Radiocirurgia

Publication year: 2012
Source:Journal of Clinical Neuroscience
Bradley A. Gross, Rose Du
Microsurgical resection of a cerebral arteriovenous malformation (AVM) allows for an immediate therapeutic cure. Stereotactic radiosurgery (SRS) is a reasonable alternative for inoperable or high-risk lesions requiring treatment. Few series evaluate overall results that include data from both modalities as they more often focus on their treatment method of choice. In this study, we evaluated our AVM database of 129 patients seen over the past eight years at our institution: 73 were treated with microsurgery (57%) while 37 (29%) were treated with SRS. We reviewed angiographic obliteration rates, complication rates, and outcome data, excluding seven patients treated with SRS as they did not have at least two years of angiographic follow-up. Patients undergoing microsurgery had smaller AVM (mean 2.2cm compared to 3.5cm for SRS), a smaller proportion of eloquent AVM (53% compared to 83% for SRS), a greater proportion of AVM with superficial drainage only (75% compared to 40% for SRS), and more grade 1 and 2 AVM (78% compared to 17% for SRS). The overall obliteration rate was 80%: 92% for microsurgery and 50% for SRS. The latter increased to 92% for AVM <3cm, but the obliteration rate was 18% for those AVM >3cm. Transient complications, including post-SRS hemorrhage, were seen in 11% of patients overall (8% after microsurgery, 17% after SRS). At follow-up, 53% of patients had improved, 37% remained the same, 7% had become worse and 3% had died. As a result of post-SRS hemorrhage, a greater proportion of patients was worse or had died after SRS (20%) compared to those who had been treated with microsurgery (5%).

http://www.sciencedirect.com/science?_ob=GatewayURL&_origin=IRSSSEARCH&_method=citationSearch&_piikey=S0967586812000070&_version=1&md5=387c3dbc5a8859e391dae78ab1daa698

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Júlio Leonardo B. Pereira
http://lattes.cnpq.br/7687651239699170
http://www.neurocirurgiabr.com

Radiation oncology researchers have revised the system used by doctors since the 1990s to determine the prognosis of people with glioblastoma, which is the most devastating of malignant brain tumors. The outdated system was devised for glioblastoma and related brain tumors that were treated by radiation therapy only, and it relied on clinical signs and symptoms…

http://www.medicalnewstoday.com/releases/245524.php

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Júlio Leonardo B. Pereira
http://lattes.cnpq.br/7687651239699170
http://www.neurocirurgiabr.com

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-7, Ahead of Print.
Object Nonfunctioning pituitary macroadenomas often recur after microsurgery and thereby require further treatment. Gamma Knife surgery (GKS) has been used to treat recurrent adenomas. In this study, the authors evaluated outcomes following GKS of nonfunctioning pituitary macroadenomas and assessed predictors of tumor control, neurological deficits, and delayed hypopituitarism. Methods Between June 1989 and March 2010, 140 consecutive patients with nonfunctioning pituitary macroadenomas were treated using GKS at the University of Virginia. The median patient age was 51 years (range 21–82 years), and 56% of patients were male. Mean tumor volume was 5.6 cm3 (range 0.6–35 cm3). Thirteen patients were treated with GKS as primary therapy, and 127 had undergone at least 1 open resection prior to GKS. Ninety-three patients had a history of hormone therapy prior to GKS. The mean maximal dose of GKS was 38.6 Gy (range 10–70 Gy), the mean marginal dose was 18 Gy (range 5–25 Gy), and the mean number of isocenters was 9.8 (range 1–26). Follow-up evaluations were performed in all 140 patients, ranging from 0.5 to 17 years (mean 5 years, median 4.2 years). Results Tumor volume remained stable or decreased in 113 (90%) of 125 patients with available follow-up imaging. Kaplan-Meier analysis demonstrated radiographic progression free survival at 2, 5, 8, and 10 years to be 98%, 97%, 91%, and 87%, respectively. In multivariate analysis, a tumor volume greater than 5 cm3 (hazard ratio = 5.0, 95% CI 1.5–17.2; p = 0.023) was the only factor predictive of tumor growth. The median time to tumor progression was 14.5 years. Delayed hypopituitarism occurred in 30.3% of patients. No factor was predictive of post-GKS hypopituitarism. A new or worsening cranial nerve deficit occurred in 16 (13.7%) of 117 patients. Visual decline was the most common neurological deficit (12.8%), and all patients experiencing visual decline had evidence of tumor progression. In multivariate analysis, a tumor volume greater than 5 cm3 (OR = 3.7, 95% CI 1.2–11.7; p = 0.025) and pre-GKS hypopituitarism (OR = 7.5, 95% CI 1.1–60.8; p = 0.05) were predictive of a new or worsened neurological deficit. Conclusions In patients with nonfunctioning pituitary macroadenomas, GKS confers a high rate of tumor control and a low rate of neurological deficits. The most common complication following GKS is delayed hypopituitarism, and this occurs in a minority of patients.

http://thejns.org/doi/abs/10.3171/2012.4.JNS112250?ai=ru&mi=0&af=R

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Júlio Leonardo B. Pereira
http://lattes.cnpq.br/7687651239699170
http://www.neurocirurgiabr.com

Journal of Neurosurgery: Spine, Volume 0, Issue 0, Page 1-8, Ahead of Print.
Object The authors compared the effectiveness of single-session (SS) and multisession (MS) stereotactic radiosurgery (SRS) for the treatment of spinal metastases. Methods The authors conducted a retrospective review of the clinical outcomes of 348 lesions in 228 patients treated with the CyberKnife radiosurgery at the University of Pittsburgh Cancer Institute and Georgetown University Medical Center. One hundred ninety-five lesions were treated using an SS treatment regimen (mean 16.3 Gy), whereas 153 lesions were treated using an MS approach (mean 20.6 Gy in 3 fractions, 23.8 Gy in 4 fractions, and 24.5 Gy in 5 fractions). The primary end point was pain control. Secondary end points included neurological deficit improvement, toxicity, local tumor control, need for retreatment, and overall survival. Results Pain control was significantly improved in the SS group (SSG) for all measured time points up to 1 year posttreatment (100% vs 88%, p = 0.003). Rates of toxicity and neurological deficit improvement were not statistically different. Local tumor control was significantly better in the MS group (MSG) up to 2 years posttreatment (96% vs 70%, p = 0.001). Similarly, the need for retreatment was significantly lower in the MSG (1% vs 13%, p < 0.001). One-year overall survival was significantly greater in the MSG than the SSG (63% vs 46%, p = 0.002). Conclusions Single-session and MS SRS regimens are both effective in the treatment of spinal metastases. While an SS approach provides greater early pain control and equivalent toxicity, an MS approach achieves greater tumor control and less need for retreatment in long-term survivors.

http://thejns.org/doi/abs/10.3171/2012.4.SPINE11902?ai=rt&mi=0&af=R

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Júlio Leonardo B. Pereira
http://lattes.cnpq.br/7687651239699170
http://www.neurocirurgiabr.com

Abstract The purpose of this prospective study is to evaluate the efficacy and limitations of two-session Gamma Knife radiosurgery (GKS) alone for large metastatic brain tumors. Inclusion criteria were as follows: (i) patients with large metastatic brain tumors (volume >15 cm3 in the supratentorial region or >10 cm3 in the infratentorial region), and (ii) tumors not causing clinical signs of impending cerebral herniation. Twenty-eight lesions in 27 consecutive patients (18 men and 9 women, age range 32 to 88 years, median age 65 years) were included in this study. The radiosurgical protocol was as follows: 20–30 Gy given in two fractions 3–4 weeks apart. The local tumor control rate and the overall survival rate were calculated by using the Kaplan–Meier method. Median tumor volumes were 17.8 cm3 at first GKS and 9.7 cm3 at second GKS. Median follow-up time was 8.9 months. The local control rate was 85 % at 6 months and 61 % at 12 months. The overall survival rate after GKS was 63 % at 6 months and 45 % at 12 months. The 1-year rate of prevention of neurological death was maintained at 78 %. Mean Karnofsky performance status (KPS) improved from 61 [95 % confidence interval (CI), 57–71] at first GKS to 80 (95 % CI, 74–85) at second GKS; the best follow-up mean KPS was 85 (95 % CI, 78–91) (p < 0.001). Local tumor recurrence necessitated craniotomy in two patients and repeat GKS in three patients. Seventeen patients died, and the causes of death were as follows: 3 from local progression, 2 from meningeal carcinomatosis, and 12 from progression of the primary tumor. Delayed symptomatic perilesional edema developed in one patient and eventually resolved with conservative treatment. Two-session GKS for large brain metastases appears to be an effective treatment in terms of both local tumor control and neurological palliation with minimal treatment-related morbidity. These data suggest that two-session GKS could be used as an alternative to surgical resection of large tumors in patients with significant comorbidity and/or at an advanced age. The optimum regimen for dose and fraction schedule remains to be established.

• Content Type Journal Article
• Category Clinical Study
• Pages 1-7
• DOI 10.1007/s11060-012-0882-8
• Authors
  • Shoji Yomo, Saitama Gamma Knife Center, San-ai Hospital, 4-35-17 Tajima Sakura-ku, Saitama, 338-0837 Japan
  • Motohiro Hayashi, Saitama Gamma Knife Center, San-ai Hospital, 4-35-17 Tajima Sakura-ku, Saitama, 338-0837 Japan
  • Claire Nicholson, Regional Neurosciences Centre, Newcastle upon Tyne, UK

• Journal Journal of Neuro-Oncology
• Online ISSN 1573-7373
• Print ISSN 0167-594X

http://www.springerlink.com/content/k1p163301r30h1km/

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Júlio Leonardo B. Pereira
http://lattes.cnpq.br/7687651239699170
http://www.neurocirurgiabr.com

Abstract Gamma knife radiosurgery (GKRS) is an important additional strategy for unresected clinically active pituitary adenomas. Radiosurgery for acromegaly aims to achieve tumor growth control and endocrine remission, potentially obviating the need for lifetime medication suppression therapy. Forty patients with clinically active acromegaly underwent GKRS between 1988 and 2009. Thirty-four patients had undergone prior surgical resection. The median follow-up interval was 72 months (range 24–145). Endocrine remission was defined as growth hormones (GH) level <2.5 ng/ml and a normal insulin-like growth factor 1 (IGF-1) level (age and sex adjusted) off growth hormone inhibiting drugs for at least 3 months. Endocrine control was defined as normal GH and IGF-1 levels on suppression medication. Endocrine remission was achieved in 19 (47.5 %) patients and endocrine control in four additional (10.0 %) patients. Patients with lower IGF-1 level and with tumors that were less invasive of the cavernous sinus before GKRS were associated with better GH remission rates. Imaging-defined local tumor control was achieved in 39 (97.5 %) patients (27 had tumor regression). One patient with delayed tumor progression underwent a second GKRS procedure. Three other patients had repeat GKRS because of persistently elevated and clinically symptomatic GH and IGF-1 levels. Sixteen (40.0 %) patients eventually developed a new pituitary axis deficiency at a median onset of 36 months after radiosurgery. No patient developed new visual dysfunction. Gamma knife radiosurgery, which is most often applied in clinically symptomatic acromegaly persistent after initial microsurgery, was most effective when the tumor was less invasive of the cavernous sinus and when patients had lower IGF-1 levels before GKRS. Almost one half of the patients no longer required long term medication suppression.

• Content Type Journal Article
• Category Clinical Study
• Pages 1-9
• DOI 10.1007/s11060-012-0862-z
• Authors
  • Xiaomin Liu, Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, USA
  • Hideyuki Kano, Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, USA
  • Douglas Kondziolka, Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, USA
  • Kyung-Jae Park, Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, USA
  • Aditya Iyer, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
  • Ajay Niranjan, Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, USA
  • John C. Flickinger, Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
  • L. Dade Lunsford, Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, USA

• Journal Journal of Neuro-Oncology
• Online ISSN 1573-7373
• Print ISSN 0167-594X

http://www.springerlink.com/content/x3rn7w86434k92h2/

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Júlio Leonardo B. Pereira
http://lattes.cnpq.br/7687651239699170
http://www.neurocirurgiabr.com

Won Kim, Claire Clelland, Isaac Yang, Nader Pouratian

Surgical Neurology International 2012 3(3):79-89

Despite advances in surgical techniques and medical therapies, a significant proportion of pituitary adenomas remain endocrinologically active, demonstrate persistent radiographic disease, or recur when followed for long periods of time. While surgical intervention remains the first-line therapy, stereotactic radiosurgery is increasingly recognized as a viable treatment option for these often challenging tumors. In this review, we comprehensively review the literature to evaluate both endocrinologic and radiographic outcomes of radiosurgical management of pituitary adenomas. The literature clearly supports the use of radiosurgery, with endocrinologic remission rates and time to remission varying by tumor type [prolactinoma: 20-30%, growth hormone secreting adenomas: ~50%, adrenocorticotrophic hormone (ACTH)-secreting adenomas: 40-65%] and radiographic control rates almost universally greater than 90% with long-term follow-up. We stratify the outcomes by tumor type, review the importance of prognostic factors (particularly, pre-treatment endocrinologic function and tumor size), and discuss the complications of treatment (with special attention to endocrinopathy and visual complications). We conclude that the literature supports the use of radiosurgery for treatment-refractory pituitary adenomas, providing the patient with a minimally invasive, safe, and effective treatment option for an otherwise resistant tumor. As such, we provide literature-based treatment considerations, including radiosurgical dose, endocrinologic, radiographic, and medical considerations for each adenoma type.

http://www.surgicalneurologyint.com/article.asp?issn=2152-7806;year=2012;volume=3;issue=3;spage=79;epage=89;aulast=Kim

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Júlio Leonardo B. Pereira
http://lattes.cnpq.br/7687651239699170
http://www.neurocirurgiabr.com

Andres R Plasencia, Alejandro Santillan

Surgical Neurology International 2012 3(3):90-104

The treatment of arteriovenous malformations (AVMs) requires a multidisciplinary management including microsurgery, endovascular embolization, and stereotactic radiosurgery (SRS). This article reviews the recent advancements in the multimodality treatment of patients with AVMs using endovascular neurosurgery and SRS. We describe the natural history of AVMs and the role of endovascular and radiosurgical treatment as well as their interplay in the management of these complex vascular lesions. Also, we present some representative cases treated at our institution.

http://www.surgicalneurologyint.com/article.asp?issn=2152-7806;year=2012;volume=3;issue=3;spage=90;epage=104;aulast=Plasencia

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Júlio Leonardo B. Pereira
http://lattes.cnpq.br/7687651239699170
http://www.neurocirurgiabr.com

Huan-Chih Wang, Rachel J Chang, Furen Xiao

Surgical Neurology International 2012 3(3):105-110

Cerebral arteriovenous malformations (AVMs) are abnormal connections between the arteries and veins, with possible serious consequences of intracranial hemorrhage. The curative treatment for AVMs includes microsurgery and radiosurgery, sometimes with embolization as an adjunct. However, controversies exist with the treatment options available for large to giant AVMs. Hypofractionated stereotactic radiotherapy (HSRT) is one treatment option for such difficult lesions. We aim to review recent literature, looking at the treatment outcome of HSRT in terms of AVM obliteration rate and complications. The rate of AVM obliteration utilizing HSRT as a primary treatment was comparable with that of stereotactic radiosurgery (SRS). For those not totally obliterated, HSRT makes them smaller and turns some lesions manageable by single-dose SRS or microsurgery. Higher doses per fraction seemed to exhibit better response. However, patients receiving higher total dose may be at risk for higher rates of complications. Fractionated regimens of 7 Gy × 4 and 6-6.5 Gy × 5 may be accepted compromises between obliteration and complication. Embolization may not be beneficial prior to HSRT in terms of obliteration rate or the volume reduction. Future work should aim on a prospectively designed study for larger patient groups and long-term follow-up results.

http://www.surgicalneurologyint.com/article.asp?issn=2152-7806;year=2012;volume=3;issue=3;spage=105;epage=110;aulast=Wang

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Júlio Leonardo B. Pereira
http://lattes.cnpq.br/7687651239699170
http://www.neurocirurgiabr.com