiosurgery (SRS) for patients with asymptomatic, petroclival region meningiomas.
Methods
This retrospective, international, multicenter study involved patients treated with SRS for an asymptomatic, petroclival region meningioma. Study endpoints included local tumor control rate, procedural complications, and the emergence of new neurological deficits.
Results
There were 72 patients (22 males, mean age 59.53 years (SD ± 11.9)) with an asymptomatic meningioma located in the petroclival region who were treated with upfront SRS. Mean margin dose and maximum dose were 13.26 (SD ± 2.72) Gy and 26.14 (SD ± 6.75) Gy respectively. Median radiological and clinical follow-up periods post-SRS were 52.5 (IQR 61.75) and 47.5 months (IQR 69.75) respectively. At last follow-up, tumor control was achieved in all patients. SRS-related complications occurred in 6 (8.33%) patients, with 3 of them (4.17%) exhibiting new neurological deficits.
Conclusions
Upfront SRS for asymptomatic, petroclival region meningiomas affords excellent local tumor control and does so with a relatively low risk of SRS-related complications. SRS can be considered at diagnosis of an asymptomatic petroclival region meningioma. If active surveillance is initially chosen, SRS should be recommended when growth is noted during radiological follow-up.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Intra-thecal baclofen pump has been proven a safe and effective treatment of spasticity. Subdural hematoma has been rarely described following intra-thecal drug delivery device insertion.
...Case presentation
We report on the rare case of a 45-year-old male with multiple sclerosis who presented with symptoms of intra-cranial hypotension 1 month after insertion of an intra-thecal baclofen pump for severe spasticity. Non-contrast head computerized tomography scan revealed bilateral, sub-acute, subdural hematomas. Due to the nature of the patient’s symptoms suggesting intra-cranial hypotension, surgical repair of the cerebrospinal fluid leak only was initially performed. However, after an initial improvement, the patient experienced increasing in severity headache and worsening tetraparesis. Subsequently, the patient underwent burr hole evacuation of the subdural hematomas with improvement of his symptoms. On the 6-week follow-up, he reported no headache and he was able to walk with assistance.
Conclusion
Subdural hematomas should be considered in all patients presenting with new neurologic deficits or persistent headache following intra-thecal drug delivery device insertion. Early recognition and appropriate management of this rare but potentially life-threatening complication is of great importance to improve prognosis and patient outcomes.
With the diminishing use of whole-brain radiotherapy (WBRT), there is increasing debate regarding the maximum number of brain metastases that should be treated with stereotactic radiosurgery (SRS). ...In patients with >10-15 lesions, some groups are proposing a new approach - selected-lesion SRS (SL-SRS) - where only a subset of intracranial lesions are chosen for irradiation. This study is an initial look into this practice.
This is a cross-sectional exploratory survey study. A survey of 19 questions was created by the International Radiosurgery Research Foundation (IRRF) using open-ended and multiple-choice style questions on SL-SRS practices and indications with the goal of qualitatively understanding how SL-SRS is being implemented worldwide. The survey was distributed to physicians in the United States (US) and internationally who are members of the IRRF and who perform SRS frequently. Ten out of 50 IRRF institutions provided responses reflecting the practices of 16 physicians.
SL-SRS is being performed at 8/10 institutions. The most common reasons for using SL-SRS included patients with prior WBRT, patients with progressing systemic disease with central nervous system (CNS)-penetrating or immunotherapies available, specific requests from medical oncology, and cooperative studies using this approach. Lesion size was cited as the most important factor when choosing to irradiate any single lesion. The majority of respondents reported 30 mm and 40 mm as size cutoffs (by largest dimension) for treatment of a lesion in eloquent and non-eloquent locations, respectively. Eloquence of lesion location and attributable symptoms were also considered important. Progression of untreated lesions was the most common reason reported for bringing patients back for additional treatment.
The responses to this survey show that SL-SRS is being used, allowing for small/asymptomatic brain metastases to be left safely unirradiated. It is currently used in patients who have >10-15 lesions with prior WBRT, those with progression of extracranial disease but with acceptable systemic treatment options, and those with poor functional status. The incorporation of this new approach into clinical trials should be considered for the safe study of the efficacy of new CNS-penetrating systemic therapies.
INTRODUCTION: Stereotactic radiosurgery (SRS) represents an effective treatment for pediatric arteriovenous malformations (AVMs). Biologic effective dose (BED) is recognized as a predictive variable ...for outcomes in the adult population, but its role has never been studied in pediatric outcomes. METHODS: Retrospective data for = 18 years old patients treated with single-session SRS for AVM was collected from 1989 – 2019. BED calculations were performed using an a/b ratio of 2.47. Kaplan-Meier analysis was used to evaluate obliteration, new hemorrhage, and radiation-induced changes (RIC). Cox-regression analysis was used for obliteration prediction using two models (margin dose versus BED). RESULTS: One-hundred-ninety-seven patients median age = 13.1 years, Interquartile range (IQR) = 5.2 were included; 72.6% presented initially with spontaneous hemorrhage. A median margin dose of 22 Gy (IQ = 4.0) with a median BED of 183.2Gy (IQR = 70.54) was used to treat AVMs with a median volume of 2.8 cm3 (IQR = 2.9). Following SRS, obliteration was confirmed in 115 patients (58.4%) using MRI and angiography at a median follow-up of 2.85 years (IQR = 2.26). The cumulative obliteration probability was 43.6% (95% CI = 36.1-50.3), 60.5% (95% CI+=2.2-67.4), 66.0% (95% CI= 56.0-73.7) at 3, 5 and 10 years respectively. In multivariate analysis, a BED >180 Gy HR = 2.11, 95% CI=1.30-3.40, p = 0.002 in model 1, and a margin dose >20 Gy HR = 1.90, 95% CI = 1.15-3.13, p = 0.019 in model 2, were associated with obliteration. An AVM nidus volume >4 cm 3 was associated with lower obliteration rates in both models. The probability of symptomatic RIC at 10 years was 8.6% (95% CI = 3.5-13.4). Neither BED nor margin dose were associated with RIC occurrence, with the only predictive factor being deep AVM location HR = 3, 95% CI = 1-9.1, p = 0.048. CONCLUSIONS: This study confirms BED as a predictor for pediatric AVM obliteration. Optimization of BED in pediatric AVM SRS planning may improve cumulative obliteration rates.
The role of stereotactic radiosurgery (SRS) in the management of recurrent and residual intracranial primary melanocytomas (PMC) remains unclear. The aim of this study is to evaluate the safety and ...efficacy of SRS in the management of these rare tumors.
One patient treated with SRS in our institution for an intracranial PMC was retrospectively identified. Additionally, a systematic review of English articles using MEDLINE was performed to identify studies reporting on treatment and tumor characteristics and patient outcomes following SRS-management of intracranial PMC.
Including our institution’s patient, a total of 13 patients (11 male and 2 female) met the inclusion criteria and were analyzed. The median age at SRS treatment was 49 years (interquartile range IQR 27). At a median follow-up of 24 (IQR 48) months, the aggregate local tumor-control rate was 76.9%. Progression occurred in 3 patients and was managed with repeat SRS (1 of 13) or salvage resection (2 of 13). One case of malignant transformation to melanoma leading to leptomeningeal dissemination and death was noted.
SRS appears to be a reasonable treatment option for recurrent and residual melanocytomas. A higher prescription dose might be reasonable in the treatment of intermediate grade or recurring PMC. Close longitudinal follow-up for recurrence or malignant transformation of melanocytomas after SRS is recommended.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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