The Coronavirus pandemic has created unprecedented strain on medical resources at health care institutions around the world. At many institutions, this has resulted in efforts to prioritize cases ...with an attempt to balance the acuity of medical needs with available resources. Here, we provide a framework for institutions and governments to help adjudicate treatment allocations to patients with neuro-oncologic disease.
Radiation therapy represents a mainstay of treatment for patients with brain metastases. Recently, the widespread adoption of immune checkpoint blockade has led to keen interest in treating cancers ...with checkpoint inhibitors in place of, or as an adjunct to, traditional chemotherapy. However, with the exception of melanoma, immune checkpoint blockade in solid tumors has failed to achieve significant brain control in patients with brain metastases. The possibility of combining immune checkpoint blockade with radiation for the treatment of brain and other metastases represents an exciting new strategy that is in its early stages of investigation. Success with this combinatorial strategy has the potential to result in enhanced rates of brain control, less brain exposure to radiation, and improved cognitive outcomes. In this review, we discuss the mechanisms behind this synergy, describe its limitations, and suggest ways to move the field forward.
External beam radiotherapy (RT) has long played a crucial role in the treatment of glioblastoma. Over the past several decades, significant advances in RT treatment and image-guidance technology have ...led to enormous improvements in the ability to optimize definitive and salvage treatments. This review highlights several of the latest developments and controversies related to RT, including the treatment of elderly patients, who continue to be a fragile and vulnerable population; potential salvage options for recurrent disease including reirradiation with chemotherapy; the latest imaging techniques allowing for more accurate and precise delineation of treatment volumes to maximize the therapeutic ratio of conformal RT; the ongoing preclinical and clinical data regarding the combination of immunotherapy with RT; and the increasing evidence of cancer stem-cell niches in the subventricular zone which may provide a potential target for local therapies. Finally, continued development on many fronts have allowed for modestly improved outcomes while at the same time limiting toxicity.
Hospital readmission is a key component in value-based healthcare models but there are limited data about the 30-day readmission rate after endonasal endoscopic transsphenoidal surgery (EETS) for ...pituitary adenoma. The objective of this study was to determine the incidence and identify factors associated with 30-day readmission after EETS for pituitary adenoma.
The authors analyzed a prospectively acquired database of patients who underwent EETS for pituitary adenoma from 2005 to 2018 at NewYork-Presbyterian Hospital, Weill Cornell Medicine. Clinical, socioeconomic, and radiographic data were reviewed for cases of unplanned readmission within 30 days of surgery and, as a control group, for all other patients in the series who were not readmitted. Statistical significance was determined with an alpha < 0.05 using Pearson's chi-square and Fisher's exact tests for categorical variables and the independent-samples t-test for continuous variables.
Of 584 patients undergoing EETS for pituitary adenoma, 27 (4.6%) had unplanned readmission within 30 days. Most readmissions occurred within the first week after surgery, with a mean time to readmission of 6.6 ± 3.9 days. The majority of readmissions (59%) were for hyponatremia. These patients had a mean sodium level of 120.6 ± 4.6 mEq/L at presentation. Other causes of readmission were epistaxis (11%), spinal headache (11%), sellar hematoma (7.4%), CSF leak (3.7%), nonspecific headache (3.7%), and pulmonary embolism (3.7%). The postoperative length of stay was significantly shorter for patients who were readmitted than for the controls (2.7 ± 1.0 days vs 3.9 ± 3.2 days; p < 0.05). Patients readmitted for hyponatremia had an initial length of stay of 2.6 ± 0.9 days, the shortest of any cause for readmission. The mean BMI was significantly lower for readmitted patients than for the controls (26.4 ± 3.9 kg/m2 vs 29.3 ± 6.1 kg/m2; p < 0.05).
Readmission after EETS for pituitary adenoma is a relatively rare phenomenon, with delayed hyponatremia being the primary cause. The study results demonstrate that shorter postoperative length of stay and lower BMI were associated with 30-day readmission.
Introduction
Stereotactic radiosurgery (SRS) was born in an attempt to treat complex intracranial pathologies in a fashion whereby open surgery would create unnecessary or excessive risk. To create ...this innovation, it was necessary to harness advances in other fields such as engineering, physics, radiology, and computer science.
Methods
We review the history of SRS to provide context to today’s current state, as well as guide future advancement in the field.
Results
Since time of Lars Leksell, the young Swedish neurosurgeon who pioneered the development of the SRS, the collegial and essential partnership between neurosurgeons, radiation oncologists and physicists has given rise to radiosurgery as a prominent and successful tool in neurosurgical practice.
Conclusion
We examine how neurosurgeons have helped foster the SRS evolution and how this evolution has impacted neurosurgical practice as well as that of radiation oncology and neuro-oncology.
Introduction
Evidence-based medicine guidelines are increasingly published and sanctioned by organized neurosurgery. However, implementation, interpretation, and use of clinical guidelines may vary ...substantially on a regional, national and international basis. Survey research can help bridge the gap by providing a snapshot of neurosurgeon attitudes, knowledge, and practices. The American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Section on Tumors formed a Survey Committee to formalize the process by which surveys are submitted and reviewed before distribution to our membership. The goal of this committee is to provide peer-review so that collected information will be scientifically robust and useful to the neurosurgical community.
Methods
Surveys submitted to the AANS/CNS tumor section between 2015 and 2019 were reviewed and metrics such as response rate and publication status assessed.
Results
Six surveys were submitted to the Survey Committee of the AANS/CNS section on tumors between 2015 and 2019. Four have been circulated to section members, of which three have been published. Response rate has averaged 19% (range 16–23%), a majority of respondents (mean 70%) practice in academic settings.
Conclusions
The AANS/CNS Section on Tumors Survey Committee has and continues to help promote and improve the practice of surveying our community to answer important questions that can advance future training, research, and practice. There remains significant room for improvement in response rates, but ongoing tumor section efforts to increase member engagement will likely improve these numbers.
WHO grade 3 meningiomas are rare and poorly understood and have a higher propensity for recurrence, metastasis, and worsened clinical outcomes compared with lower-grade meningiomas. The purpose of ...our study was to prospectively evaluate the molecular profile, PET characteristics, and outcomes of patients with World Health Organization grade 3 meningiomas who were imaged with gallium 68 (
Ga) DOTATATE PET/MR imaging.
Patients with World Health Organization grade 3 meningiomas enrolled in our prospective observational cohort evaluating the utility of (
Ga) DOTATATE PET/MR imaging in somatostatin receptor positive brain tumors were included. We stratified patients by de novo-versus-secondary-progressive status and evaluated the differences in the PET standard uptake value, molecular profiles, and clinical outcomes.
Patients met the inclusion criteria (secondary-progressive: 7/14; de novo: 7/14). The secondary-progressive cohort had a significantly higher per-patient number of surgeries (4.1 versus 1.6;
= .011) and trended toward a higher number of radiation therapy courses (2.4 versus 1.6;
= .23) and cumulative radiation therapy doses (106Gy versus 68.3Gy;
= .31). The secondary-progressive cohort had a significantly lower progression-free survival compared with the de novo cohort (4.8 versus 37.7 months;
= .004). Secondary-progressive tumors had distinct molecular pathology profiles with higher numbers of mutations (3.5 versus 1.2;
= .024). Secondary-progressive tumors demonstrated higher PET standard uptake values (17.1 versus 12.4;
= .0021).
Our study confirms prior work illustrating distinct clinical outcomes in secondary-progressive and de novo World Health Organization grade 3 meningiomas. Furthermore, our findings support (
Ga) DOTATATE PET/MR imaging as a useful management strategy in World Health Organization grade 3 meningiomas and provide insight into meningioma biology, as well as clinical management implications.
Studies on adjuvant stereotactic radiosurgery to the cavity of resected brain metastases have suggested that larger tumors (>2.0 cm) have greater rates of recurrence and radionecrosis (RN). The ...present study assessed the effect of permanent low-dose
Cs brachytherapy on local control and RN in patients treated for large brain metastases.
After institutional review board approval, 42 patients with 46 metastases ≥2.0 cm in preoperative diameter were accrued to a prospective trial from 2010 to 2015. Patients underwent surgical resection with intraoperative placement of stranded
Cs seeds as permanent volume implants in the resection cavity. The primary endpoint was local freedom from progression (FFP). Secondary endpoints included regional and distant FFP, overall survival (OS), and RN rate. Failures 5 to 20 mm from the cavity and dural-based failures were considered regional. A separate analysis was performed for metastases >3.0 cm.
Of the 46 metastases, 18 were >3.0 cm in diameter. The median follow-up period was 11.9 months (range 0.6-51.9). The metastases had a median preoperative diameter of 3.0 cm (range 2.0-6.8). The local FFP rate was 100% for all tumor sizes. Regional recurrence developed in 3 of 46 lesions (7%), for a 1-year regional FFP rate of 89% (for tumors >3.0 cm, the FFP rate was 80%, 95% confidence interval 54%-100%). Distant recurrences were found in 19 of 46 lesions (41%), for a 1-year distant FFP rate of 52%. The median OS was 15.1 months, with a 1-year OS rate of 58%. Lesion size was not significantly associated with any endpoint on univariate or multivariate analysis. Radioresistant histologic features resulted in worse survival (P=.036). No cases of RN developed.
Intraoperative
Cs brachytherapy is a promising and effective therapy for large brain metastases requiring neurosurgical intervention, which can offer improved local control and lower rates of RN compared with stereotactic radiosurgery to the resection cavity.
Introduction
Neurofibromatosis type 2 (NF2) is characterized by often bilateral vestibular schwannomas (VS) that result in progressive hearing loss and compression of nearby brainstem structures ...causing cranial nerve palsies. Treatment of these tumors remains challenging, as both surgical removal and expectant management can result in symptom progression. Stereotactic radiosurgery (SRS) has been investigated for the management of NF2-associated VS; however, the role, promises, and pitfalls of this treatment modality remain unclear.
Methods
Ovid MEDLINE, EMBASE, Web of Science, and Cochrane Reviews were searched for studies assessing SRS outcome in NF2-associated VS only. Primary endpoints included tumor control, serviceable hearing, presence of tinnitus, and cranial nerve V and VII symptoms.
Results
A total of 16 studies (589 patients harboring 750 tumors) were analyzed. Clinical tumor control was achieved in 88% of cases (95% CI 80–95%); salvage surgery was needed in 8% (95% CI 4–13%) of cases. Treatment resulted in a worsening of pre-treatment serviceable hearing (OR = 0.26, p < 0.01), increased facial nerve (OR = 1.62, p < 0.01) and trigeminal nerve (OR = 1.42, p = 0.07) impairment. The incidence of vestibular symptoms and hydrocephalus were not consistently reported and thus could not be assessed.
Conclusions
The treatment of NF2-associated VS continues to pose a challenge, as current SRS regimens result in impaired hearing and worse cranial nerve comorbidities, despite achieving high tumor control. It remains unclear if these findings have to be regarded as treatment complications or, rather, continued disease progression.
Objectives
Texture analysis performed on MRI images can provide additional quantitative information that is invisible to human assessment. This study aimed to evaluate the feasibility of texture ...analysis on preoperative conventional MRI images in predicting early malignant transformation from low- to high-grade glioma and compare its utility to histogram analysis alone.
Methods
A total of 68 patients with low-grade glioma (LGG) were included in this study, 15 of which showed malignant transformation. Patients were randomly divided into training (60%) and testing (40%) sets. Texture analyses were performed to obtain the most discriminant factor (MDF) values for both training and testing data. Receiver operating characteristic (ROC) curve analyses were performed on MDF values and 9 histogram parameters in the training data to obtain cutoff values for determining the correct rates of discrimination between two groups in the testing data.
Results
The ROC analyses on MDF values resulted in an area under the curve (AUC) of 0.90 (sensitivity 85%, specificity 84%) for T2w FLAIR, 0.92 (86%, 94%) for ADC, 0.96 (97%, 84%) for T1w, and 0.82 (78%, 75%) for T1w + Gd and correctly discriminated between the two groups in 93%, 100%, 93%, and 92% of cases in testing data, respectively. In the astrocytoma subgroup, AUCs were 0.92 (88%, 83%) for T2w FLAIR and 0.90 (92%, 74%) for T1w + Gd and correctly discriminated two groups in 100% and 92% of cases. The MDF outperformed all 9 of the histogram parameters.
Conclusion
Texture analysis on conventional preoperative MRI images can accurately predict early malignant transformation of LGGs, which may guide therapeutic planning.
Key Points
•
Texture analysis performed on MRI images can provide additional quantitative information that is invisible to human assessment.
•
Texture analysis based on conventional preoperative MR images can accurately predict early malignant transformation from low- to high-grade glioma.
•
Texture analysis is a clinically feasible technique that may provide an alternative and effective way of determining the likelihood of early malignant transformation and help guide therapeutic decisions.
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