Radiocirurgia

Abstract To characterize the development of leptomeningeal seeding (LMS) in patients with brain metastases after gamma knife radiosurgery (GKRS). Eight hundred and twenty-seven patients that underwent GKRS as a part of an initial treatment plan for brain metastases between January 2002 and December 2010 were included in the study. Six hundred and fifty patients were treated with GKRS alone and 177 patients received GKRS combined with upfront whole brain radiation therapy (WBRT). Actuarial curves for overall survival (OS) and the development of LMS were plotted using the Kaplan-Meier method. Median overall survival for all patients was 55 weeks (95 % CI, 47.8–62.2), and the overall incidence of LMS was 5.3 %. The actuarial rates for LMS at 6 and 12 months were 3.1 and 5.8, respectively. Uni- and multivariate analysis suggested that breast cancer and a large number of metastases (n ≥ 4) are significant risk factors of LMS (P < 0.05). Regarding treatment modalities, the addition of WBRT was found to have a significant impact on lowering the risk of LMS by multivariate analysis (P = 0.045). LMS is an important pattern of CNS failure. The risk of LMS following GKRS may be associated with multiple lesions, breast cancer, and the omission of WBRT. Additional data from large-scale, randomized controlled trials are required to identify risk factors associated with the LMS more accurately.

• Content Type Journal Article
• Category Clinical Study
• Pages 1-7
• DOI 10.1007/s11060-012-0892-6
• Authors
  • Kyung-Il Jo, Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710 Republic of Korea
  • Do-Hoon Lim, Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
  • Sung-Tae Kim, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
  • Yong-Seok Im, Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710 Republic of Korea
  • Doo Sik Kong, Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710 Republic of Korea
  • Ho Jun Seol, Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710 Republic of Korea
  • Do-Hyun Nam, Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710 Republic of Korea
  • Jung-Il Lee, Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710 Republic of Korea

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

http://www.springerlink.com/content/x53r344538h70207/

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

Purpose: To verify how the classification according to the American Society for Therapeutic Radiation Oncology (ASTRO) consensus statement (CS) for the application of accelerated partial breast irradiation (APBI) fits patients treated with intraoperative radiotherapy with electrons (ELIOT) at a single institution.Methods and Materials: The study included 1,822 patients treated with ELIOT as the sole radiation modality outside of a clinical trial at the European Institute of Oncology after breast-conserving surgery for invasive breast cancer, who were classified into CS groups of suitable, cautionary, and unsuitable. The outcome in terms of ipsilateral breast recurrence, regional node relapse, distant metastases, progression free-survival, cause-specific survival, and overall survival were assessed.Results: All the 1,822 cases except for 25 could be classified according to ASTRO CS: 294 patients met the criteria for inclusion into the suitable group, 691 patients into the cautionary group, and 812 patients into the unsuitable group. The 5-year rate of ipsilateral breast recurrence for suitable, cautionary, and unsuitable groups were 1.5%, 4.4%, and 8.8%, respectively (p = 0.0003). Whereas the regional node relapse showed no difference, the rate of distant metastases was significantly different in the unsuitable group compared with the suitable and cautionary groups, having a significant impact on survival.Conclusion: In the context of patients treated with ELIOT, the ASTRO guidelines identify well the groups for whom APBI might be considered as an effective alternative to whole breast radiotherapy and also identify groups for whom APBI is not indicated.

http://www.redjournal.org/article/PIIS0360301611031683/abstract?rss=yes

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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 1-9, Ahead of Print.
Object To better establish the role of stereotactic radiosurgery (SRS) in treating patients with 10 or more intracranial metastases, the authors assessed clinical outcomes and identified prognostic factors associated with survival and tumor control in patients who underwent radiosurgery using the Leksell Gamma Knife Perfexion (LGK PFX) unit. Methods The authors retrospectively reviewed data in all patients who had undergone LGK PFX surgery to treat 10 or more brain metastases in a single session at the University of Pittsburgh. Posttreatment imaging studies were used to assess tumor response, and patient records were reviewed for clinical follow-up data. All data were collected by a neurosurgeon who had not participated in patient care. Results Sixty-one patients with 10 or more brain metastases underwent SRS for the treatment of 806 tumors (mean 13.2 lesions). Seven patients (11.5%) had no previous therapy. Stereotactic radiosurgery was the sole prior treatment modality in 8 patients (13.1%), 22 (36.1%) underwent whole-brain radiation therapy (WBRT) only, and 16 (26.2%) had prior SRS and WBRT. The total treated tumor volume ranged from 0.14 to 40.21 cm3, and the median radiation dose to the tumor margin was 16 Gy. The median survival following SRS for 10 or more brain metastases was 4 months, with improved survival in patients with fewer than 14 brain metastases, a nonmelanomatous primary tumor, controlled systemic disease, a better Karnofsky Performance Scale score, and a lower recursive partitioning analysis (RPA) class. Prior cerebral treatment did not influence survival. The median survival for a patient with fewer than 14 brain metastases, a nonmelanomatous primary tumor, and controlled systemic disease was 21.0 months. Sustained local tumor control was achieved in 81% of patients. Prior WBRT predicted the development of new adverse radiation effects. Conclusions Stereotactic radiosurgery safely and effectively treats intracranial disease with a high rate of local control in patients with 10 or more brain metastases. In patients with fewer metastases, a nonmelanomatous primary lesion, controlled systemic disease, and a low RPA class, SRS may be most valuable. In selected patients, it can be considered as first-line treatment.

http://thejns.org/doi/abs/10.3171/2012.4.JNS11870?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, Volume 0, Issue 0, Page 1-11, Ahead of Print.
Object In this paper the authors’ goal was to define the long-term benefits and risks of stereotactic radiosurgery (SRS) for patients with arteriovenous malformations (AVMs) who underwent prior embolization. Methods Between 1987 and 2006, the authors performed Gamma Knife surgery in 996 patients with brain AVMs; 120 patients underwent embolization followed by SRS. In this series, 64 patients (53%) had at least one prior hemorrhage. The median number of embolizations varied from 1 to 5. The median target volume was 6.6 cm3 (range 0.2–26.3 cm3). The median margin dose was 18 Gy (range 13.5–25 Gy). Results After embolization, 25 patients (21%) developed symptomatic neurological deficits. The overall rates of total obliteration documented by either angiography or MRI were 35%, 53%, 55%, and 59% at 3, 4, 5, and 10 years, respectively. Factors associated with a higher rate of AVM obliteration were smaller target volume, smaller maximum diameter, higher margin dose, timing of embolization during the most recent 10-year period (1997–2006), and lower Pollock-Flickinger score. Nine patients (8%) had a hemorrhage during the latency period, and 7 patients died of hemorrhage. The actuarial rates of AVM hemorrhage after SRS were 0.8%, 3.5%, 5.4%, 7.7%, and 7.7% at 1, 2, 3, 5, and 10 years, respectively. The overall annual hemorrhage rate was 2.7%. Factors associated with a higher risk of hemorrhage after SRS were a larger target volume and a larger number of prior hemorrhages. Permanent neurological deficits due to adverse radiation effects (AREs) developed in 3 patients (2.5%) after SRS, and 1 patient had delayed cyst formation 210 months after SRS. No patient died of AREs. A larger 12-Gy volume was associated with higher risk of symptomatic AREs. Using a case-control matched approach, the authors found that patients who underwent embolization prior to SRS had a lower rate of total obliteration (p = 0.028) than patients who had not undergone embolization. Conclusions In this 20-year experience, the authors found that prior embolization reduced the rate of total obliteration after SRS, and that the risks of hemorrhage during the latency period were not affected by prior embolization. For patients who underwent embolization to volumes smaller than 8 cm3, success was significantly improved. A margin dose of 18 Gy or more also improved success. In the future, the role of embolization after SRS should be explored.

http://thejns.org/doi/abs/10.3171/2012.4.JNS111935?ai=ru&mi=0&af=R

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

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