Linac radiosurgery for skull base meningiomas

INTRODUCTION

Skull base meningiomas present a difficult surgical challenge because of the high potential morbidity of radical surgical extirpation and their low potential for incapacitating symptomatology. The focal character of meningiomas makes stereotactic radiosurgery an attractive adjuvant treatment modality to resection. The purpose of this study was to evaluate the local control rates and complications in 56 patients with base of skull meningiomas undergoing radiosurgery.

METHODS

Patients underwent radiosurgery using the dedicated stereotactic linear accelerator at the Brigham and Women's Hospital. Minimal peripheral doses of radiosurgery ranged from 12 to 18.5 Gy (mean 15 Gy). Doses were designed to conform to the frequently irregular tumor volumes using the X-Knife treatment planning system. Multiple isocenters were used when required to increase conformality of dose. For 36 patients (64%), radiosurgery was used as an adjunct to surgery; for 20 patients (36%) it was the primary treatment.

RESULTS

Median followup was five years. Nineteen patients (34%) were improved clinically at follow-up; 32 (57%) were unchanged; and 5 patients (9%) developed new or worsened neurologic deficits. Serial imaging studies after radiosurgery showed a reduction in tumor volume in 23 patients (41%); 30 (54%) showed stable disease; 3 patients (5%) had tumors which increased in size (2 being outside the radiosurgery treatment site). The actuarial freedom from progression rate (defined as further tumor growth) was thus 95%, with a median imaging follow-up of 26 months (range, 6-66 months). Although further follow-up is necessary, the results of this series clearly demonstrate that these lesions are feasible for treatment by modern radiosurgical techniques. Linac radiosurgery can stabilize skull base meningiomas, with decreased or unchanged tumor volumes on radiologic follow-up in approximately 95% of patients. Radiosurgery is a low-morbidity, effective technique as adjunct and sometimes primary treatment of small to moderate-sized meningiomas of the skull base.

Optimizing brain tumor resection. Midfield interventional MR imaging

The development of the intraoperative MR imager represents an important example of creative vision and interdisciplinary teamwork. The result is a remarkable tool for neurosurgical applications. MRT allows surgical manipulation under direct visualization of the intracranial contents through the eye of the surgeon and through the volumetric images of the MR imaging system. This technology can be applied to cranial and spinal cases, and forseeably can encompass application to the entire gamut of neurosurgical efforts. The author's experience has been that this device is easy and comfortable for the surgeon to use. Image acquisition, giving views in the plane of choice, lasts no more than 2 to 60 seconds (depending on the imaging method), and does not increase the duration of a given procedure substantially. The author believes that the information received through intraoperative MR imaging scanning ultimately will contribute to decreasing the duration of surgery. Future possibilities include combining the intraoperative MR imager with other technologies, such as the endoscope, focused ultrasound, robotics, and the evaluation of brain function intraoperatively. The development of the intraoperative MR imager marks a significant advance in neurosurgery, an advance that will revolutionize intraoperative visualization as fully as the operating microscope. The combination of intraoperative visualization and precise surgical navigation is unparalleled, and its enhancement of surgical applications will be widespread. Considering the remarkable potential of the intraoperative MR imager for neurosurgical applications, optimal magnet design, image quality, and navigational methods are necessary to capitalize on the advantages of this revolutionary tool. The intraoperative MR imaging system that the author's team has developed and used has combined these features, and allows the performance of open surgical procedures without the need of patient or magnet repositioning. By using advanced navigational tools and computer technology, it represents an integration of frameless stereotactic methods with real-time interactive imaging. The midfield imager provides sufficient spatial and temporal resolution and image quality to assess anatomy and pathology adequately, to monitor a surgical procedure, and make image-based decisions. The intraoperative use of this unique system is not limited to biopsies or limited-access procedures. The entire range of neurosurgical procedures can be performed, if the requisite instrumentation is available. Much work remains to be done, however. The team did not develop this system only to enable the performance of current neurosurgical procedures. Forty years ago, the operating microscope enabled not only the performance of undreamt-of procedures but opened the door to entire new subspecialties. The entire landscape of neurosurgery will change at a fundamental level as the full ramifications of this exciting idea come to fruition. The holy grail of image-guided surgery is a seamless interface between the eye and hand in the purest sense (i.e., the mind's eye and hand). Ideally, this seamless interface represents effortless flow between the procedural goal compared with the present situation and the manipulation of the tools available to accomplish the task, whether they be the scalpel, drill, laser, ultrasonic aspirator, phased array focused ultrasound, microrobot, or high-dose irradiator. As in the realm of high-performance military jet fighters, the physical limits of the human being demarcate the confining boundary of the system. Those limits are much tighter around the domain of tool manipulation, where the surgeon will yield, early on, to the enhanced performance of robotics and other technical adjuncts. The era of large open magnet imaging systems for surgical procedures then will come to a close; however, the grander era of the surgeon's integration of precision-guided, multimodality therapeutics will just be beginning. The future will be very bright, indeed.

Clear cell pleomorphic xanthoastrocytoma: case report

Pleomorphic xanthoastrocytoma (PXA) is a well-described astrocytic neoplasm with distinctive clinical and pathological features. Although most patients with PXAs are cured by surgical excision, other patients experience malignant progression and tumor recurrence. We describe a 47-year-old woman with a left temporal lobe PXA that had classic histopathological characteristics as well as extensive clear cell and focal papillary changes, and some anaplastic findings. The patient has now suffered two recurrences after complete resection. The case illustrates a rare, previously undescribed histological variant of PXA, with a prominent clear cell and focal papillary morphology. The study of histologically similar cases is needed to determine whether this variant is always associated with a greater likelihood of recurrence.

[The efficacy of an individualized treatment schedule to maintain treatment adherence in an urban community mental health center]

OBJECTIVE

We present an observational study on the efficacy of an individualized treatment schedule, which is meant to support treatment adherence in an urban community mental health center (CMHC).

METHODS

The present investigation was carried out in the natural setting of a CMHC in Vienna. During a 3-month period we observed the compliance with the appointments and the actions taken by the team in response to missed appointments as well as the utilization of the CMHC during a follow-up period of 6 months.

RESULTS

During the observation period 393 (19,2 %) of 2049 scheduled visits were missed affecting more than half of the patients. Only a minority of patients with low-intensity treatment and a high rate of missed appointments had a high risk for discontinuing treatment.

CONCLUSIONS

Missed appointments in outpatient psychiatric care are a common phenomenon but they constitute no major threat to the continuity of care for the majority of the patients due to the graduated efforts of the team. The time required to make up for missed appointments is considerable but the results of the follow-up confirmed the beneficial effects on utilization of psychiatric care.

Radiosurgery in the management of pediatric brain tumors

OBJECTIVE

To describe the outcome of pediatric brain tumor patients following stereotactic radiosurgery (SRS), and factors associated with progression-free survival.

METHODS

We reviewed the outcome of 90 children treated with SRS for recurrent (n = 62) or residual (n = 28) brain tumors over a 10-year period. Median follow-up from SRS was 24 months for all patients and 55.5 months for the 34 patients currently alive.

RESULTS

The median progression-free survival (PFS) for all patients was 13 months. Median PFS according to tumor histology was medulloblastoma = 11 months, ependymoma = 8.5 months, glioblastoma and anaplastic astrocytoma = 12 months. Median PFS in patients treated to a single lesion was 15.4 months. No patient undergoing SRS to more than 1 lesion survived disease free beyond 2 years. After adjusting for histology and other clinical factors, SRS for tumor recurrence (RR = 2.49) and the presence of > 1 lesion (RR = 2.3) were associated with a significantly increased rate of progression (p < 0.05). Three-year actuarial local control (LC) was as follows: medulloblastoma = 57%, ependymoma = 29%, anaplastic astrocytoma/glioblastoma = 60%, other histologies = 56%. Nineteen patients with radionecrosis and progressive neurologic symptoms underwent reoperation after an interval of 0.6-62 months following SRS. Pathology revealed necrosis with no evidence of tumor in 9 of these cases.

CONCLUSION

SRS can be given safely to selected children with brain tumors. SRS appears to reduce the proportion of first failures occurring locally and is associated with better outcome when given as a part of initial management. Some patients with unresectable relapsed disease can be salvaged with SRS. SRS to multiple lesions does not appear to be curative. Serious neurologic symptoms requiring reoperation is infrequently caused by radionecrosis alone.

The case for radiosurgery

Brain metastases represent a significant health-care problem, with almost 200,000 patient in the Unite States annually suffering from symptomatic parenchymal lesions. Lung, breast, melanoma, renal, and gastrointestinal cancers contribute the majority of lesions that come to clinical attention. Although median survival once brain metastases are diagnosed is less than a year, timely therapy can restore neurological function and can often prevent further neurological complications of cancer for the duration of a patient's survival. Important prognostic features associated with improved survival include the absence of extracranial disease progression, young age, a high pretreatment neurological status, one to three versus more than three lesions, and a long interval from primary disease diagnosis to the development of brain metastases. The need to aggressively treat brain metastases effectively is becoming increasingly important, however, as advances in the treatment of systemic disease result in an increasing number of patients developing brain metastases in the setting of limited systemic disease. For many such patients, surgery provides the best therapy, but results are still not encouraging because even patients with the best prognostic indicators often die within 18 to 24 months. Until Superior treatment modalities are developed, the judicious use of available techniques for treatment of patients with limited systemic disease provides the best opportunities for palliation and extended survival. Perhaps the most significant development in the treatment of patients with brain metastases during the last decade is the increasing use of radiosurgery. For patients with a single lesion, local control and survival rates of radiosurgery compare well with those produced with surgical resection. Radiosurgery remains an important treatment modality and, when used promptly, can reverse neurological deficits, often for the remainder of a patients life. There is compelling evidence to suggest that aggressive local therapy (surgery or radiosurgery) for patients with a single brain metastasis produces superior survival and quality of life compared with treatment with whole brain radiotherapy alone. However, surgery should be restricted to the minority of patients for whom brain metastases represents the life-threatening site of their disease. For an asymptomatic or mildly symptomatic patient with a lesion smaller than 3 cm in diameter, radiosurgery is an excellent alternative to surgery. Although radiosurgery is a noninvasive procedure, the same selection criteria should be considered as for those patients undergoing surgical resection.

The present and future role of intraoperative MRI in neurosurgical procedures

OBJECTIVE

We have worked in conjunction with scientists from the General Electric Corporation over 6 years to develop an open-bore MR imaging system (0.5 T) enabling optimal vertical access of surgeon and assistant to the patient, and real-time imaging during major neurosurgical procedures.

METHODS

The intraoperative MR system (MRT) is located in a specially modified operative suite that combines the features of an MR-imaging suite with a fully functional operating room. An MR-compatible anesthesia machine and patient-monitoring device are located next to the magnet. The position of instruments, platforms and supports may be mapped in the operative field using 3 charge-coupled device video cameras mounted in the overhead support truncheon that follow various light-emitting diodes on the devices (Pixsys). The MR image plane can be defined as the axial, coronal or sagittal views through a point along the vector beneath the Pixsys tripod. A variety of surface coils were designed to take full advantage of full open patient access. The software, implemented by a technologist located outside the MR room, is now equivalent to that available on the commercial 0.5-tesla Signa Advantage system. Development of very robust 3-dimensional software in conjunction with the Surgical Planning Laboratory (SPL) at the Brigham & Women's Hospital is the subject of significant effort. The MRT system has been shown to possess imaging capabilities comparable, or even slightly superior (by 10%), to a conventional 0.5-tesla MR scanner. Two modified liquid-crystal display screens are mounted on the magnet housing for the surgeon to monitor the images during the procedures. Projection into larger screens or the operating microscope is under development.

RESULTS

We have performed 110 neurosurgical cases in MRT as of January 29, 1997, including 47 biopsies, 6 catheter placements, 4 cyst drainages, 47 craniotomies for resection, 3 spinal cases (1 syrinx drainage), and 3 laser tumor ablations.

CONCLUSIONS

MRT is especially useful in guiding biopsies and resections near cysts, ventricles and critical vascular structures where preoperative images with framed/frameless techniques would be inadequate to show anatomic changes during the procedure. Real-time images of a biopsy needle within the abnormal area are very useful in cases of subtle pathologic change. More complete resection of infiltrative tumor is readily accomplished. SPL image fusion of SPECT and neurofunctional data (e.g. from magnetic stimulation preoperatively) into the imaging space enables the surgeon to better visualize tumor invasion or neural function in real-time imaging during resection. Imaging of thermal gradients for cryoprobe or laser ablation, and combination with endoscopy and robotics will offer additional benefit in the performance of difficult neurosurgical procedures.

Disease concomitance in psoriasis: a clinical study of 61 cases

Sixty-one patients with psoriasis were studied for concomitant diseases and compared with 61 age and sex-matched controls. Concomitant cutaneous diseases most often seen with psoriasis were lichen simplex chronicus (16.3%), verruca vulgaris (9.8%) and me Iasina (4.9%). Of the systemic disorders, diabetes showed the highest frequency (13.1%) followed by hypertension (8.1%). Two patients had HIV infection (3.2%). Both the patients had severe and atypical lesions.

Spinal neurenteric cysts and their relation to more common aspects of occult spinal dysraphism

Object

Neurenteric cysts are infrequently reported congenital abnormalities believed to be derived from an abnormal connection between the primitive endoderm and ectoderm. The authors report a series of 13 patients treated over a 50-year period.

Methods

Of the 13 patients, seven were female and six were male. Their ages at presentation ranged widely from 5 weeks to 52 years of age. Children presented more commonly with cutaneous stigmata of occult spinal dysraphism (OSD) whereas adults presented primarily with pain. Neurological deficit as a presenting symptom was less common in our series, a finding that reflects the slow growth of these lesions. In all but one patient some form of vertebral anomaly was associated with the cystic lesions, including two patients with Klippel–Feil abnormalities. There was a high incidence of associated forms of OSD including split cord malformation, lipoma, dermal sinus tract, and tethered spinal cord. In previous reports the authors have suggested that neurenteric cysts are more common in the cervical region and in a position ventral to the cord. In the present series these cysts most commonly occurred as intradural, extramedullary masses in the thoracolumbar region, situated dorsal to the spinal cord. The median follow-up period was 7.5 years, and postoperative outcome reflected a patient's preoperative neurological status; in no patient was outcome worsened due to surgery.

Conclusions

Complete excision of the neurenteric cyst remains the treatment of choice, as subtotal excision is associated with recurrence.

Frameless stereotactic neurosurgery using intraoperative magnetic resonance imaging: stereotactic brain biopsy

OBJECTIVE

To assess the application accuracy of intraoperative magnetic resonance imaging for frameless stereotactic surgery, and to evaluate the performance of intraoperative magnetic resonance imaging for the brain biopsy, a standard stereotactic procedure.

METHODS

A series of spatial coordinate and phantom experiments were performed to analyze the application accuracy of the system. A prospective analysis of 68 consecutive patients undergoing stereotactic brain biopsy was then performed.

RESULTS

The spatial coordinate experiments revealed a mean overall error in acquisition of 0.2 mm. The phantom experiments demonstrated a 1:1 correlation between the magnetic resonance image of a stereotactically guided probe and its relationship to a target and the actual relationship of the probe and target. Sixty-eight brain biopsies were successfully performed in all intracranial compartments except the sella. The radiographic abnormality was localized successfully in all patients (100%). Sixty-six (97.1%) of the biopsies yielded diagnostic tissue. Two biopsies (2.9%) were complicated by intraparenchymal hemorrhage. One expanding temporal lobe hemorrhage was evacuated by immediate craniotomy in the magnet with no postoperative sequelae. A deep hemorrhage from a lymphoma was managed conservatively with interval resolution of symptoms. There were no infections. There was no perioperative mortality.

CONCLUSION

Intraoperative magnetic resonance imaging allows excellent target localization, provides true real-time imaging to account for anatomic changes during surgery, and permits intraoperative confirmation that the biopsy needle has reached the targeted lesion. Immediate postoperative imaging in the operating room allows assessment of adverse events and the potential for immediate management of hemorrhagic complications.

3131C--World War II neurosurgery

Preparation for surgical care of the wounded in a two-theater war was extensive and skillfully organized by Michael DeBakey, one of the prime advisors to the Surgeon General of the Army, and by his colleague, Eli Ginzberg, Ph.D. Some of the ways in which this organization was carried out are described. Although the number of neurosurgeons who can recall any involvement of neurosurgery in World War II is diminishing, there remain a significant number who do remember such involvement, many of whom have helped to provide information for this article.

World War II: a neurosurgeon in New Guinea

During World War II, many doctors joined the military after completing their medical training. Civilian careers were put on hold until after the war was over. In 1942, Eben Alexander, Jr., joined the Air Force, then the United States Army, and served 4 years, much of it overseas, as a "3131C" neurosurgeon.

Craniotomy for tumor treatment in an intraoperative magnetic resonance imaging unit

OBJECTIVE

The complex three-dimensional anatomic features of the brain and its vulnerability to surgical intervention make the surgical treatment of intracranial tumors challenging. We evaluated the surgical treatment of supratentorial tumors using intraoperative magnetic resonance imaging (MRI), which provides real-time guidance, allows localization of intracranial tumors and their margins, and facilitates continuous assessment of surgical progress.

METHODS

Sixty patients underwent craniotomies for tumor treatment in the General Electric intraoperative MRI unit at the Brigham and Women's Hospital (Boston, MA) during a 1-year period. The patients selected were those with intracranial tumors that were considered difficult to resect because of their locations or previous incomplete operations. Twenty-nine low-grade and 19 high-grade gliomas, 8 metastatic lesions, 2 meningiomas, 1 pineoblastoma, and 1 astroblastoma were resected.

RESULTS

Tumors were accurately localized and targeted, and the extent of resection, as well as any intraoperative complications, could be immediately assessed during surgery. Marked brain shifting occurred during the procedures, and repeated intraoperative imaging allowed surgical accommodation for this shifting. In more than one-third of the cases, intraoperative imaging showed residual tumor when resection appeared complete on the basis of surgical observation alone.

CONCLUSION

Intraoperative MRI is a revolutionary tool for the surgical treatment of brain tumors, providing observation of the procedure as it is being performed. With intraoperative MRI, tumor resection is safer, the extent of resection can be directly evaluated, and intraoperative complications can be noted if they occur. Outcomes after resection depend on minimizing injury to normal brain tissue and achieving maximal tumor resection. The use of intraoperative MRI directly affects these factors.

The viable-but-nonculturable condition is induced by copper in Agrobacterium tumefaciens and Rhizobium leguminosarum

Many bacteria respond to changes in environmental conditions by entering the viable-but-nonculturable state. We have determined that copper can induce nutrient-starved Agrobacterium tumefaciens and Rhizobium leguminosarum cells to become viable but nonculturable. This is the first report of a chemical inducer of this condition.