Saturday, June 30, 2012

'Visual Migraine' Linked to PFO (CME/CE)

(MedPage Today) -- For the first time, a patent foramen ovale (PFO) has been linked with the occurrence of a visual aura without the migraine headache, researchers found.





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[Articles] Temozolomide chemotherapy alone versus radiotherapy alone for malignant astrocytoma in th

Temozolomide alone is non-inferior to radiotherapy alone in the treatment of elderly patients with malignant astrocytoma. MGMT promoter methylation seems to be a useful biomarker for outcomes by treatment and could aid decision-making.





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[News] US cancer survivors to number 18 million by 2022

There will be an estimated 18 million cancer survivors in the USA by 2022, according to a new report from the American Cancer Society ( ACS) and the National Cancer Institute. The report—in which a cancer survivor was broadly defined as any living person who has been diagnosed with the disease at any time—used data from national registries to estimate that roughly 13·7 million Americans with a history of cancer were alive at the beginning of 2012, and used mortality data and population projections to calculate an estimate for 2022.





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Clinical Trials of Small Molecule Inhibitors in High-Grade Glioma

High-grade gliomas are rapidly progressing and generally fatal neoplasms of the brain. Chemotherapy has continued to provide only limited benefit for patients harboring these tumors. The recurrence of common mutations, combined with the similarities of many of the acquired capabilities and characteristics of solid tumors, suggest many common therapeutic targets. During the past few decades, an increased understanding of many of the cellular regulatory mechanisms associated with carcinogenesis has provided an opportunity for the development of pathway-specific small molecule targeted inhibitors (SMIs). This article reviews the use of SMIs in the treatment of high-grade glioma.





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Glioblastoma Multiforme Treatment with Clinical Trials for Surgical Resection (Aminolevulinic Acid)

5-Aminolevulinic acid (5-ALA)-induced tumor fluorescence can be used to identify tissue for resection using an adapted operating microscope. A multi-institutional clinical trial comparing fluorescence-guided versus white light tumor resection reported significant improvement in completeness of resection and 6-month progression-free survival. The degree of 5-ALA-induced fluorescence correlates with histopathologic grade of tumor, degree of tumor cell infiltration, and proliferation indices. Quantitative methodologies for assessment of tissue fluorescence have significantly improved the ability to detect tumor tissue and intraoperative diagnostic performance. These developments extend the applicability of this technology to additional tumor histologies and provide the rationale for further instrumentation development.





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Thursday, June 28, 2012

Outcomes of hypofractionated stereotactic radiotherapy for metastatic brain tumors with high risk fa

Abstract  
The present study aimed to analyze outcomes of hypofractionated stereotactic radiotherapy (HFSRT) delivered in five fractions to metastatic brain tumors. Between June 2008 and June 2011, 39 consecutive patients with 46 brain metastases underwent HFSRT at Kyoto University Hospital. Selection criteria included high risk factors such as eloquent location, history of whole-brain radiotherapy (WBRT), or large tumor size. Given these factors, fractionated schedules were preferable in terms of radiobiology. The prescribed dose at the isocenter was basically 35 Gy in five fractions. Brainstem lesions with a history of WBRT were treated with 20–25 Gy in five fractions. Planning target volume was covered by the 80 % isodose line of the prescribed dose to the isocenter. Local-control probability and overall survival were estimated using the Kaplan–Meier method. For the analysis of local control, the response criteria were defined as follows: complete response (CR) was defined as no visible gross tumor or absence of contrast enhancement, partial response (PR) as more than a 30 % decrease in size, progressive disease as more than a 20 % increase in size, and stable disease (SD) as all other responses. Local control was defined as a status of CR, PR, or SD. Only patients with at least 3 months or longer follow-up (21 patients, 27 tumors) were included in the analysis. Median age and Karnofsky performance status were 59 years (range, 39–84 years) and 90 (range, 40–100), respectively. Tumor volumes and maximum diameters ranged from 0.08 to 15.38 cm3 (median, 3.67 cm3) and from 3 to 34 mm (median, 18 mm), respectively. The median follow-up period was 329 days (range, 120–1,321 days). Local-control probabilities at 6 and 12 months were 92.1 and 86.7 %, respectively. Overall survival after HFSRT at 6 and 12 months was 85.4 and 64.5 %, respectively. Grade 3 radiation necrosis was observed in one patient according to the Common Terminology Criteria for Adverse Events version 3.0. The patient was successfully managed conservatively. HFSRT for metastatic brain tumors yields high local-control probabilities without increasing severe adverse events despite high risk factors.

  • Content Type Journal Article
  • Category Clinical Study
  • Pages 1-8
  • DOI 10.1007/s11060-012-0912-6
  • Authors
    • Kengo Ogura, Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507 Japan
    • Takashi Mizowaki, Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507 Japan
    • Masakazu Ogura, Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507 Japan
    • Katsuyuki Sakanaka, Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507 Japan
    • Yoshiki Arakawa, Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
    • Susumu Miyamoto, Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
    • Masahiro Hiraoka, Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507 Japan





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Wednesday, June 27, 2012

Number of primary melanomas is an independent predictor of survival in patients with metastatic mela

Abstract

BACKGROUND:

A history of multiple primary melanomas (PMs) has been associated with improved survival in patients with early stage melanoma, but whether it also is correlated with survival in patients with metastatic melanoma is unknown. The authors sought to address the latter question in the current study.

METHODS:

Patients with metastatic melanoma diagnosed at the Melanoma Institute Australia between 1983 and 2008 were identified. Overall survival (OS) was calculated from date of first distant metastasis. Survival analysis was performed using the Kaplan-Meier method, log-rank tests, and multivariate Cox proportional hazards models.

RESULTS:

Of 2942 patients with metastatic melanoma, 2634 (89.5%) had 1 PM and 308 (10.5%) had >1 PM. Factors that were associated independently with shorter OS were site of metastasis, including the brain (hazard ratio [HR], 2.41; 95% confidence interval [CI], 2.07-2.81; P < .001) and nonlung viscera (HR, 1.92; 95% CI, 1.67-2.22; P < .001, vs lymph node/subcutaneous/soft tissue), age >60 years (HR, 1.23; 95% CI, 1.12-1.36; P < .001), shorter disease-free interval from PM to first distant metastasis (≤12 months vs >36 months: HR, 1.62; 95% CI, 1.39-1.89; P < .001), and fewer PMs (1 vs >1; HR, 1.26; 95% CI, 1.08-1.47; P = .004).

CONCLUSIONS:

A history of multiple PM was an independent predictor of improved survival for patients with metastatic melanoma. The results indicate that a history of multiple PMs should be incorporated into multivariate analyses of prognostic factors and treatment outcomes. Cancer 2012. © 2012 American Cancer Society.






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Friday, June 22, 2012

Radiation necrosis of the brain in melanoma patients successfully treated with ipilimumab, three cas

Publication year: 2012
Source:European Journal of Cancer
Stephanie Du Four, Sofie Wilgenhof, Johnny Duerinck, Alex Michotte, Anne Van Binst, Mark De Ridder, Bart Neyns
Metastasis to the brain is a frequent event in patients with advanced melanoma. Despite treatment with neurosurgery, pancranial irradiation and high-precision conformal radiotherapy, the prognosis of patients suffering from melanoma brain metastasis has remained very poor. Ipilimumab is a new effective immunotherapy for the treatment of advanced melanoma and has demonstrated activity against brain metastases. We report three patients successfully treated with ipilimumab who subsequently developed focal necrosis of the brain following prior radiotherapy of their melanoma brain metastases. As new active systemic treatment options become available that improve the survival of patients with melanoma brain metastases, adequate diagnosis and management of the late sequela from radiation to the brain is likely to gain importance in the management of these patients.






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Is the prognosis of stage 4s neuroblastoma in patients 12months of age and older really excellent?

Publication year: 2012
Source:European Journal of Cancer, Volume 48, Issue 11
Tomoko Iehara, Eiso Hiyama, Tatsuro Tajiri, Akihiro Yoneda, Minoru Hamazaki, Masahiro Fukuzawa, Hajime Hosoi, Tohru Sugimoto, Tadashi Sawada
Purpose In the International Neuroblastoma Risk Group (INRG) classification system, stage 4s was changed into stage MS in children less than 18months of age. Stage MS is defined as a metastatic disease with skin, liver and bone marrow, similar to INSS stage 4s. To evaluate the outcome of stage 4s cases in patients 12months of age and over and to determine the appropriate treatment strategy. Method We performed a retrospective review of 3834 patients registered with the Japanese Society of Pediatric Oncology and Japanese Society of Pediatric Surgeons between 1980 and 1998. Results The rates of stage 4s patients were 10.7%, 6.3% and 3.3% in patients of ⩽11months of age, from ⩾12 to ⩽17months of age, ⩾18months of age, respectively. The 5year event-free survival rates were 89.4%, 100% and 53.1%, respectively. The rates of MYCN amplification and unfavourable histology were smaller in stage 4s groups than stage 4 groups in all ages. Conclusion In the children 12months of age and older, stage 4s cases are markedly different from stage 4 cases in regard to the clinical features and prognosis. The prognosis of stage 4s cases from ⩾12 to ⩽17months of age is excellent. The concept of stage MS appears to be appropriate.






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Trends in Surgical Utilization and Associated Patient Outcomes in the Treatment of Acoustic Neuroma

Publication year: 2012
Source:World Neurosurgery
Sahil Patel, Miriam Nuño, Debraj Mukherjee, Kristin Nosova, Shivanand P. Lad, Maxwell Boakye, Keith L. Black, Chirag G. Patil
Objective The emergence of stereotactic radiosurgery has provided an alternative to traditional surgical excision in the treatment of acoustic neuromas. In our study, we investigate the recent trends in surgical volume and associated patient outcomes in the treatment of this neoplasm. Methods A retrospective analysis was carried out using the Nationwide Inpatient Sample (NIS) database from 2000 to 2007; cases from 2005 were excluded due to coding inconsistencies. Univariate and multivariate analyses were used to describe surgical trends and analyze in-patient outcomes. Results Among the 14,928 patients studied, 87.1% were treated at large bed-size hospitals. Cases at these hospitals declined progressively from 2054 to 1467 cases (a 28.6% decrease) between 2000 and 2007; however, a 40.8% (178 cases per year, R2=.73) reduction in surgeries was observed from 2001 to 2007. While mortality remained steady at 0.3%, non-routine discharge (10.9% to 19.1%) and complication rates (21.5% to 23.3%) increased in recent years. Patients without private insurance (OR 1.7, p=.0033; OR 1.5, p=.0382), and higher comorbidity (OR 1.8, p<.0001; OR 1.5, <.0001) had an increased risk of non-routine discharge and complications, respectively. High surgical case-load reduced non-routine discharge by 30% (OR 0.7, p<.0001) and complications by 10% (OR 0.9, p<.0281). Conclusions A 41% or 178 cases per year reduction in surgical excision of acoustic neuroma cases was observed between 2001 and 2007. A possible explanation for this trend includes increased utilization of stereotactic radiosurgery. Non-routine discharge and complications after surgical excision have increased perhaps due to surgery being utilized for larger tumors.






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Stereotactic iodine-125 brachytherapy for brain tumors: temporary versus permanent implantation

Stereotactic brachytherapy (SBT) has been described in several publications as an effective,minimal invasive and safe highly focal treatment option in selected patients with wellcircumscribed brain tumors <4 cm. However, a still ongoing discussion about indications andtechnique is hindering the definition of a clear legitimation of SBT in modern brain tumortreatment. These controversies encompass the question of how intense the irradiation shouldbe delivered into the target volume (dose rate). For instance, reports about the use of highdoes rate (HDR) implantation schemes ( >40 cGy/h) in combination with adjuvant externalbeam radiation and/or chemotherapy for the treatment of malignant gliomas and metastasesresulted in increased rates of radiation induced adverse tissue changes requiring surgicalintervention. Vice versa, such effects have been only minimally observed in numerous studiesapplying low dose rate (LDR) regiments (3-8 cGy/h) for low grade gliomas, metastases andother rare indications. Besides these observations, there are, however, no data availabledirectly comparing the long term incidences of tissue changes after HDR and LDR and thereis, furthermore, no evidence regarding a difference between temporary or permanent LDRimplantation schemes. Thus, recommendations for effective and safe implantation schemeshave to be investigated and compared in future studies.





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Thursday, June 21, 2012

Role of Cancer Stem Cells in Spine Tumors: Review of Current Literature

The management of spinal column tumors continues to be a challenge for clinicians. The mechanisms of tumor recurrence after surgical intervention as well as resistance to radiation and chemotherapy continue to be elucidated. Furthermore, the pathophysiology of metastatic spread remains an area of active investigation. There is a growing body of evidence pointing to the existence of a subset of tumor cells with high tumorigenic potential in many spine cancers that exhibit characteristics similar to those of stem cells. The ability to self-renew and differentiate into multiple lineages is the hallmark of stem cells, and tumor cells that exhibit these characteristics have been described as cancer stem cells (CSCs). The mechanisms that allow nonmalignant stem cells to promote normal developmental programming by way of enhanced proliferation, promotion of angiogenesis, and increased motility may be used by CSCs to fuel carcinogenesis. The purpose of this review is to discuss what is known about the role of CSCs in tumors of the osseous spine. First, this article reviews the fundamental concepts critical to understanding the role of CSCs with respect to chemoresistance, radioresistance, and metastatic disease. This discussion is followed by a review of what is known about the role of CSCs in the most common primary tumors of the osseous spine. ABBREVIATIONS: ALDH1, aldehyde dehydrogenase enzyme CSC, cancer stem cell EMT, epithelial-mesenchymal transition GCT, giant cell tumor GBM, glioblastoma multiforme





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Short-term Complications Associated With Surgery for High-Grade Spondylolisthesis in Adults and Pedi

BACKGROUND: Although it is generally agreed upon that surgery for high-grade spondylolisthesis (HGS) is associated with more complications than low-grade spondylolisthesis, its description is primarily based on case reports and relatively small case series. OBJECTIVE: To assess short-term complication rates associated with the surgical treatment of HGS in pediatric and adult patients and to identify factors associated with increased complication rates. METHODS: All cases of HGS from the Scoliosis Research Society Morbidity and Mortality database for the year 2007 were reviewed. Patients were classified as pediatric (≤18 years) or adult (>18 years). Complications were tabulated, and the rates were compared between the patient groups and based on clinical and surgical factors. RESULTS: 165 cases of HGS were reported (88 pediatric, 77 adult). There were 49 complications (29.7%) in 41 patients (24.8%), with no difference in the proportions of pediatric vs adult patients with a complication (P = .86). Occurrence of new neurological deficit after surgery was the most common complication, seen in 19 (11.5%) patients. Performance of an osteotomy was associated with a higher incidence of new neurological deficits in both adult and pediatric groups (P = .02 and P = .012, respectively). Although most of the new neurological deficits improved over follow-up, 10% had no improvement. CONCLUSION: This study provides short-term complication rates associated with surgical treatment for HGS in adult and pediatric patients and may prove valuable for patient counseling, surgical planning, and in efforts to improve the safety of patient care. ABBREVIATIONS: HGS, high-grade spondylolisthesis LGS, low-grade spondylolisthesis M&M, Morbidity and Mortality SRS, Scoliosis Research Society





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Moyamoya Disorder in the United States

BACKGROUND: In Asian populations, moyamoya disease has a well-defined phenotype including a bimodal age of presentation with children typically presenting with ischemic phenomena and adults presenting with hemorrhage. Studies have provided evidence that moyamoya disease in the United States may exhibit a different phenotype. OBJECTIVE: To assess overall rates of admission, demographics, procedures, and outcomes of patients admitted or diagnosed with moyamoya disorder in US hospitals. METHODS: A comprehensive assessment of the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (2002-2008) was performed. Patient demographics, comorbidities, procedures, and outcomes were analyzed. RESULTS: There were 2280 admissions for moyamoya disorder with a predicted national estimate of 11 163 admissions (0.57/100 000 persons/y). Over time, there was a significant increase in diagnosis and associated ischemic strokes. Females (72%) were affected more than males (28%). Demographics included white (49%), black (24%), Hispanic (11%), Asian (11%), and other (3.3%). Mean age at presentation was 31.6 ± 18.0. Children were significantly more likely to be diagnosed with ischemic phenomena (16.4%) than hemorrhage (3.3%), as were adults (18.8% vs 11.0%). Status at discharge was largely routine (74.8%) vs short-term hospital (3%), home health care (7%), transfer to another hospital (12%), or in-hospital death in 2.3%. CONCLUSION: Patients admitted to US hospitals diagnosed with moyamoya disorder were more commonly female and white, and both adults and children were more likely to be diagnosed with ischemic vs hemorrhagic stroke. Over time, there was an increase in diagnosis, associated ischemic stroke, and treatment with extracranial-intracranial bypass. ABBREVIATIONS: CI, confidence interval EC-IC, extracranial to intracranial IQR, interquartile range LOS, length of stay NIS, Nationwide Inpatient Sample





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Subdural Hematoma in Patients With Cancer

BACKGROUND: Subdural hematoma (SDH) in patients with cancer is poorly described, and its frequency and causes may have changed with recent oncologic advances. OBJECTIVE: We conducted an analysis of the clinical and radiographic features, etiologies, treatments, and outcomes of patients with SDHs and cancer. METHODS: We retrospectively identified patients at Memorial Sloan-Kettering Cancer Center with a diagnosis of SDH and cancer from January 2000 to December 2007. We analyzed clinical and radiographic data; multivariate Cox regression was performed to associate tumor type and etiology with survival outcome. RESULTS: There were 90 patients; 66 had acute or subacute SDHs, 9 chronic SDHs, 11 subdural hygromas, and 4 SDHs of unclear chronicity. Gliomas (16%), leukemias (14%), and prostate cancers (14%) were the most frequent malignancies. The most common single etiologies were coagulopathy (27%) and trauma (11%). SDHs with multiple etiologies occurred in 25 patients (28%) with the combination of coagulopathy and trauma occurring in 15. Sixty patients (67%) were either completely or partially independent after SDH, and 1-year survival was 43% (95% confidence interval: 32.1-52.9). Overall survival correlated with etiology (P < .0001) and whether the malignancy was in remission (P = .005). Trauma was associated with the best overall survival compared with coagulopathy. CONCLUSION: Leukemia and prostate cancer are the most common systemic cancers associated with SDH, and gliomas may predispose to SDH more often than previously recognized. Coagulopathy is common and associated with the worst outcome, but many patients experience good functional outcome and survival. ABBREVIATIONS: IH, intracranial hemorrhage INR, international normalized ratio LP, lumbar puncture MSKCC, Memorial Sloan-Kettering Cancer Center SGF, subdural hygroma SDH, subdural hematoma VPS, ventriculoperitoneal shunt





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Vestibular schwannoma with repeated intratumoral hemorrhage

Publication year: 2012
Source:Journal of Clinical Neuroscience
Satoru Takeuchi, Hiroshi Nawashiro, Naoki Otani, Fumihiro Sakakibara, Kimihiro Nagatani, Kojiro Wada, Hideo Osada, Katsuji Shima
Repeated hemorrhage from a vestibular schwannoma is very rare. We report a 15-year-old male, to our knowledge the fourth known patient with repeated hemorrhage of vestibular schwannoma, who presented with rapidly progressive right-sided hearing loss and tinnitus. MRI showed a mass lesion in the right cerebellopontine angle. T1-weighted and T2-weighted MRI revealed a hyperintense intratumoral area, indicating subacute hemorrhage within the tumor. Nine weeks after the initial onset, the patient again presented with a sudden onset headache, nausea, and ataxia. A CT scan showed recurrence of an intratumoral hemorrhage. A subtotal resection was achieved. A histopathological examination of the resected specimen showed typical features of schwannoma. We review the pertinent literature and discuss the features of repeated hemorrhage from a vestibular schwannoma.






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Early recurrence in standard-risk medulloblastoma patients with the common idic(17)(p11.2) rearrange

Medulloblastoma is diagnosed histologically; treatment depends on staging and age of onset. Whereas clinical factors identify a standard- and a high-risk population, these findings cannot differentiate which standard-risk patients will relapse and die. Outcome is thought to be influenced by tumor subtype and molecular alterations. Poor prognosis has been associated with isochromosome (i)17q in some but not all studies. In most instances, molecular investigations document that i17q is not a true isochromosome but rather an isodicentric chromosome, idic(17)(p11.2), with rearrangement breakpoints mapping within the REPA/REPB region on 17p11.2. This study explores the clinical utility of testing for idic(17)(p11.2) rearrangements using an assay based on fluorescent in situ hybridization (FISH). This test was applied to 58 consecutive standard- and high-risk medulloblastomas with a 5-year minimum of clinical follow-up. The presence of i17q (ie, including cases not involving the common breakpoint), idic(17)(p11.2), and histologic subtype was correlated with clinical outcome. Overall survival (OS) and disease-free survival (DFS) were consistent with literature reports. Fourteen patients (25%) had i17q, with 10 (18%) involving the common isodicentric rearrangement. The presence of i17q was associated with a poor prognosis. OS and DFS were poor in all cases with anaplasia (4), unresectable disease (7), and metastases at presentation (10); however, patients with standard-risk tumors fared better. Of these 44 cases, tumors with idic(17)(p11.2) were associated with significantly worse patient outcomes and shorter mean DFS. FISH detection of idic(17)(p11.2) may be useful for risk stratification in standard-risk patients. The presence of this abnormal chromosome is associated with early recurrence of medulloblastoma.






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Current clinical development of PI3K pathway inhibitors in glioblastoma

Glioblastoma (GBM) is the most common and lethal primary malignant tumor of the central nervous system, and effective therapeutic options are lacking. The phosphatidylinositol 3-kinase (PI3K) pathway is frequently dysregulated in many human cancers, including GBM. Agents inhibiting PI3K and its effectors have demonstrated preliminary activity in various tumor types and have the potential to change the clinical treatment landscape of patients with solid tumors. In this review, we describe the activation of the PI3K pathway in GBM, explore why inhibition of this pathway may be a compelling therapeutic target for this disease, and provide an update of the data on PI3K inhibitors in clinical trials and from earlier investigation.






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Monday, June 18, 2012

Health status of adolescent and young adult cancer survivors

Abstract

BACKGROUND:

Adolescents and young adults (AYA) ages 15 to 29 years who are diagnosed with cancer are at risk for long-term morbidity and mortality associated with treatment of their cancer and the cancer itself. In this article, the authors describe the self-reported health status of AYA cancer survivors.

METHODS:

The authors examined 2009 data from the Behavioral Risk Factor Surveillance System, including demographic characteristics, risk behaviors, chronic conditions, health status, and health care access, among AYA cancer survivors compared with respondents who had no history of cancer.

RESULTS:

The authors identified 4054 AYA cancer survivors and 345,592 respondents who had no history of cancer. AYA cancer survivors, compared with respondents who had no history of cancer, reported a significantly higher prevalence of current smoking (26% vs 18%); obesity (31% vs 27%); chronic conditions, including cardiovascular disease (14% vs 7%), hypertension (35% vs 29%), asthma (15% vs 8%), disability (36% vs 18%), and poor mental health (20% vs 10%) and physical health (24% vs 10%); and not receiving medical care because of cost (24% vs 15%).

CONCLUSIONS:

AYA cancer survivors commonly reported adverse behavioral, medical, and health care access characteristics that may lead to poor long-term medical and psychosocial outcomes. Increased adherence to established follow-up guidelines may lead to improved health among AYA cancer survivors. Cancer 2012. © 2012 American Cancer Society.






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Saturday, June 16, 2012

Residual 18F-FDG-PET Uptake 12 Weeks After Stereotactic Ablative Radiotherapy for Stage I Non-Small-

Purpose: To investigate the prognostic value of [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) uptake at 12 weeks after stereotactic ablative radiotherapy (SABR) for stage I non-small-cell lung cancer (NSCLC).Methods and Materials: From November 2006 to February 2010, 132 medically inoperable patients with proven Stage I NSCLC or FDG-PET-positive primary lung tumors were analyzed retrospectively. SABR consisted of 60 Gy delivered in 3 to 8 fractions. Maximum standardized uptake value (SUVmax) of the treated lesion was assessed 12 weeks after SABR, using FDG-PET. Patients were subsequently followed at regular intervals using computed tomography (CT) scans. Association between post-SABR SUVmax and local control (LC), mediastinal failure, distant failure, overall survival (OS), and disease-specific survival (DSS) was examined.Results: Median follow-up time was 17 months (range, 3–40 months). Median lesion size was 25 mm (range, 9–70 mm). There were 6 local failures: 15 mediastinal failures, 15 distant failures, 13 disease-related deaths, and 16 deaths from intercurrent diseases. Glucose corrected post-SABR median SUVmax was 3.0 (range, 0.55–14.50). Using SUVmax 5.0 as a cutoff, the 2-year LC was 80% versus 97.7% for high versus low SUVmax, yielding an adjusted subhazard ratio (SHR) for high post-SABR SUVmax of 7.3 (95% confidence interval [CI], 1.4–38.5; p = 0.019). Two-year DSS rates were 74% versus 91%, respectively, for high and low SUVmax values (SHR, 2.2; 95% CI, 0.8–6.3; p = 0.113). Two-year OS was 62% versus 81% (hazard ratio [HR], 1.6; 95% CI, 0.7–3.7; p = 0.268).Conclusions: Residual FDG uptake (SUVmax ≥5.0) 12 weeks after SABR signifies increased risk of local failure. A single FDG-PET scan at 12 weeks could be used to tailor further follow-up according to the risk of failure, especially in patients potentially eligible for salvage surgery.





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Radiotherapy and concomitant temozolomide may improve survival of elderly patients with glioblastoma

Abstract  
Survival of elderly patients with glioblastoma (GBM) is poor, but improves with tumor resection and radiotherapy (RT). Concurrent temozolomide (TMZ) chemotherapy during RT improves the survival of younger patients with GBM, but the benefit in elderly patients is unclear. Medical records of patients ≥65 years old with primary GBM, histologically confirmed at Memorial Sloan-Kettering Cancer Center and treated with RT, were reviewed. Survival was associated with patient (age, performance status), tumor (single or multiple), and treatment (extent of surgery, RT field, technique, fractionation and use of concurrent TMZ) characteristics in a multivariable Cox regression model. Grade ≥3 hematologic toxicity rates were compared to reported rates in younger patients. Median age of the 291 patients studied was 71 years. Longer survival was associated with younger age, tumor resection, and concomitant TMZ and RT (p < 0.01). Concurrent TMZ and RT improved median survival of patients with favorable prognostic factors from 12 to 21 months and from 10 to 13 months in patients 65–70 and ≥71 years old, respectively. Concomitant TMZ and RT increased the 2 year OS rate from 14 to 41 % and from 5 to 24 % in patients 65–70 and ≥71 years old, respectively. Grade 3–4 thrombocytopenia was significantly more frequent in the present cohort. Survival of elderly patients with GBM may be prolonged with the use of concomitant TMZ during RT. An ongoing randomized study will determine the benefit of this approach in a prospective fashion.

  • Content Type Journal Article
  • Category Clinical Study
  • Pages 1-7
  • DOI 10.1007/s11060-012-0906-4
  • Authors
    • Christopher A. Barker, Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
    • Maria Chang, Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
    • Joanne F. Chou, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
    • Zhigang Zhang, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
    • Kathryn Beal, Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
    • Philip H. Gutin, Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
    • Fabio M. Iwamoto, Neuro-Oncology Branch, National Cancer Institute, Bethesda, MD, USA





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Transient enlargement of craniopharyngioma after radiation therapy: pattern of magnetic resonance im

Abstract  
Clinical experience suggests that craniopharyngiomas may temporarily increase in size after radiation therapy (RT). The study goal is to determine the incidence and natural history of this response in a cohort of patients managed at Children's Healthcare of Atlanta (CHOA) or Emory Healthcare (EHC). Between 08/1998 and 06/2009, 41 children and young adults were diagnosed with craniopharyngioma at CHOA and/or EHC. Of these, 21 received external-beam radiation and were included in our analysis. Serial magnetic resonance imaging (MRI) studies were evaluated volumetrically to assess response to RT. Median age at diagnosis was 8.2 years (range 3.2–23.5 years). Median radiation dose was 54.0 Gy using standard fractionation (1.8–2.0 Gy/day). With median follow-up of 41.3 months (range 7.2–121.8 months), actuarial local control and overall survival rates at 5 years were 78.7 % and 100 %, respectively. Of subjects, 52.4 % of subjects (11 of 21) were noted on serial MRI evaluation to have tumor enlargement (mostly cystic component) after radiation before eventual shrinkage without further intervention. For tumors that expanded, the median volume increase was 33.9 % (range 15.6–224.4 %). Median time to maximal tumor/cyst expansion was 1.5 months (range 1.0–5.0 months). Finally, nearly all patients (20 of 21) showed a measurable objective response to therapy by MRI regardless of ultimate disease control. Median time to maximal response post-radiation, as defined by MRI, was 9.5 months (range 3.5–39.9 months). In summary, RT is effective for managing craniopharyngioma. However, despite good ultimate responses, approximately 50 % of the patients show tumor/cyst expansion on MRI over the first few months post-radiation. Caution should be taken not to subject these patients to "salvage surgery" or cyst aspiration during this early time unless there are other overriding surgical indications. Understanding the natural history of this phenomenon could potentially help guide the management of these craniopharyngioma patients.

  • Content Type Journal Article
  • Category Clinical Study
  • Pages 1-7
  • DOI 10.1007/s11060-012-0900-x
  • Authors
    • Zheng Shi, Department of Radiation Oncology and Winship Cancer Institute, Emory University, 1365 Clifton Rd., NE, Suite CT-104, Atlanta, GA 30322, USA
    • Natia Esiashvili, Department of Radiation Oncology and Winship Cancer Institute, Emory University, 1365 Clifton Rd., NE, Suite CT-104, Atlanta, GA 30322, USA
    • Anna J. Janss, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
    • Claire M. Mazewski, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
    • Tobey J. MacDonald, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
    • David M. Wrubel, Pediatric Neurosurgery Associates at Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
    • Barunashish Brahma, Pediatric Neurosurgery Associates at Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
    • Frederick P. Schwaibold, Department of Radiation Oncology, Piedmont Hospital, Atlanta, GA, USA
    • Robert B. Marcus, Department of Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, FL, USA
    • Ian R. Crocker, Department of Radiation Oncology and Winship Cancer Institute, Emory University, 1365 Clifton Rd., NE, Suite CT-104, Atlanta, GA 30322, USA
    • Hui-Kuo G. Shu, Department of Radiation Oncology and Winship Cancer Institute, Emory University, 1365 Clifton Rd., NE, Suite CT-104, Atlanta, GA 30322, USA





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Surgical management of intradural extramedullary tumors located anteriorly to the spinal cord

Publication year: 2012
Source:Journal of Clinical Neuroscience
Andrei Fernandes Joaquim, João Paulo Almeida, Marcos Juliano dos Santos, Enrico Ghizoni, Evandro de Oliveira, Helder Tedeschi
Meningiomas and nerve sheath tumors are the most common lesions found in the intradural extramedullary compartment of the spine. Some of these lesions can be located anteriorly to the spinal cord, constituting a challenge for spine surgeons. We present a surgical technique that improves the surgical exposure of lesions located anteriorly or antero-laterally to the spinal cord. A microsurgical technique of tenting of the dentate ligament with sutures and rotation of the spinal cord is described in detail and illustrated with surgical cases. This technique increases the small microsurgical operative field and allows spinal cord retraction with the use of a natural cord component, minimizing pressure on the spinal cord delicate tissue, allowing total tumor resection. In conclusion, total resection without new neurological deficit of anterior and antero-lateral tumors can be performed using an isolated posterior approach with rotation of the spinal cord using tenting of the dentate ligament with sutures.






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Friday, June 15, 2012

Avastin Shrinks Tumours - New Research

Patients affected by a form of Neurofibromatosis have seen their tumours shrink dramatically after being treated with the drug Avastin. The latest research, which involved 24 patients in England, has provided remarkable results. The majority of people given the drug as part of the nationally-funded NF2 service have seen significant improvements...





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Avastin Shrinks Tumours - New Research

Patients affected by a form of Neurofibromatosis have seen their tumours shrink dramatically after being treated with the drug Avastin. The latest research, which involved 24 patients in England, has provided remarkable results. The majority of people given the drug as part of the nationally-funded NF2 service have seen significant improvements...





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Monday, June 11, 2012

Resection of gliomas in the cingulate gyrus: functional outcome and survival

Abstract  
Functional outcome after resection of tumors arising from the gyrus cinguli (GC), part of the limbic system, is not well analyzed. The purpose of this study was to evaluate the feasibility and functional outcome of surgical treatment for a series of 65 patients with gliomas involving the GC. Preoperative data, extent of resection, functional outcome (Karnofsky performance index, KPI, and the National Institute of Health Stroke Scale, NIHSS), and survival of 65 patients with gliomas arising from the GC were analyzed on the basis of a prospectively conducted database of gliomas between 06/1999 and 07/2010. Extent of resection (complete, subtotal, or partial) was based on early postoperative MRI. Eighty-six percent of the gliomas were located in the anterior part of the GC and 14 % in the posterior part. Fifty-five percent of the patients presented with seizures and 17 % with hemiparesis (mean preoperative KPI = 86 ± 17, NIHSS = 1.4 ± 1.7). Histologically, the tumors were WHO Grade II in 25 %, Grade III in 26 %, and Grade IV in 49 %. Complete resection was achieved for 59 %, subtotal resection for 32%, and partial resection for 9 %. Postoperative transient deficits included SMA lesion (14 %) and new or worsened hemiparesis (8 %), which resolved within 30 days (NIHSS early postoperatively 1.7 ± 1.4, late postoperatively 0.8 ± 1.4, and after 6 months 0.6 ± 1.4). According to histopathological grading, median survival was 67 months (WHO°II), 87 months (WHO°III), and 16.5 months (WHO°IV), and overall survival was 34 months. Microsurgical resection of gliomas arising from the GC is feasible; gross total resection can be achieved for 90 % of gliomas arising from the GC with 5 % long-term morbidity.

  • Content Type Journal Article
  • Category Clinical Study
  • Pages 1-8
  • DOI 10.1007/s11060-012-0898-0
  • Authors
    • Ági Oszvald, Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Schleusenweg 2-16, 60528 Frankfurt, Germany
    • Johanna Quick, Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Schleusenweg 2-16, 60528 Frankfurt, Germany
    • Kea Franz, Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Schleusenweg 2-16, 60528 Frankfurt, Germany
    • Erdem Güresir, Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Schleusenweg 2-16, 60528 Frankfurt, Germany
    • Andrea Szelényi, Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Schleusenweg 2-16, 60528 Frankfurt, Germany
    • Hartmut Vatter, Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Schleusenweg 2-16, 60528 Frankfurt, Germany
    • Volker Seifert, Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Schleusenweg 2-16, 60528 Frankfurt, Germany





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Exposure to CT scans in children slightly increases risk of leukaemia or brain tumour, study shows

Children who have computed tomography scans run a higher risk of developing leukaemia or a brain tumour later in life, a large cohort study using NHS data has shown. In absolute terms the risks...





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Gamma Knife surgery for the management of glomus tumors: a multicenter study

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-9, Ahead of Print.
Object Glomus tumors are rare skull base neoplasms that frequently involve critical cerebrovascular structures and lower cranial nerves. Complete resection is often difficult and may increase cranial nerve deficits. Stereotactic radiosurgery has gained an increasing role in the management of glomus tumors. The authors of this study examine the outcomes after radiosurgery in a large, multicenter patient population. Methods Under the auspices of the North American Gamma Knife Consortium, 8 Gamma Knife surgery centers that treat glomus tumors combined their outcome data retrospectively. One hundred thirty-four patient procedures were included in the study (134 procedures in 132 patients, with each procedure being analyzed separately). Prior resection was performed in 51 patients, and prior fractionated external beam radiotherapy was performed in 6 patients. The patients' median age at the time of radiosurgery was 59 years. Forty percent had pulsatile tinnitus at the time of radiosurgery. The median dose to the tumor margin was 15 Gy. The median duration of follow-up was 50.5 months (range 5–220 months). Results Overall tumor control was achieved in 93% of patients at last follow-up; actuarial tumor control was 88% at 5 years postradiosurgery. Absence of trigeminal nerve dysfunction at the time of radiosurgery (p = 0.001) and higher number of isocenters (p = 0.005) were statistically associated with tumor progression–free tumor survival. Patients demonstrating new or progressive cranial nerve deficits were also likely to demonstrate tumor progression (p = 0.002). Pulsatile tinnitus improved in 49% of patients who reported it at presentation. New or progressive cranial nerve deficits were noted in 15% of patients; improvement in preexisting cranial nerve deficits was observed in 11% of patients. No patient died as a result of tumor progression. Conclusions Gamma Knife surgery was a well-tolerated management strategy that provided a high rate of long-term glomus tumor control. Symptomatic tinnitus improved in almost one-half of the patients. Overall neurological status and cranial nerve function were preserved or improved in the vast majority of patients after radiosurgery.





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Blogs for neurosurgeons

Júlio Leonardo Barbosa Pereira, Pieter L Kubben, Lucas Alverne Freitas de Albuquerque, Gervásio Teles C de Carvalho, Atos Alves de Sousa

Surgical Neurology International 2012 3(1):62-62

Blogs are useful tools to research and to disseminate information. As they allow people who do not have specific knowledge on the building of sites to post content on the internet, they turned out to be very popular. In the past years, there has been a rapid expansion of blogs on several subjects and nowadays there are over 156 million blogs online. Neurosurgery was not out of this wave, and several blogs related to it can be found on the internet. The objective of this paper is to describe, in general, the functions of a blog and to provide initial guidance for the creation and the adequate use of neurosurgical blogs. Some interesting blogs and their features are also listed as examples.





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Temozolomide or bevacizumab for spinal cord high-grade gliomas

Abstract  
High-grade gliomas of the spinal cord are rare tumors, traditionally managed with surgery and radiotherapy. Once patients fail standard treatment, many receive some chemotherapy, although the data supporting such is limited. We reviewed our experience treating high-grade gliomas of the spinal cord with standard intracranial regimens including temozolomide and bevacizumab. Outcomes investigated include radiographic response, clinical response, progression-free survival, and overall survival. We identified eight patients who were treated with temozolomide and six who were treated with bevacizumab. Temozolomide was administered to three patients at initial diagnosis and five patients at recurrence after failing prior radiotherapy. For the recurrent patients, the median time-to-progression was 6.6 months (range 1–40 months) and the median overall survival from initiation of temozolomide was 16.6 months (range 1.2–64.5 months). We identified six patients who received bevacizumab at the time of recurrence. MRI demonstrated a partial response in five patients which also correlated with clinical improvement. The median time to progression was 20.7 months (range 3.3–29.9 months) and median overall survival was 22.8 months (range 3.3–31.8 months). This retrospective review suggests that temozolomide and bevacizumab may be beneficial in spinal cord high-grade gliomas. The compact architecture of the spinal cord makes bevacizumab a particularly appealing agent due to the drug's effect on peritumoral edema and mass effect.

  • Content Type Journal Article
  • Category Clinical Study
  • Pages 1-5
  • DOI 10.1007/s11060-012-0905-5
  • Authors
    • Thomas J. Kaley, Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
    • Ijah Mondesire-Crump, Department of Surgery, St Luke's-Roosevelt Hospital, New York, NY, USA
    • Igor T. Gavrilovic, Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA





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Wednesday, June 6, 2012

Stereotactic radiation therapy for progressive residual pilocytic astrocytomas

Abstract  
This report shows the results of stereotactic radiation therapy for progressive residual pilocytic astrocytomas. Medical records of patients who had undergone stereotactic radiation therapy for a progressive residual pilocytic astrocytoma were reviewed. Between 1995 and 2010, 12 patients with progression of a residual pilocytic astrocytoma underwent stereotactic radiation therapy at UCLA. Presentation was headache (4), visual defects (3), hormonal disturbances (2), gelastic seizures (2) and ataxia (1). MRI showed a cystic (9), mixed solid/cystic (2) or solid tumor (1); located in the hypothalamus (5), midbrain (3), thalamus (2), optic chiasm (1) or deep cerebellum (1). Median age was 21 years (range 5–41). Nine tumors received stereotactic radiotherapy (SRT). Three tumors received stereotactic radiosurgery (SRS), two of them to their choline positive regions. SRT median total dose was 50.4 Gy (40–50.4 Gy) in a median of 28 fractions (20–28), using a median fraction dose of 1.8 Gy (1.8–2 Gy) to a median target volume of 6.5 cm3. (2.4–33.57 cm3) SRS median dose was 18.75 Gy (16.66–20 Gy) to a median target volume of 1.69 cm3 (0.74–2.22 cm3). Median follow-up time was 37.5 months. Actuarial long-term progression-free and disease-specific survival probabilities were 73.3 and 91.7 %, respectively. No radiation-induced complications were observed. Stereotactic radiation therapy is a safe and effective modality to control progressive residual pilocytic astrocytomas. Better outcomes are obtained with SRT to entire tumor volumes than with SRS targeting choline positive tumor regions.

  • Content Type Journal Article
  • Category Clinical Study
  • Pages 1-7
  • DOI 10.1007/s11060-012-0877-5
  • Authors
    • Karlo J. Lizarraga, Division of Neurosurgery, David Geffen School of Medicine, University of California at Los Angeles (UCLA), 10945 Le Conte Avenue, Room 2120, Los Angeles, CA 90095, USA
    • Alessandra Gorgulho, Division of Neurosurgery, David Geffen School of Medicine, University of California at Los Angeles (UCLA), 10945 Le Conte Avenue, Room 2120, Los Angeles, CA 90095, USA
    • Steve P. Lee, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles (UCLA), 200 UCLA Medical Plaza, Suite B265, Los Angeles, CA 90095, USA
    • Glenn Rauscher, Division of Neurosurgery, David Geffen School of Medicine, University of California at Los Angeles (UCLA), 10945 Le Conte Avenue, Room 2120, Los Angeles, CA 90095, USA
    • Michael T. Selch, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles (UCLA), 200 UCLA Medical Plaza, Suite B265, Los Angeles, CA 90095, USA
    • Antonio A. F. DeSalles, Division of Neurosurgery, David Geffen School of Medicine, University of California at Los Angeles (UCLA), 10945 Le Conte Avenue, Room 2120, Los Angeles, CA 90095, USA





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Key concepts in glioblastoma therapy

Glioblastoma is the most common form of primary brain cancer and remains one of the most aggressive forms of human cancer. Current standard of care involves maximal surgical resection followed by concurrent therapy with radiation and the DNA alkylating agent temozolomide. Despite this aggressive regimen, the median survival remains approximately 14 months. Meaningful strategies for therapeutic intervention are desperately needed. Development of such strategies will require an understanding of the therapeutic concepts that have evolved over the past three decades. This article reviews the key principles that drive the formulation of therapeutic strategies in glioblastoma. Specifically, the concepts of tumour heterogeneity, oncogene addiction, non-oncogene addiction, tumour initiating cells, tumour microenvironment, non-coding sequences and DNA damage response will be reviewed.






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Radiotherapy and temozolomide in anaplastic astrocytoma: a retrospective multicenter study by the Ce

Although the evidence for the benefit of adding temozolomide (TMZ) to radiotherapy (RT) is limited to glioblastoma patients, there is currently a trend toward treating anaplastic astrocytomas (AAs) with combined RT + TMZ. The aim of the present study was to describe the patterns of care of patients affected by AA and, particularly, to compare the outcome of patients treated exclusively with RT with those treated with RT + TMZ. Data of 295 newly diagnosed AAs treated with postoperative RT ± TMZ in the period from 2002 to 2007 were reviewed. More than 75% of patients underwent a surgical removal. All the patients had postoperative RT; 86.1% of them were treated with 3D-conformal RT (3D-CRT). Sixty-seven percent of the entire group received postoperative chemotherapy with TMZ (n = 198). One-hundred sixty-six patients received both concomitant and sequential TMZ. Prescription of postoperative TMZ increased in the most recent period (2005–2007). One- and 4-year survival rates were 70.2% and 28.6%, respectively. No statistically significant improvement in survival was observed with the addition of TMZ to RT (P = .59). Multivariate analysis showed the statistical significance of age, presence of seizures, Recursive Partitioning Analysis classes I–III, extent of surgical removal, and 3D-CRT. Changes in the care of AA over the past years are documented. Currently there is not evidence to justify the addition of TMZ to postoperative RT for patients with newly diagnosed AA outside a clinical trial. Results of prospective and randomized trials are needed.






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