Cushing's disease is a challenging neuroendocrine disorder. Although resection remains the primary treatment option for most patients, the disease persists if there is residual or recurrent tumor. ...Stereotactic radiosurgery has been used to treat patients with persistent Cushing's disease after a prior resection. The authors report on the long-term risks and benefits of radiosurgery for Cushing's disease.
A retrospective review of a prospectively collected database of radiosurgery patients was undertaken at the University of Virginia. All patients with Cushing's disease treated with Gamma Knife surgery (GKS) were identified. Those without at least 12 months of clinical and radiological follow-up were excluded from this analysis. Rates of endocrine remission, tumor control, and adverse events were assessed. Statistical methods were used to identify favorable and unfavorable prognostic factors.
Ninety-six patients with the required follow-up data were identified. The mean tumor margin dose was 22 Gy. The median follow-up was 48 months (range 12-209.8 months). At the last follow-up, remission of Cushing's disease occurred in 70% of patients. The median time to remission among all patients was 16.6 months (range 1-165.7 months). The median time to remission in those who had temporarily stopped taking ketoconazole at the time of GKS was 12.6 months, whereas it was 21.8 months in those who continued to receive ketoconazole (p < 0.012). Tumor control was achieved in 98% of patients. New loss of pituitary function occurred in 36% of patients. New or worsening cranial neuropathies developed in 5 patients after GKS, with the most common involving cranial nerves II and III.
Gamma Knife surgery offers a high rate of tumor control and a reasonable rate of endocrine remission in patients with Cushing's disease. The cessation of cortisol-lowering medications around the time of GKS appears to result in a more rapid rate of remission. Delayed hypopituitarism and endocrine recurrence develop in a minority of patients and underscore the need for long-term multidisciplinary follow-up.
Our understanding of the background of the EPIC/pn camera on board XMM-Newton is incomplete. This affects the study of extended sources and can influence the predictions of the expected background of ...future X-ray missions, such as the Advanced Telescope for High Energy Astrophysics (ATHENA). Here we provide new results based on the analysis of the largest data set ever used. We focus on the unconcentrated component of the EPIC/pn background, supposedly related to cosmic rays interacting with detector and telescope structures. We show that the so-called out field-of-view region of the pn detector is actually exposed to the sky. After carefully cleaning from the sky contamination, the unconcentrated background measured in the out field-of-view region does not show significant spatial variations, and its time behavior is anticorrelated with the solar cycle. We find a very tight linear correlation between unconcentrated backgrounds detected in the EPIC/pn and EPIC/MOS2 cameras. This relationship permits the correct evaluation of the pn unconcentrated background of each exposure on the basis of MOS2 data, avoiding the use of the contaminated out field-of-view region of the pn, as done in standard techniques. We find a tight linear correlation between the pn unconcentrated background and the proton flux in the 630-970 MeV energy band, as measured by the EPHIN instrument on board SOHO. Through this relationship, we quantify the contribution of cosmic-ray interaction to the pn unconcentrated background. This reveals a second source that contributes to the pn unconcentrated background for a significant fraction (30%-70%). This agent does not depend on the solar cycle or vary with time and is roughly isotropic. After having ruled out several candidates, we find that the hard X-ray photons of the cosmic X-ray background satisfy all known properties of the constant component. Our findings provide an important observational confirmation of simulation results on ATHENA and suggest that a high-energy particle monitor could contribute decisively to the reproducibility of the background for both experiments on ATHENA.
Epidural hematomas (EHs) usually originate from traumatic injury to the middle meningeal artery (MMA). Although large EHs may need to be emergently evacuated, the management of smaller EHs is less ...clear, especially in the absence of significant mass effect or neurologic deficits. Endovascular treatment via MMA embolization for epidural hematomas has only been recently reported. Herein, we present a case whereby MMA embolization was performed to prevent further growth of an expanding, right-sided EH after a larger left EH was surgically evacuated.
A 31-year-old male patient was brought to the emergency department after he was found down by the police at his house. He was initially conversant but quickly became obtunded within a few minutes. An initial scan showed bilateral (left larger than right) acute EHs, and the patient was taken to the operating room for a left craniotomy. Immediate postoperative imaging demonstrated an expanding right-sided EH. The patient was emergently taken to the endovascular suite and obvious contrast extravasation was noticed from the parietal branch of the MMA. The MMA was embolized via a transradial approach. Follow-up imaging revealed stable hematoma size without the need for additional surgery. The patient was discharged without any neurologic deficits.
Herein, we report the successful endovascular treatment of an expanding EH following a contralateral craniotomy. Active bleeding of the MMA was observed via angiography and may predict further EH expansion. Endovascular exploration and possible treatment can be justified in patients with EH that do not have a clear surgical indication.
Gamma Knife surgery (GKS) is a safe and effective treatment for patients with small to moderately sized vestibular schwannomas (VSs). Reports of stereotactic radiosurgery for large VSs have ...demonstrated worse tumor control and preservation of neurological function. The authors endeavored to assess the effect of size of VSs treated using GKS.
This study was a retrospective comparison of 24 patients with large VSs (> 3 cm in maximum diameter) treated with GKS compared with 49 small VSs (≤ 3 cm) matched for age, sex, radiosurgical margin and maximal doses, length of follow-up, and indication.
Actuarial tumor progression-free survival (PFS) for the large VS cohort was 95.2% and 81.8% at 3 and 5 years, respectively, compared with 97% and 90% for small VSs (p = 0.009). Overall clinical outcome was better in small VSs compared with large VSs (p < 0.001). Patients with small VSs presenting with House-Brackmann Grade I (good facial function) had better neurological outcomes compared with patients with large VSs (p = 0.003). Treatment failure occurred in 6 patients with large VSs; 3 each were treated with resection or repeat GKS. Treatment failure did not occur in the small VS group. Two patients in the large VS group required ventriculoperitoneal shunt placement. Univariate analysis did not identify any predictors of treatment failure among the large VS cohort.
Patients with large VSs treated using GKS had shorter PFS and worse clinical outcomes compared with age-, sex-, and indication-matched patients with small VSs. Nevertheless, GKS has efficacy for some patients with large VSs and represents a reasonable treatment option for selected patients.
It has been generally accepted that Gamma Knife surgery (GKS) is an effective primary or adjunct treatment for patients with 1-4 metastases to the brain. The number of studies detailing the use of ...GKS for 5 or more brain metastases, however, remains minimal. The aim of the current retrospective study was to elucidate the utility of GKS in patients with 5-15 brain metastases.
Patients were chosen for GKS based on prior MRI of these metastatic lesions and a known primary cancer diagnosis. Magnetic resonance imaging was used post-GKS to assess tumor control; patients were also followed up clinically. Overall survival (OS) from the date of GKS was used as the primary end point. Statistical analysis was performed to identify prognostic factors related to OS.
Between 2003 and 2012, 96 patients were treated for a total of 704 metastatic brain lesions. The histology of these lesions varied among non-small cell lung cancer (NSCLC), breast cancer, melanoma, renal cancer, and other more rare carcinomas. At the initial treatment, 18 of the patients (18.8%) were categorized in Recursive Partitioning Analysis (RPA) Class 1 and 77 (80.2%) in RPA Class 2; none were in RPA Class 3. The median number of treated lesions was 7 (mean 7.13), and the median planned treatment volume was 6.12 cm(3) (range 0.42-57.83 cm(3)) per patient. The median clinical follow-up was 4.1 months (range 0.1-40.70 months). Actuarial tumor control was calculated to be 92.4% at 6 months, 84.8% at 12 months, and 74.9% at 24 months post-GKS. The median OS was found to be 4.73 months (range 0.4-41.8 months). Multivariate analysis demonstrated that RPA class was a significant predictor of death (HR = 2.263, p = 0.038). Number of lesions, tumor histology, Graded Prognostic Assessment score, prior whole-brain radiation therapy, prior resection, prior chemotherapy, patient age, patient sex, controlled primary tumor, extracranial metastases, and planned treatment volume were not significant predictors of OS.
In patients with 5-15 brain metastases at presentation, the number of lesions did not predict survival after GKS; however, the RPA class was predictive of OS in this group of patients. Gamma Knife surgery for such patients offers an excellent rate of local tumor control.
Increasingly, meningiomas are detected incidentally, prior to symptom development. While these lesions are traditionally managed conservatively until symptoms develop or lesion growth occurs, it is ...conceivable that patients at high risk for symptom development may benefit from earlier intervention prior to the appearance of symptoms. However, little research has been performed to determine whether Gamma Knife surgery (GKS) can alter the rate of symptom development in such patients.
A retrospective case study was performed by screening the University of Virginia GKS database for patients treated for asymptomatic meningiomas. From the patient's medical records, pertinent demographic and treatment information was obtained. Yearly follow-up MRI had been performed to assess tumor control and detect signs of radiation-induced injury. Clinical follow-up via neurological examination had been performed to assess symptom development.
Forty-two patients, 33 females (78.6%) and 9 males (21.4%), with 42 asymptomatic meningiomas were included in the analysis. The median age at GKS was 53 years. The most common lesion location was the cerebral convexities (10 lesions 23.8%), and the median lesion size was 4.0 ml. The median duration of imaging and clinical follow-ups was 59 and 76 months, respectively. During the follow-up period, 1 tumor (2.4%) increased in size, 2 patients (4.8%) demonstrated symptoms, and 1 patient (2.4%) exhibited possible signs of radiation-induced injury. Thus, actuarial tumor control rates were 100%, 95.7%, and 95.7% for 2, 5, and 10 years, respectively. Actuarial symptom control at 5 and 10 years was 97% and 93.1%, respectively. Overall progression-free survival was 91.1% and 77.8% at 5 and 10 years, respectively.
Compared with published rates of symptom development in patients with untreated meningiomas, results in this study indicated that patients with asymptomatic lesions may benefit from prophylactic radiosurgery prior to the appearance of symptoms. Additionally, GKS is a treatment option that offers low morbidity.
We study the timing and spectral properties of the low-magnetic field, transient magnetar SWIFT J1822.3-1606 as it approached quiescence. We coherently phase-connect the observations over a time-span ...of ~500 d since the discovery of SWIFT J1822.3-1606 following the Swift-Burst Alert Telescope (BAT) trigger on 2011 July 14, and carried out a detailed pulse phase spectroscopy along the outburst decay. We follow the spectral evolution of different pulse phase intervals and find a phase and energy-variable spectral feature, which we interpret as proton cyclotron resonant scattering of soft photon from currents circulating in a strong (...10 super( 14) G) small-scale component of the magnetic field near the neutron star surface, superimposed to the much weaker (~3 ... 10 super( 13) G) magnetic field. We discuss also the implications of the pulse-resolved spectral analysis for the emission regions on the surface of the cooling magnetar. (ProQuest: ... denotes formulae/symbols omitted.)
Preoperative chronic narcotic use has been linked to poor outcomes after surgery for degenerative spinal disorders in the form of lower health-related quality of life scores, higher revision rates, ...increased infections, lower likelihood of return to work, and higher 90-day readmission rates. This study evaluated the impact of preoperative chronic narcotic use on patient reported outcome measures following adult spinal reconstructive surgery.
Patients who underwent adult spinal reconstructive surgery over 2 years at our institution were identified from a prospectively maintained spine registry. These patients were grouped into chronic opiate users as defined by a 6-month duration of use with a minimum morphine equivalent dose of 30 mg/day. Patient reported outcome measures were collected prospectively.
Of 140 patients included for analysis, 30 (21.4%) patients were categorized as chronic opiate users. No differences were identified in mean preoperative patient reported outcome measures, including Oswestry Disability Index, health state, visual analog scale, and EQ-5D indices. At both 6 weeks and 6 months postoperatively, patients in the opiate group demonstrated significantly worse mean visual analog scale back pain scores relative to the nonopiate group. At 6 months postoperatively and at the last known clinical follow-up, Oswestry Disability Index scores were higher in the opiate group.
Chronic opiate use before adult spinal reconstructive surgery was associated with worse pain and disability following intervention. Further work is needed to understand the role of opiate weaning as part of a larger prehabilitation strategy for adult spinal reconstructive surgery.
We present an accurate characterization of the particle background behaviour on
XMM-Newton
based on the entire EPIC archive. This corresponds to the largest EPIC data set ever examined. Our results ...have been obtained thanks to the collaboration between the FP7 European program EXTraS and the ESA R&D ATHENA activity AREMBES. We used as a diagnostic an improved version of the diagnostic which compares the data collected in unexposed region of the detector with the region of the field of view in the EPIC-MOS. We will show that the in Field-of-View excess background is made up of two different components, one associated to flares produced by soft protons and the other one to a low-intensity background. Its origin needs to be further investigated.
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