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Lehrer EJ, Khosla AA, Ozair A, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Mathieu D, Trudel C, Deibert CP, Malouff TD, Ruiz-Garcia H, Peterson JL, Patel S, Bonney P, Hwang L, Yu C, Zada G, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Fakhoury KR, Rusthoven CG, Dickstein DR, Sheehan JP, Trifiletti DM, Ahluwalia MS. Immune checkpoint inhibition and single fraction stereotactic radiosurgery in brain metastases from non-small cell lung cancer: an international multicenter study of 395 patients. J Neurooncol 2023; 165:63-77. [PMID: 37889444 DOI: 10.1007/s11060-023-04413-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/02/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE Approximately 80% of brain metastases originate from non-small cell lung cancer (NSCLC). Immune checkpoint inhibitors (ICI) and stereotactic radiosurgery (SRS) are frequently utilized in this setting. However, concerns remain regarding the risk of radiation necrosis (RN) when SRS and ICI are administered concurrently. METHODS A retrospective study was conducted through the International Radiosurgery Research Foundation. Logistic regression models and competing risks analyses were utilized to identify predictors of any grade RN and symptomatic RN (SRN). RESULTS The study included 395 patients with 2,540 brain metastases treated with single fraction SRS and ICI across 11 institutions in four countries with a median follow-up of 14.2 months. The median age was 67 years. The median margin SRS dose was 19 Gy; 36.5% of patients had a V12 Gy ≥ 10 cm3. On multivariable analysis, V12 Gy ≥ 10 cm3 was a significant predictor of developing any grade RN (OR: 2.18) and SRN (OR: 3.95). At 1-year, the cumulative incidence of any grade and SRN for all patients was 4.8% and 3.8%, respectively. For concurrent and non-concurrent groups, the cumulative incidence of any grade RN was 3.8% versus 5.3%, respectively (p = 0.35); and for SRN was 3.8% vs. 3.6%, respectively (p = 0.95). CONCLUSION The risk of any grade RN and symptomatic RN following single fraction SRS and ICI for NSCLC brain metastases increases as V12 Gy exceeds 10 cm3. Concurrent ICI and SRS do not appear to increase this risk. Radiosurgical planning techniques should aim to minimize V12 Gy.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Atulya A Khosla
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Ahmad Ozair
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | | | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA, USA
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Piero Picozzi
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Andrea Franzini
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Luca Attuati
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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Rusthoven CG, Staley AW, Gao D, Yomo S, Bernhardt D, Wandrey N, El Shafie R, Kraemer A, Padilla O, Chiang V, Faramand AM, Palmer JD, Zacharia BE, Wegner RE, Hattangadi-Gluth JA, Levy A, Bernstein K, Mathieu D, Cagney DN, Chan MD, Grills IS, Braunstein S, Lee CC, Sheehan JP, Kluwe C, Patel S, Halasz LM, Andratschke N, Deibert CP, Verma V, Trifiletti DM, Cifarelli CP, Debus J, Combs SE, Sato Y, Higuchi Y, Aoyagi K, Brown PD, Alami V, Niranjan A, Lunsford LD, Kondziolka D, Camidge DR, Kavanagh BD, Robin TP, Serizawa T, Yamamoto M. Comparison of first-line radiosurgery for small-cell and non-small cell lung cancer brain metastases (CROSS-FIRE). J Natl Cancer Inst 2023; 115:926-936. [PMID: 37142267 PMCID: PMC10407696 DOI: 10.1093/jnci/djad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/23/2023] [Accepted: 04/28/2023] [Indexed: 05/06/2023] Open
Abstract
INTRODUCTION Historical reservations regarding stereotactic radiosurgery (SRS) for small-cell lung cancer (SCLC) brain metastases include concerns for short-interval and diffuse central nervous system (CNS) progression, poor prognoses, and increased neurological mortality specific to SCLC histology. We compared SRS outcomes for SCLC and non-small cell lung cancer (NSCLC) where SRS is well established. METHODS Multicenter first-line SRS outcomes for SCLC and NSCLC from 2000 to 2022 were retrospectively collected (n = 892 SCLC, n = 4785 NSCLC). Data from the prospective Japanese Leksell Gamma Knife Society (JLGK0901) clinical trial of first-line SRS were analyzed as a comparison cohort (n = 98 SCLC, n = 814 NSCLC). Overall survival (OS) and CNS progression were analyzed using Cox proportional hazard and Fine-Gray models, respectively, with multivariable adjustment for cofactors including age, sex, performance status, year, extracranial disease status, and brain metastasis number and volume. Mutation-stratified analyses were performed in propensity score-matched retrospective cohorts of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) positive NSCLC, mutation-negative NSCLC, and SCLC. RESULTS OS was superior for patients with NSCLC compared to SCLC in the retrospective dataset (median OS = 10.5 vs 8.6 months; P < .001) and in the JLGK0901 dataset. Hazard estimates for first CNS progression favoring NSCLC were similar in both datasets but reached statistical significance in the retrospective dataset only (multivariable hazard ratio = 0.82, 95% confidence interval = 0.73 to 0.92, P = .001). In the propensity score-matched cohorts, there were continued OS advantages for NSCLC patients (median OS = 23.7 [EGFR and ALK positive NSCLC] vs 13.6 [mutation-negative NSCLC] vs 10.4 months [SCLC], pairwise P values < 0.001), but no statistically significant differences in CNS progression were observed in the matched cohorts. Neurological mortality and number of lesions at CNS progression were similar for NSCLC and SCLC patients. Leptomeningeal progression was increased in patients with NSCLC compared to SCLC in the retrospective dataset only (multivariable hazard ratio = 1.61, 95% confidence interval = 1.14 to 2.26, P = .007). CONCLUSIONS After SRS, SCLC histology was associated with shorter OS compared to NSCLC. CNS progression occurred earlier in SCLC patients overall but was similar in patients matched on baseline factors. SCLC was not associated with increased neurological mortality, number of lesions at CNS progression, or leptomeningeal progression compared to NSCLC. These findings may better inform clinical expectations and individualized decision making regarding SRS for SCLC patients.
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Affiliation(s)
- Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alyse W Staley
- University of Colorado Cancer Center, Biostatistics Core, Aurora, CO, USA
| | - Dexiang Gao
- University of Colorado Cancer Center, Biostatistics Core, Aurora, CO, USA
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Division of Radiation Oncology, Aizawa Hospital, Matsumoto, Japan
| | - Denise Bernhardt
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany
| | - Narine Wandrey
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rami El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Radiation Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Anna Kraemer
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Oscar Padilla
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, USA
| | - Veronica Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew M Faramand
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Comprehensive Cancer Center at The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | | | - Antonin Levy
- Department of Radiation Oncology, Gustave Roussy, Villejuif, Université Paris Saclay, France
| | - Kenneth Bernstein
- Department of Radiation Oncology, New York University Langone Medical Center, New York, NY, USA
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Daniel N Cagney
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Cheng-Chia Lee
- Taipei Veterans General Hospital, Department of Neurosurgery, Neurological Institute, Taipei, Taiwan
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Christien Kluwe
- Department of Radiation Oncology, Vanderbilt University, Nashville, TN, USA
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich (USZ), The University of Zurich, Zurich, Switzerland
| | | | - Vivek Verma
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | | | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kyoko Aoyagi
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Vida Alami
- University of Colorado Cancer Center, Biostatistics Core, Aurora, CO, USA
| | - Ajay Niranjan
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Douglas Kondziolka
- Department of Neurosurgery and Radiation Oncology, New York University Langone Medical Center, New York, NY, USA
| | - D Ross Camidge
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tyler P Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
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3
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Kowalchuk RO, Niranjan A, Hess J, Antonios JP, Zhang MY, Braunstein S, Ross RB, Pikis S, Deibert CP, Lee CC, Yang HC, Langlois AM, Mathieu D, Peker S, Samanci Y, Rusthoven CG, Chiang V, Wei Z, Lunsford LD, Trifiletti DM, Sheehan JP. Stereotactic radiosurgery and local control of brain metastases from triple-negative breast cancer. J Neurosurg 2023; 138:1608-1614. [PMID: 36433878 DOI: 10.3171/2022.10.jns221900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is an effective treatment for intracranial metastatic disease, but its role in triple-negative breast cancer requires further study. Herein, the authors report overall survival (OS) and local tumor control in a multiinstitutional cohort with triple-negative breast cancer metastases treated with SRS. METHODS Patients treated from 2010 to 2019 at 9 institutions were included in this retrospective study if they had biopsy-proven triple-negative breast cancer with intracranial metastatic lesions treated with SRS. Patients were excluded if they had undergone prior SRS, whole-brain radiation therapy, or resection of the metastatic lesions. A retrospective chart review was conducted to determine OS, local control, and treatment efficacy. RESULTS Sixty-eight patients with 315 treated lesions were assessed. Patients had a median Karnofsky Performance Status of 80 (IQR 70-90) and age of 57 years (IQR 48-67 years). Most treated patients had 5 or fewer intracranial lesions, with 34% of patients having a single lesion. Treated lesions were small, having a median volume owf 0.11 cm3 (IQR 0.03-0.60 cm3). Patients were treated with a median margin dose of 18 Gy (IQR 18-20 Gy) to the median 71% isodose line (IQR 50%-84%). Overall, patients had a 1-year OS of 43% and 2-year OS of 20%. Most patients (88%) were followed until death, by which time local tumor progression had occurred in only 7% of cases. Furthermore, 76% of the lesions demonstrated regression. Tumor volume was correlated with local tumor progression (p = 0.012). SRS was very well tolerated, and only 3 patients (5%) developed symptomatic radiation necrosis. CONCLUSIONS SRS is a safe and efficacious treatment for well-selected patients with triple-negative breast cancer, especially for those with a favorable performance status and small- to moderate-volume metastatic lesions.
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Affiliation(s)
- Roman O Kowalchuk
- 1Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Ajay Niranjan
- 2Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Judith Hess
- 3Department of Neurosurgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Joseph P Antonios
- 3Department of Neurosurgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Michael Y Zhang
- 4Department of Radiation Oncology, University of California, San Francisco, California
| | - Steve Braunstein
- 4Department of Radiation Oncology, University of California, San Francisco, California
| | - Richard B Ross
- 5Department of Radiation Oncology, University of Colorado, Boulder, Colorado
| | - Stylianos Pikis
- 6Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | | | - Cheng-Chia Lee
- 8Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 9National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Huai-Che Yang
- 8Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 9National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Anne-Marie Langlois
- 10Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - David Mathieu
- 10Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - Selcuk Peker
- 11Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey; and
| | - Yavuz Samanci
- 11Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey; and
| | - Chad G Rusthoven
- 5Department of Radiation Oncology, University of Colorado, Boulder, Colorado
| | - Veronica Chiang
- 3Department of Neurosurgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Zhishuo Wei
- 2Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 2Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Jason P Sheehan
- 6Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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4
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Pikis S, Mantziaris G, Kormath Anand R, Nabeel AM, Sheehan D, Sheehan K, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad Eldin R, Peker S, Samanci Y, Kaisman-Elbaz T, Speckter H, Hernández W, Isidor J, Tripathi M, Madan R, Zacharia BE, Daggubati LC, Martínez Moreno N, Martínez Álvarez R, Langlois AM, Mathieu D, Deibert CP, Sudhakar VR, Cifarelli CP, Arteaga Icaza D, Cifarelli DT, Wei Z, Niranjan A, Barnett GH, Lunsford LD, Bowden GN, Sheehan JP. Stereotactic radiosurgery for Koos grade IV vestibular schwannoma: a multi-institutional study. J Neurosurg 2023; 138:405-412. [PMID: 36303474 DOI: 10.3171/2022.4.jns22203] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/13/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Though stereotactic radiosurgery (SRS) is an established safe treatment for small- and medium-sized vestibular schwannomas (VSs), its role in the management of Koos grade IV VS is still unclear. In this retrospective multicenter study, the authors evaluated tumor control and the patient outcomes of primary, single-session SRS treatment for Koos grade IV VS. METHODS This study included patients treated with primary, single-session SRS for Koos grade IV VS at 10 participating centers. Only those patients presenting with non-life-threatening or incapacitating symptoms and at least 12 months of clinical and neuroimaging follow-up were eligible for inclusion. Relevant data were collected, and the Kaplan-Meier method was used to perform time-dependent analysis for post-SRS tumor control, hearing preservation, and facial nerve function preservation. Univariate and multivariate analyses were performed for outcome measures using Cox regression analysis. RESULTS Six hundred twenty-seven patients (344 females, median patient age 54 [IQR 22] years) treated with primary SRS were included in this study. The median tumor volume was 8.7 (IQR 5) cm3. Before SRS, serviceable hearing, facial nerve weakness (House-Brackmann grade > I), and trigeminal neuropathy were present in 205 (33%), 48 (7.7%), and 203 (32.4%) patients, respectively. The median prescription dose was 12 (IQR 1) Gy. At a median radiological follow-up of 38 (IQR 54) months, tumor control was achieved in 94.1% of patients. Early tumor expansion occurred in 67 (10.7%) patients and was associated with a loss of tumor control at the last follow-up (p = 0.001). Serviceable hearing preservation rates at the 5- and 10-year follow-ups were 65% and 44.6%, respectively. Gardner-Robertson class > 1 (p = 0.003) and cochlear dose ≥ 4 Gy (p = 0.02) were risk factors for hearing loss. Facial nerve function deterioration occurred in 19 (3.0%) patients at the last follow-up and was associated with margin doses ≥ 13 Gy (p = 0.03) and early tumor expansion (p = 0.04). Post-SRS, 33 patients developed hydrocephalus requiring shunting. Adverse radiation effects occurred in 92 patients and were managed medically or surgically in 34 and 18 cases, respectively. CONCLUSIONS SRS is a safe and effective method of obtaining tumor control in patients with Koos grade IV VS presenting with non-life-threatening or debilitating symptoms, especially those with surgical comorbidities that contraindicate resection. To decrease the incidence of post-SRS facial palsy, a prescription dose < 13 Gy is recommended.
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Affiliation(s)
- Stylianos Pikis
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Georgios Mantziaris
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Rithika Kormath Anand
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Ahmed M Nabeel
- 2Gamma Knife Center Cairo.,3Nasser Institute, Department of Neurosurgery, Benha University, Qalubya
| | - Darrah Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Kimball Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Wael A Reda
- 2Gamma Knife Center Cairo.,Departments of4Neurosurgery and
| | | | - Khaled Abdelkarim
- 2Gamma Knife Center Cairo.,5Clinical Oncology, Ain Shams University, Cairo
| | | | - Reem Emad Eldin
- 2Gamma Knife Center Cairo.,6Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Selcuk Peker
- 7Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- 7Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Tehila Kaisman-Elbaz
- 8Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Herwin Speckter
- 9Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santa Domingo, Dominican Republic
| | - Wenceslao Hernández
- 9Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santa Domingo, Dominican Republic
| | - Julio Isidor
- 9Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santa Domingo, Dominican Republic
| | | | - Renu Madan
- 11Radiation Therapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Brad E Zacharia
- 12Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, Pennsylvania
| | - Lekhaj C Daggubati
- 12Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Anne-Marie Langlois
- 14Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - David Mathieu
- 14Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | | | - Vivek R Sudhakar
- 15Department of Neurological Surgery, Emory University, Atlanta, Georgia
| | - Christopher P Cifarelli
- Departments of16Neurosurgery and.,17Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | | | | | - Zhishuo Wei
- 18Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Ajay Niranjan
- 18Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Gene H Barnett
- 8Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - L Dade Lunsford
- 18Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Greg N Bowden
- 19Department of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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5
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Lehrer EJ, Kowalchuk RO, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Fakhoury KR, Rusthoven CG, Mathieu D, Trudel C, Malouff TD, Ruiz-Garcia H, Bonney P, Hwang L, Yu C, Zada G, Patel S, Deibert CP, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Harmsen WS, Jones BM, Sharma S, Ahluwalia MS, Sheehan JP, Trifiletti DM. Concurrent Administration of Immune Checkpoint Inhibitors and Single Fraction Stereotactic Radiosurgery in Patients With Non-Small Cell Lung Cancer, Melanoma, and Renal Cell Carcinoma Brain Metastases is Not Associated With an Increased Risk of Radiation Necrosis Over Nonconcurrent Treatment: An International Multicenter Study of 657 Patients. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00057-3. [PMID: 36690161 DOI: 10.1016/j.ijrobp.2023.01.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICI) are highly effective treatments for brain metastases, particularly when these therapies are administered concurrently. However, there are limited data reporting the risk of radiation necrosis (RN) in this setting. METHODS AND MATERIALS Patients with brain metastases from primary non-small cell lung cancer, renal cell carcinoma, or melanoma treated with SRS and ICI were considered. Time-to-event analyses were conducted for any grade RN and symptomatic RN (SRN) with death incorporated as a competing risk. As a secondary analysis, recursive partitioning analysis (RPA) was used for model development, and a loop of potential models was analyzed, with the highest-fidelity model selected. Brain V12 Gy thresholds identified on RPA were then incorporated into the competing risks analysis. Concurrent SRS and ICI administration. RESULTS Six hundred fifty-seven patients with 4182 brain metastases across 11 international institutions were analyzed. The median follow-up for all patients was 13.4 months. The median follow-up was 12.8 months and 14.1 months for the concurrent and nonconcurrent groups, respectively (P = .03). The median patient age was 66 years, and the median Karnofsky Performance Status was 90. In patients with any grade RN, 1- and 2-year rates were 6.4% and 9.9%, respectively. In patients with SRN, 1- and 2-year rates were 4.8% and 7.2%, respectively. On RPA, the highest-fidelity models consistently identified V12 Gy as the dominant variable predictive of RN. Three risk groups were identified by V12 Gy: (1) < 12 cm3; (2) 20 cm3 ≥ V12 Gy ≥ 12 cm3; (3) V12 Gy > 20 cm3. In patients with any grade RN, 1-year rates were 3.7% (V12 Gy < 12 cm3), 10.3% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 12.6% (V12 Gy > 20 cm3); the 2-year rates were 7.5% (V12 Gy < 12 cm3), 13.8% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 15.4% (V12 Gy > 20 cm3) (P < 0.001). In patients with any SRN, 1-year rates were 2.4% (V12 Gy < 12 cm3), 8.9% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 10.3% (V12 Gy > 20 cm3); the 2-year rates were 4.4% (V12 Gy < 12 cm3), 12.4% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 13.1% (V12 Gy > 20 cm3; P < 0.001). There were no statistically significant differences in rates of any grade RN or SRN when accounting for therapy timing for all patients and by V12 risk group identified on RPA. CONCLUSIONS The use of SRS and ICI results in a low risk of any grade RN and SRN. This risk is not increased with concurrent administration. Therefore, ICI can safely be administered within 4-weeks of SRS. Three risk groups based on V12 Gy were identified, which clinicians may consider to further reduce rates of RN.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Roman O Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minneapolis
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | | | - Piero Picozzi
- Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Rozzano (Mi), Italy
| | - Andrea Franzini
- Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Rozzano (Mi), Italy
| | - Luca Attuati
- Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Rozzano (Mi), Italy
| | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | | | - Brianna M Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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6
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Dumot C, Pikis S, Mantziaris G, Xu Z, Dayawansa S, Anand RK, Nabeel AM, Sheehan D, Sheehan K, Reda WA, Tawadros SR, Karim KA, El-Shehaby AMN, Eldin RME, Peker S, Samanci Y, Kaisman-Elbaz T, Speckter H, Hernández W, Isidor J, Tripathi M, Madan R, Zacharia BE, Daggubati LC, Moreno NM, Álvarez RM, Langlois AM, Mathieu D, Deibert CP, Sudhakar VR, Cifarelli CP, Icaza DA, Cifarelli DT, Wei Z, Niranjan A, Barnett GH, Lunsford LD, Bowden GN, Sheehan JP. Stereotactic radiosurgery for Koos grade IV vestibular schwannoma in patients ≥ 65 years old: a multi-institutional retrospective study. Acta Neurochir (Wien) 2023; 165:211-220. [PMID: 36543963 DOI: 10.1007/s00701-022-05454-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgery is the preferred treatment for large vestibular schwannomas (VS). Good tumor control and cranial nerve outcomes were described in selected Koos IV VS after single-session stereotactic radiosurgery (SRS), but outcomes in elderly patients have never been specifically studied. The aim of this study is to report clinical and radiological outcomes after single-session SRS for Koos IV VS in patients ≥ 65 years old. METHOD This multicenter, retrospective study included patients ≥ 65 years old, treated with primary, single-session SRS for a Koos IV VS, and at least 12 months of follow-up. Patients with life-threatening or incapacitating symptoms were excluded. Tumor control rate, hearing, trigeminal, and facial nerve function were studied at last follow-up. RESULTS One-hundred and fifty patients (median age of 71.0 (IQR 9.0) years old with a median tumor volume of 8.3 cc (IQR 4.4)) were included. The median prescription dose was 12.0 Gy (IQR 1.4). The local tumor control rate was 96.0% and 86.2% at 5 and 10 years, respectively. Early tumor expansion occurred in 6.7% and was symptomatic in 40% of cases. A serviceable hearing was present in 16.1% prior to SRS and in 7.4% at a last follow-up of 46.5 months (IQR 55.8). The actuarial serviceable hearing preservation rate was 69.3% and 50.9% at 5 and 10 years, respectively. Facial nerve function preservation or improvement rates at 5 and 10 years were 98.7% and 91.0%, respectively. At last follow-up, the trigeminal nerve function was improved in 14.0%, stable in 80.7%, and worsened in 5.3% of the patients. ARE were noted in 12.7%. New hydrocephalus was seen in 8.0% of patients. CONCLUSION SRS can be a safe alternative to surgery for selected Koos IV VS in patients ≥ 65 years old. Further follow-up is warranted.
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Affiliation(s)
- Chloe Dumot
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA.,Department of Neurological Surgery, Hospices Civils de Lyon, Lyon, France
| | - Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Sam Dayawansa
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Rithika Kormath Anand
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Neurosurgery Department, Faculty of Medecine, Benha University, Qalubya, Egypt
| | - Darrah Sheehan
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Kimball Sheehan
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Departments of Neurosurgery and Clinical Oncology, Faculty of Medeine, Ain Shams University, Cairo, Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Departments of Neurosurgery and Clinical Oncology, Faculty of Medeine, Ain Shams University, Cairo, Egypt
| | - Khaled Abdel Karim
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Departments of Neurosurgery and Clinical Oncology, Faculty of Medeine, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Departments of Neurosurgery and Clinical Oncology, Faculty of Medeine, Ain Shams University, Cairo, Egypt
| | - Reem M Emad Eldin
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Tehila Kaisman-Elbaz
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Herwin Speckter
- Department of Radiology and Dominican Gamma Knife Center, CEDIMAT, Santo Domingo, Dominican Republic
| | - Wenceslao Hernández
- Department of Radiology and Dominican Gamma Knife Center, CEDIMAT, Santo Domingo, Dominican Republic
| | - Julio Isidor
- Department of Radiology and Dominican Gamma Knife Center, CEDIMAT, Santo Domingo, Dominican Republic
| | - Manjul Tripathi
- Departments of Neurosurgery and Radiation Therapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Renu Madan
- Departments of Neurosurgery and Radiation Therapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, PA, USA
| | - Lekhaj C Daggubati
- Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, PA, USA
| | - Nuria Martínez Moreno
- Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, PA, USA
| | | | - Anne-Marie Langlois
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | | | - Vivek R Sudhakar
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Christopher P Cifarelli
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Denisse Arteaga Icaza
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Daniel T Cifarelli
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Zhishuo Wei
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ajay Niranjan
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gene H Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Greg N Bowden
- Department of Neurosurgery, University of Alberta, Edmonton, AB, Canada
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA.
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7
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Lehrer EJ, Gurewitz J, Bernstein K, Kondziolka D, Fakhoury KR, Rusthoven CG, Niranjan A, Wei Z, Lunsford LD, Malouff TD, Ruiz-Garcia H, Peterson JL, Bonney P, Hwang L, Yu C, Zada G, Deibert CP, Prasad RN, Raval RR, Palmer JD, Patel S, Picozzi P, Franzini A, Attuati L, Mathieu D, Trudel C, Lee CC, Yang HC, Jones BM, Green S, Ahluwalia MS, Sheehan JP, Trifiletti DM. Concurrent Administration of Immune Checkpoint Inhibitors and Stereotactic Radiosurgery Is Well-Tolerated in Patients With Melanoma Brain Metastases: An International Multicenter Study of 203 Patients. Neurosurgery 2022; 91:872-882. [PMID: 36255215 DOI: 10.1227/neu.0000000000002127] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Melanoma brain metastases are commonly treated with stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICIs). However, the toxicity of these 2 treatments is largely unknown when administered concurrently. OBJECTIVE To evaluate the risk of radiation necrosis (RN) with concurrent and nonconcurrent SRS and ICIs. METHODS The guidelines from the Strengthening the Reporting of Observational Studies in Epidemiology checklist were used. Inverse probability of treatment weighting, univariable and multivariable logistic regression, and the Kaplan-Meier method was utilized. RESULTS There were 203 patients with 1388 brain metastases across 11 international institutions in 4 countries with a median follow-up of 15.6 months. The rates of symptomatic RN were 9.4% and 8.2% in the concurrent and nonconcurrent groups, respectively ( P =.766). On multivariable logistic regression, V12 ≥ 10 cm 3 (odds ratio [OR]: 2.76; P =.006) and presence of BRAF mutation (OR: 2.20; P =.040) were associated with an increased risk of developing symptomatic RN; the use of concurrent over nonconcurrent therapy was not associated with an increased risk (OR: 1.06; P =.877). There were 20 grade 3 toxic events reported, and no grade 4 events reported. One patient experienced a grade 5 intracranial hemorrhage. The median overall survival was 36.1 and 19.8 months for the concurrent and nonconcurrent groups (log-rank P =.051), respectively. CONCLUSION Concurrent administration of ICIs and SRS are not associated with an increased risk of RN. Tumors harboring BRAF mutation, or perhaps prior exposure to targeted agents, may increase this risk. Radiosurgical optimization to maintain V12 < 10 cm 3 is a potential strategy to reduce the risk of RN.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Denver, Colorado, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Denver, Colorado, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | | | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Piero Picozzi
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Andrea Franzini
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Luca Attuati
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | - Brianna M Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sheryl Green
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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8
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Dumot C, Pikis S, Mantziaris G, Xu Z, Anand RK, Nabeel AM, Sheehan D, Sheehan K, Reda WA, Tawadros SR, Abdel Karim K, El-Shehaby AMN, Emad Eldin RM, Peker S, Samanci Y, Kaisman-Elbaz T, Speckter H, Hernández W, Isidor J, Tripathi M, Madan R, Zacharia BE, Daggubati LC, Moreno NM, Álvarez RM, Langlois AM, Mathieu D, Deibert CP, Sudhakar VR, Cifarelli CP, Icaza DA, Cifarelli DT, Wei Z, Niranjan A, Barnett GH, Lunsford LD, Bowden GN, Sheehan JP. Stereotactic radiosurgery for Koos grade IV vestibular schwannoma in young patients: a multi-institutional study. J Neurooncol 2022; 160:201-208. [PMID: 36166113 DOI: 10.1007/s11060-022-04134-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/12/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Surgery is the treatment of choice for large vestibular schwannomas (VS). Stereotactic radiosurgery (SRS) has been suggested as an alternative to resection in selected patients. However, the safety and efficacy of SRS in Koos grade IV patients ≤ 45 years old has not been evaluated. The aim of this study is to describe the clinical and radiological outcomes of Koos grade IV in young patient managed with a single-session SRS. METHODS This retrospective, multicenter analysis included SRS-treated patients, ≤ 45 years old presenting with non-life threatening or incapacitating symptoms due to a Koos Grade IV VS and with follow-up ≥ 12 months. Tumor control and neurological outcomes were evaluated. RESULTS 176 patients [median age of 36.0 (IQR 9) and median tumor volume of 9.3 cm3 (IQR 4.7)] were included. The median prescription dose was 12 Gy (IQR 0.5). Median follow-up period was 37.5 (IQR 53.5) months. The 5- and 10-year progression-free survival was 90.9% and 86.7%. Early tumor enlargement occurred in 10.9% of cases and was associated with tumor progression at the last follow-up. The probability of serviceable hearing preservation at 5- and 10-years was 56.8% and 45.2%, respectively. The probability of improvement or preservation of facial nerve function was 95.7% at 5 and 10-years. Adverse radiation effects were noted in 19.9%. New-onset hydrocephalus occurred in 4.0%. CONCLUSION Single-session SRS is a safe and effective alternative to surgical resection in selected patients ≤ 45 years old particularly those with medical co-morbidities and those who decline resection. Longer term follow up is warranted.
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Affiliation(s)
- Chloe Dumot
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA.,Department of Neurological Surgery, Hospices civils de Lyon, Lyon, France
| | - Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Rithika Kormath Anand
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Neurosurgery Department, Faculty of Medecine, Benha University, Qalubya, Egypt
| | - Darrah Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Kimball Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Department of Neurosurgery, Faculty of Medecine, Ain Shams University, Cairo, Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Department of Neurosurgery, Faculty of Medecine, Ain Shams University, Cairo, Egypt
| | - Khaled Abdel Karim
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Department of Clinical Oncology, Faculty of Medecine, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Department of Neurosurgery, Faculty of Medecine, Ain Shams University, Cairo, Egypt
| | - Reem M Emad Eldin
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Tehila Kaisman-Elbaz
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Herwin Speckter
- Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo, Dominican Republic
| | - Wenceslao Hernández
- Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo, Dominican Republic
| | - Julio Isidor
- Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo, Dominican Republic
| | - Manjul Tripathi
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Renu Madan
- Department of Radiation Therapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, PA, USA
| | - Lekhaj C Daggubati
- Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, PA, USA
| | | | | | - Anne-Marie Langlois
- Division of Neurosurgery, Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - David Mathieu
- Division of Neurosurgery, Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Vivek R Sudhakar
- Department of Neurosurgery, West Virginia University, Morgantown, WV, USA
| | - Christopher P Cifarelli
- Department of Neurosurgery, West Virginia University, Morgantown, WV, USA.,Department of Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | | | - Daniel T Cifarelli
- Department of Neurosurgery, West Virginia University, Morgantown, WV, USA
| | - Zhishuo Wei
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ajay Niranjan
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gene H Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Greg N Bowden
- Department of Neurosurgery, University of Alberta, Edmonton, AB, Canada
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA.
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9
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Lehrer EJ, Ahluwalia MS, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Fakhoury KR, Rusthoven CG, Mathieu D, Trudel C, Malouff TD, Ruiz-Garcia H, Bonney P, Hwang L, Yu C, Zada G, Patel S, Deibert CP, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Jones BM, Green S, Sheehan JP, Trifiletti DM. Imaging-defined necrosis after treatment with single-fraction stereotactic radiosurgery and immune checkpoint inhibitors and its potential association with improved outcomes in patients with brain metastases: an international multicenter study of 697 patients. J Neurosurg 2022; 138:1178-1187. [PMID: 36115055 DOI: 10.3171/2022.7.jns22752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) and stereotactic radiosurgery (SRS) are commonly utilized in the management of brain metastases. Treatment-related imaging changes (TRICs) are a frequently observed clinical manifestation and are commonly classified as imaging-defined radiation necrosis. However, these findings are not well characterized and may predict a response to SRS and ICIs. The objective of this study was to investigate predictors of TRICs and their impact on patient survival. METHODS This retrospective multicenter cohort study was conducted through the International Radiosurgery Research Foundation. Member institutions submitted de-identified clinical and dosimetric data for patients with non-small cell lung cancer (NSCLC), melanoma, and renal cell carcinoma (RCC) brain metastases that had been treated with SRS and ICIs. Data were collected from March 2020 to February 2021. Univariable and multivariable Cox and logistic regression analyses were performed. The Kaplan-Meier method was used to evaluate overall survival (OS). The diagnosis-specific graded prognostic assessment was used to guide variable selection. TRICs were determined on the basis of MRI, PET/CT, or MR spectroscopy, and consensus by local clinical providers was required. RESULTS The analysis included 697 patients with 4536 brain metastases across 11 international institutions in 4 countries. The median follow-up after SRS was 13.6 months. The median age was 66 years (IQR 58-73 years), 54.1% of patients were male, and 57.3%, 36.3%, and 6.4% of tumors were NSCLC, melanoma, and RCC, respectively. All patients had undergone single-fraction radiosurgery to a median margin dose of 20 Gy (IQR 18-20 Gy). TRICs were observed in 9.8% of patients. The median OS for all patients was 24.5 months. On univariable analysis, Karnofsky Performance Status (KPS; HR 0.98, p < 0.001), TRICs (HR 0.67, p = 0.03), female sex (HR 0.67, p < 0.001), and prior resection (HR 0.60, p = 0.03) were associated with improved OS. On multivariable analysis, KPS (HR 0.98, p < 0.001) and TRICs (HR 0.66, p = 0.03) were associated with improved OS. A brain volume receiving ≥ 12 Gy of radiation (V12Gy) ≥ 10 cm3 (OR 2.78, p < 0.001), prior whole-brain radiation therapy (OR 3.46, p = 0.006), and RCC histology (OR 3.10, p = 0.01) were associated with an increased probability of developing TRICs. The median OS rates in patients with and without TRICs were 29.0 and 23.1 months, respectively (p = 0.03, log-rank test). CONCLUSIONS TRICs following ICI and SRS were associated with a median OS benefit of approximately 6 months in this retrospective multicenter study. Further prospective study and additional stratification are needed to validate these findings and further elucidate the role and etiology of this common clinical scenario.
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Affiliation(s)
- Eric J Lehrer
- 1Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | - Ajay Niranjan
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zhishuo Wei
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kareem R Fakhoury
- 6Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Chad G Rusthoven
- 6Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | | | - Claire Trudel
- 8Medicine, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - Timothy D Malouff
- 9Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Henry Ruiz-Garcia
- 9Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | - Lindsay Hwang
- 11Radiation Oncology, University of Southern California, Los Angeles, California
| | - Cheng Yu
- Departments of10Neurosurgery and
| | | | - Samir Patel
- 12Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Piero Picozzi
- 14Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Andrea Franzini
- 14Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Luca Attuati
- 14Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Rahul N Prasad
- 15Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raju R Raval
- 15Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua D Palmer
- 15Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Cheng-Chia Lee
- 16Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Huai-Che Yang
- 16Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Brianna M Jones
- 1Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sheryl Green
- 1Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jason P Sheehan
- 17Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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10
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Mustroph CM, Stewart CM, Mann LM, Saberian S, Deibert CP, Thompson PW. Systematic Review of Syndrome of the Trephined and Reconstructive Implications. J Craniofac Surg 2022; 33:e647-e652. [PMID: 36054899 DOI: 10.1097/scs.0000000000008724] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/23/2022] [Indexed: 11/25/2022] Open
Abstract
Syndrome of the trephined (SoT) is a severe complication following decompressive craniectomy resulting in neurological decline which can progress to aphasia, catatonia, and even death. While cranioplasty can reverse neurological symptoms of SoT, awareness of SoT is poor outside of the neurosurgery community. The authors performed a systematic review of the literature on SoT with a focus on reconstructive implications. Search terms "syndrome of the trephined" and "sunken flap syndrome" were applied to PubMed to identify primary studies through October 2021. Full-text review yielded 11 articles discussing SoT and reconstructive techniques or implications with 56 patients undergoing cranial reconstruction. Average age of the patients was 41.8±9.5 years. Sixty-three percent of the patients were male. The most common indication for craniectomy was traumatic brain injury (43%), followed by tumor resection (23%), intracerebral hemorrhage (11%), and aneurysmal subarachnoid hemorrhage (2%). Patients most commonly suffered from motor deficits (52%), decreased wakefulness (30%), depression or anxiety (21%), speech deficits (16%), headache (16%), and cognitive difficulties (2%). Time until presentation of symptoms following decompression was 4.4±8.9 months. Patients typically underwent cranioplasty with polyetheretherketone (48%), titanium mesh (21%), split thickness calvarial bone (16%), full thickness calvarial bone (14%), or split thickness rib graft (4%). Eight percent of patients required free tissue transfer for soft tissue coverage. Traumatic Brain Injury (TBI) was a risk factor for development of SoT when adjusting for age and sex (odds ratio: 8.2, 95% confidence interval: 1.2-8.9). No difference significant difference was observed between length until initial improvement of neurological symptoms following autologous versus allograft reconstruction (P=0.47). SoT can be a neurologically devastating complication of decompressive craniectomy which can resolve following urgent cranioplasty. Familiarity with this syndrome and its reconstructive implications is critical for the plastic surgery provider, who may be called upon to assist with these urgent cases.
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11
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Mannam SS, Bray DP, Nwagwu CD, Goyal S, Deibert CP, Pradilla G, Nduom EK, Olson JJ, Hoang KB. LOCL-05 CEREBRAL METASTATIC LUNG CARCINOMA: EFFECT OF ALK- AND EGFR-MUTATION STATUS AND SURGICAL MANAGEMENT UPON CLINICAL OUTCOME. Neurooncol Adv 2022. [PMCID: PMC9354143 DOI: 10.1093/noajnl/vdac078.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
PURPOSE
There have been many advancements in the surgical and medical treatment of metastatic lung carcinoma. In the post-genomic era, new directed-oncological therapies such as monoclonal antibodies (mAbs) and tyrosine-kinase inhibitors (TKIs) may offer increased survival for lung carcinoma patients with EGFR- and ALK- mutations. No surgical series have investigated the role of these mutations upon patient survival in lung brain metastases (BM).
METHODS
We performed a multi-site, retrospective study of all patients who had BM with primary lung cancer undergoing surgical resection at Emory University Hospital between January 2012 and March 2021. Driver mutational statuses were categorized as EGFR-amplified, ALK-rearranged, or wild-type from biopsied brain tissue. Descriptive, univariate, and multivariate survival analyses were performed.
RESULTS
95 patients (mean age: 65.8 ± 10.6) met the inclusion criteria. 6 (6.3%) had ALK-rearranged mutations and 19 (20.0%) had EGFR-amplified mutations. 9 (9.5%) received second line therapies in the form of TKIs and mAbs. The majority of patients who underwent craniotomies had gross total resection (GTR) (n=72, 79.1%) with 83.5% (95% CI: 71.2-90.8%) and 89.9% (95% CI: 74.9-96.2%) 1-year overall survival (OS) and progression-free survival (PFS), respectively. On univariate analysis, ALK-rearranged (HR: 2.92; 95% CI: 0.57-9.75; p-value = 0.230) and EGFR-amplified (HR: 0.56; 95% CI: 0.15-1.61; p-value = 0.260) mutations were not significantly associated with OS.
CONCLUSION
After assessing ALK- and EGFR- mutations on OS, we found no benefit with mutational status, unlike other cancer types such as Melanoma BRAF mutations. Our low sample size of patients receiving targeted therapies may bias our measures of association to the null hypothesis. However, the OS and PFS in our cohort were better than earlier trials in literature, demonstrating the improvement in systemic lung metastasis therapy. We suspect that as further targeted therapies become available, OS and PFS for lung BM patients will continue to improve.
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Affiliation(s)
| | - David P Bray
- Emory University School of Medicine , Atlanta, GA , USA
| | | | - Subir Goyal
- Emory University School of Medicine , Atlanta, GA , USA
| | | | | | - Edjah K Nduom
- Emory University School of Medicine , Atlanta, GA , USA
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12
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Zhang X, Kim WJ, Rao AV, Jaman E, Deibert CP, Sandlesh P, Krueger K, Allen JC, Amankulor NM. In vivo efficacy of decitabine as a natural killer cell-mediated immunotherapy against isocitrate dehydrogenase mutant gliomas. Neurosurg Focus 2022; 52:E3. [PMID: 35104792 DOI: 10.3171/2021.11.focus21489] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Isocitrate dehydrogenase (IDH) mutations are found in more than 80% of low-grade gliomas and in the majority of secondary glioblastomas. IDH mutation (IDHmut) leads to aberrant production of an oncogenic metabolite that promotes epigenetic dysregulation by inducing hypermethylation to suppress transcription of various tumor suppressor genes. Hypermethylation in IDHmut gliomas leads to transcriptional repression of NKG2D ligands, especially UL16-binding protein (ULBP)-1 and ULBP-3, and subsequent evasion of natural killer (NK) cell-mediated lysis. The demethylating agent 5-aza-2'deoxycytodine (decitabine [DAC]) is a DNA methyltransferase 1 inhibitor that prevents hypermethylation and is capable of restoring NKG2D ligand expression in IDHmut gliomas to resensitize them to NK cells. Given its capacity for sustained epigenetic reprogramming, the authors hypothesized that DCA would be an effective immunotherapeutic agent in treating IDHmut gliomas in an NK cell-dependent manner by upregulating epigenetically repressed activating NKG2D ligands in IDHmut tumors. In this study, the authors sought to use a glioma stem cell, preclinical animal model to determine the efficacy of DAC in IDHmut and IDH wild-type (IDHwt) tumors, and to characterize whether the activity of DAC in gliomas is dependent on NK cell function. METHODS Xenograft models of IDHwt and IDHmut gliomas were established in athymic-nude mice. When tumors were grossly visible and palpable, mice were treated with either DCA or dimethylsulfoxide intraperitoneally every 7 days. Tumor sizes were measured every 2 to 3 days. After the animals were euthanized, xenografts were harvested and analyzed for the following: tumor expression of NKG2D ligands, tumor susceptibility to human and murine NK cells, immunohistochemistry for NK infiltration, and tumor-infiltrating lymphocyte characterization. RESULTS DAC significantly inhibited the growth of IDHmut xenografts in the athymic nude mice. This effect was abrogated with NK cell depletion. Ex vivo analysis of tumor cells from harvested xenografts confirmed that DAC increased NKG2D ligand ULBP-1 and ULBP-3 expressions, and enhanced susceptibility to lysis of both human and murine IDHmut glial cells with corresponding NK cells. Immunohistochemical analysis of the xenografts indicated that DCA-treated IDHmut gliomas had a greater level of NK infiltration into the tumor compared with the negative control. Finally, DCA radically altered the tumor-infiltrating lymphocyte landscape of IDHmut glioma xenografts by increasing NK cells, dendritic cells, and M1 macrophages, while decreasing suppressive monocyte infiltration. CONCLUSIONS DCA displayed novel immunotherapeutic functions in IDHmut gliomas. This effect was critically dependent on NK cells. Additionally, DCA significantly altered the tumor immune landscape in IDHmut gliomas from suppressive to proinflammatory.
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Affiliation(s)
- Xiaoran Zhang
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Wi Jin Kim
- 2Department of Neurological Surgery, University of California, Los Angeles, California
| | - Aparna V Rao
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Emade Jaman
- 3University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | | | - Poorva Sandlesh
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Katharine Krueger
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Jordan C Allen
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Nduka M Amankulor
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
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13
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Lehrer EJ, Gurewitz J, Bernstein K, Patel D, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Malouff TD, Ruiz‐Garcia H, Patel S, Bonney PA, Hwang L, Yu C, Zada G, Mathieu D, Trudel C, Prasad RN, Palmer JD, Jones BM, Sharma S, Fakhoury KR, Rusthoven CG, Deibert CP, Picozzi P, Franzini A, Attuati L, Lee C, Yang H, Ahluwalia MS, Sheehan JP, Trifiletti DM. Radiation necrosis in renal cell carcinoma brain metastases treated with checkpoint inhibitors and radiosurgery: An international multicenter study. Cancer 2022; 128:1429-1438. [DOI: 10.1002/cncr.34087] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/08/2021] [Accepted: 11/22/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | - Jason Gurewitz
- Department of Radiation Oncology NYU Langone Medical Center New York New York
| | - Kenneth Bernstein
- Department of Radiation Oncology NYU Langone Medical Center New York New York
| | - Dev Patel
- Department of Neurosurgery NYU Langone Medical Center New York New York
| | | | - Ajay Niranjan
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Zhishuo Wei
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - L. Dade Lunsford
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | | | | | - Samir Patel
- Division of Radiation Oncology Department of Oncology University of Alberta Edmonton Alberta Canada
| | - Phillip A. Bonney
- Department of Neurosurgery University of Southern California Los Angeles California
| | - Lindsay Hwang
- Department of Radiation Oncology University of Southern California Los Angeles California
| | - Cheng Yu
- Department of Neurosurgery University of Southern California Los Angeles California
| | - Gabriel Zada
- Department of Neurosurgery University of Southern California Los Angeles California
| | - David Mathieu
- Department of Neurosurgery Université de Sherbrooke, Centre de Recherche du CHUS Quebec Quebec Canada
| | - Claire Trudel
- Department of Medicine Université de Sherbrooke, Centre de Recherche du CHUS Quebec Quebec Canada
| | - Rahul N. Prasad
- Department of Radiation Oncology Ohio State University Wexner Medical Center Columbus Ohio
| | - Joshua D. Palmer
- Department of Radiation Oncology Ohio State University Wexner Medical Center Columbus Ohio
| | - Brianna M. Jones
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | - Sonam Sharma
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | | | - Chad G. Rusthoven
- Department of Radiation Oncology University of Colorado Denver Colorado
| | | | - Piero Picozzi
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Andrea Franzini
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Luca Attuati
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Cheng‐Chia Lee
- Department of Neurosurgery Neurological InstituteTaipei Veteran General Hospital Taipei Taiwan
| | - Huai‐Che Yang
- Department of Neurosurgery Neurological InstituteTaipei Veteran General Hospital Taipei Taiwan
| | | | - Jason P. Sheehan
- Department of Neurological Surgery University of Virginia Charlottesville Virginia
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14
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Zhang X, Deibert CP, Kim WJ, Jaman E, Rao AV, Lotze MT, Amankulor NM. Autophagy inhibition is the next step in the treatment of glioblastoma patients following the Stupp era. Cancer Gene Ther 2021; 28:971-983. [PMID: 32759988 DOI: 10.1038/s41417-020-0205-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 01/30/2023]
Abstract
It has now been nearly 15 years since the last major advance in the treatment of patients with glioma. "The addition of temozolomide to radiotherapy for newly diagnosed glioblastoma resulted in a clinically meaningful and statistically significant survival benefit with minimal additional toxicity". Autophagy is primarily a survival pathway, literally self-eating, that is utilized in response to stress (such as radiation and chemotherapy), enabling clearance of effete protein aggregates and multimolecular assemblies. Promising results have been observed in patients with glioma for over a decade now when autophagy inhibition with chloroquine derivatives coupled with conventional therapy. The application of autophagy inhibitors, the role of immune cell-induced autophagy, and the potential role of novel cellular and gene therapies, should now be considered for development as part of this well-established regimen.
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Affiliation(s)
- Xiaoran Zhang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christopher P Deibert
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Wi-Jin Kim
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emade Jaman
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Aparna V Rao
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael T Lotze
- Department of Surgery, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - Nduka M Amankulor
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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15
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Rusthoven CG, Yamamoto M, Bernhardt D, Smith DE, Gao D, Serizawa T, Yomo S, Aiyama H, Higuchi Y, Shuto T, Akabane A, Sato Y, Niranjan A, Faramand AM, Lunsford LD, McInerney J, Tuanquin LC, Zacharia BE, Chiang V, Singh C, Yu JB, Braunstein S, Mathieu D, Touchette CJ, Lee CC, Yang HC, Aizer AA, Cagney DN, Chan MD, Kondziolka D, Bernstein K, Silverman JS, Grills IS, Siddiqui ZA, Yuan JC, Sheehan JP, Cordeiro D, Nosaki K, Seto T, Deibert CP, Verma V, Day S, Halasz LM, Warnick RE, Trifiletti DM, Palmer JD, Attia A, Li B, Cifarelli CP, Brown PD, Vargo JA, Combs SE, Kessel KA, Rieken S, Patel S, Guckenberger M, Andratschke N, Kavanagh BD, Robin TP. Evaluation of First-line Radiosurgery vs Whole-Brain Radiotherapy for Small Cell Lung Cancer Brain Metastases: The FIRE-SCLC Cohort Study. JAMA Oncol 2021; 6:1028-1037. [PMID: 32496550 DOI: 10.1001/jamaoncol.2020.1271] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Although stereotactic radiosurgery (SRS) is preferred for limited brain metastases from most histologies, whole-brain radiotherapy (WBRT) has remained the standard of care for patients with small cell lung cancer. Data on SRS are limited. Objective To characterize and compare first-line SRS outcomes (without prior WBRT or prophylactic cranial irradiation) with those of first-line WBRT. Design, Setting, and Participants FIRE-SCLC (First-line Radiosurgery for Small-Cell Lung Cancer) was a multicenter cohort study that analyzed SRS outcomes from 28 centers and a single-arm trial and compared these data with outcomes from a first-line WBRT cohort. Data were collected from October 26, 2017, to August 15, 2019, and analyzed from August 16, 2019, to November 6, 2019. Interventions SRS and WBRT for small cell lung cancer brain metastases. Main Outcomes and Measures Overall survival, time to central nervous system progression (TTCP), and central nervous system (CNS) progression-free survival (PFS) after SRS were evaluated and compared with WBRT outcomes, with adjustment for performance status, number of brain metastases, synchronicity, age, sex, and treatment year in multivariable and propensity score-matched analyses. Results In total, 710 patients (median [interquartile range] age, 68.5 [62-74] years; 531 men [74.8%]) who received SRS between 1994 and 2018 were analyzed. The median overall survival was 8.5 months, the median TTCP was 8.1 months, and the median CNS PFS was 5.0 months. When stratified by the number of brain metastases treated, the median overall survival was 11.0 months (95% CI, 8.9-13.4) for 1 lesion, 8.7 months (95% CI, 7.7-10.4) for 2 to 4 lesions, 8.0 months (95% CI, 6.4-9.6) for 5 to 10 lesions, and 5.5 months (95% CI, 4.3-7.6) for 11 or more lesions. Competing risk estimates were 7.0% (95% CI, 4.9%-9.2%) for local failures at 12 months and 41.6% (95% CI, 37.6%-45.7%) for distant CNS failures at 12 months. Leptomeningeal progression (46 of 425 patients [10.8%] with available data) and neurological mortality (80 of 647 patients [12.4%] with available data) were uncommon. On propensity score-matched analyses comparing SRS with WBRT, WBRT was associated with improved TTCP (hazard ratio, 0.38; 95% CI, 0.26-0.55; P < .001), without an improvement in overall survival (median, 6.5 months [95% CI, 5.5-8.0] for SRS vs 5.2 months [95% CI, 4.4-6.7] for WBRT; P = .003) or CNS PFS (median, 4.0 months for SRS vs 3.8 months for WBRT; P = .79). Multivariable analyses comparing SRS and WBRT, including subset analyses controlling for extracranial metastases and extracranial disease control status, demonstrated similar results. Conclusions and Relevance Results of this study suggest that the primary trade-offs associated with SRS without WBRT, including a shorter TTCP without a decrease in overall survival, are similar to those observed in settings in which SRS is already established.
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Affiliation(s)
- Chad G Rusthoven
- University of Colorado School of Medicine, Department of Radiation Oncology, Aurora
| | | | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Derek E Smith
- University of Colorado Cancer Center, Biostatistics Core, Aurora
| | - Dexiang Gao
- University of Colorado Cancer Center, Biostatistics Core, Aurora
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
| | - Shoji Yomo
- Aizawa Comprehensive Cancer Center, Division of Radiation Oncology, Aizawa Hospital, Matsumoto, Japan
| | | | - Yoshinori Higuchi
- Chiba University Graduate School of Medicine, Department of Neurological Surgery, Chiba, Japan
| | - Takashi Shuto
- Yokohama Rosai Hospital, Department of Neurosurgery, Yokohama, Japan
| | - Atsuya Akabane
- Gamma Knife Center, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Ajay Niranjan
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew M Faramand
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James McInerney
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Leonard C Tuanquin
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Veronica Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Charu Singh
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - James B Yu
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Charles J Touchette
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Cheng-Chia Lee
- Taipei Veterans General Hospital, Department of Neurosurgery, Neurological Institute, Taipei, Taiwan
| | - Huai-Che Yang
- Taipei Veterans General Hospital, Department of Neurosurgery, Neurological Institute, Taipei, Taiwan
| | - Ayal A Aizer
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Daniel N Cagney
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York
| | - Kenneth Bernstein
- Department of Neurosurgery, New York University Langone Medical Center, New York
| | - Joshua S Silverman
- Department of Neurosurgery, New York University Langone Medical Center, New York
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Justin C Yuan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville
| | - Diogo Cordeiro
- Department of Neurological Surgery, University of Virginia, Charlottesville
| | - Kename Nosaki
- National Hospital Organization Kyushu Cancer Center, Department of Thoracic Oncology, Fukuoka, Japan
| | - Takahashi Seto
- National Hospital Organization Kyushu Cancer Center, Department of Thoracic Oncology, Fukuoka, Japan
| | | | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Samuel Day
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Ronald E Warnick
- Department of Neurosurgery, Jewish Hospital-Mercy Health, Cincinnati, Ohio
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Jacksonville, Jacksonville, Florida
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University, Columbus
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University, Nashville, Tennessee
| | - Benjamin Li
- Department of Radiation Oncology, Vanderbilt University, Nashville, Tennessee
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - John A Vargo
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Neurosurgery, West Virginia University, Morgantown
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Samir Patel
- Department of Radiation Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, The University of Zurich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, The University of Zurich, Zurich, Switzerland
| | - Brian D Kavanagh
- University of Colorado School of Medicine, Department of Radiation Oncology, Aurora
| | - Tyler P Robin
- University of Colorado School of Medicine, Department of Radiation Oncology, Aurora
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Weaver KJ, McDowell MM, White MD, Tempel ZJ, Zwagerman NT, Deibert CP, Bonfield CM, Johnson S, Greene S. Comparison of Follow-Up Length-Matched Single-Center Myelomeningocele Postnatal Closure Cohort to the Management of Myelomeningocele Study (MOMS) Trial Results. Pediatr Neurosurg 2021; 56:229-238. [PMID: 33849030 DOI: 10.1159/000515038] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We sought to compare our large single-institution cohort of postnatal myelomeningocele closure to the 2 arms of the Management of Myelomeningocele Study (MOMS) trial at the designated trial time points, as well as assess outcomes at long-term follow-up among our postnatal cohort. METHODS A single-institutional retrospective review of myelomeningocele cases presenting from 1995 to 2015 at Children's Hospital of Pittsburgh was performed. We compared outcomes at 12 and 30 months to both arms of the MOMS trial and compared our cohort's outcomes at those designated time points to our long-term outcomes. Univariate statistical analysis was performed as appropriate. RESULTS One-hundred sixty-three patients were included in this study. All patients had at least 2-year follow-up, with a mean follow-up of 10 years (range 2-20 years). There was no difference in the overall distribution of anatomic level of defect. Compared to our cohort, the prenatal cohort had a higher rate of tethering at 12 months of age, 8 versus 1.8%. Conversely, the Chiari II decompression rate was higher in our cohort (10.4 vs. 1.0%). At 30 months, the prenatal cohort had a higher rate of independent ambulation, but our cohort demonstrated the highest rate of ambulation with or without assistive devices among the 3 groups. When comparing our cohort at these early time points to our long-term follow-up data, our cohort's ambulatory function decreased from 84 to 66%, and the rate of detethering surgery increased almost 10-fold. CONCLUSIONS This study demonstrated that overall ambulation and anatomic-functional level were significantly better among our large postnatal cohort, as well as having significantly fewer complications to both fetus and mother, when compared to the postnatal cohort of the MOMS trial. Our finding that ambulatory ability declined significantly with age in this patient population is worrisome for the long-term outcomes of the MOMS cohorts, especially given the high rates of cord tethering at early ages within the prenatal cohort. These findings suggest that the perceived benefits of prenatal closure over postnatal closure may not be as substantial as presented in the original trial, with the durability of results still remaining a concern.
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Affiliation(s)
- Kristin J Weaver
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Michael M McDowell
- Department of Neurosurgery, Children's Hospital of Pittsburgh University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael D White
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Nathan T Zwagerman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | | | - Stephen Johnson
- Department of Neurosurgery, Rutgers University, Newark, New Jersey, USA
| | - Stephanie Greene
- Department of Neurosurgery, Children's Hospital of Pittsburgh University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Kellogg R, Lee P, Deibert CP, Tempel Z, Zwagerman NT, Bonfield CM, Johnson S, Greene S. Twenty years' experience with myelomeningocele management at a single institution: lessons learned. J Neurosurg Pediatr 2018; 22:439-443. [PMID: 30004312 DOI: 10.3171/2018.5.peds17584] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors reviewed 20 years' experience with the surgical management of open myelomeningocele in a well-defined retrospective cohort from a single large academic medical center. Their goal was to define the characteristics of a modern cohort of children with myelomeningocele to allow for evidence-based decision-making for the treatment of these patients. METHODS After IRB approval was obtained, the authors queried an operative database maintained by the Department of Neurological Surgery at Children's Hospital of Pittsburgh for patients who underwent closure of a myelomeningocele between 1995 and 2015. They identified 153 infants, and a retrospective chart review was performed. RESULTS Eighty-eight percent of the patients required placement of a ventriculoperitoneal shunt, and 15% of these patients acquired shunt-related infections. Eighteen percent of patients underwent Chiari malformation type II (CM-II) decompression. Sixteen percent of patients underwent a tethered cord release. Three percent of patients died within the 1st year of life. Predictors of an early demise included poor Apgar scores, large head circumference, and need for early CM-II decompression. Functional motor outcome was slightly better than predicted by anatomical level of defect. CONCLUSIONS Myelomeningoceles represent a severe birth defect with life-threatening complications. The authors provide long-term follow-up data and insight into factors that contribute to early death.
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Affiliation(s)
| | - Philip Lee
- 2Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Nathan T Zwagerman
- 5Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | | | - Stephen Johnson
- 2Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephanie Greene
- 2Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Rocque BG, Agee BS, Thompson EM, Piedra M, Baird LC, Selden NR, Greene S, Deibert CP, Hankinson TC, Lew SM, Iskandar BJ, Bragg TM, Frim D, Grant G, Gupta N, Auguste KI, Nikas DC, Vassilyadi M, Muh CR, Wetjen NM, Lam SK. Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study. J Neurosurg Pediatr 2018; 22:225-232. [PMID: 29882736 DOI: 10.3171/2018.3.peds17234] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In children, the repair of skull defects arising from decompressive craniectomy presents a unique set of challenges. Single-center studies have identified different risk factors for the common complications of cranioplasty resorption and infection. The goal of the present study was to determine the risk factors for bone resorption and infection after pediatric cranioplasty. METHODS The authors conducted a multicenter retrospective case study that included all patients who underwent cranioplasty to correct a skull defect arising from a decompressive craniectomy at 13 centers between 2000 and 2011 and were less than 19 years old at the time of cranioplasty. Prior systematic review of the literature along with expert opinion guided the selection of variables to be collected. These included: indication for craniectomy; history of abusive head trauma; method of bone storage; method of bone fixation; use of drains; size of bone graft; presence of other implants, including ventriculoperitoneal (VP) shunt; presence of fluid collections; age at craniectomy; and time between craniectomy and cranioplasty. RESULTS A total of 359 patients met the inclusion criteria. The patients' mean age was 8.4 years, and 51.5% were female. Thirty-eight cases (10.5%) were complicated by infection. In multivariate analysis, presence of a cranial implant (primarily VP shunt) (OR 2.41, 95% CI 1.17-4.98), presence of gastrostomy (OR 2.44, 95% CI 1.03-5.79), and ventilator dependence (OR 8.45, 95% CI 1.10-65.08) were significant risk factors for cranioplasty infection. No other variable was associated with infection. Of the 240 patients who underwent a cranioplasty with bone graft, 21.7% showed bone resorption significant enough to warrant repeat surgical intervention. The most important predictor of cranioplasty bone resorption was age at the time of cranioplasty. For every month of increased age the risk of bone flap resorption decreased by 1% (OR 0.99, 95% CI 0.98-0.99, p < 0.001). Other risk factors for resorption in multivariate models were the use of external ventricular drains and lumbar shunts. CONCLUSIONS This is the largest study of pediatric cranioplasty outcomes performed to date. Analysis included variables found to be significant in previous retrospective reports. Presence of a cranial implant such as VP shunt is the most significant risk factor for cranioplasty infection, whereas younger age at cranioplasty is the dominant risk factor for bone resorption.
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Affiliation(s)
- Brandon G Rocque
- 1Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bonita S Agee
- 1Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eric M Thompson
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Mark Piedra
- 3Department of Neurosurgery, Billings Clinic, Billings, Montana
| | - Lissa C Baird
- 4Department of Neurosurgery, Oregon Health Sciences University, Portland, Oregon
| | - Nathan R Selden
- 4Department of Neurosurgery, Oregon Health Sciences University, Portland, Oregon
| | - Stephanie Greene
- 5Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Todd C Hankinson
- 7Department of Neurosurgery, University of Colorado, Denver, Colorado
| | - Sean M Lew
- 8Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bermans J Iskandar
- 9Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | - Taryn M Bragg
- 10Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - David Frim
- 11Section of Neurosurgery, University of Chicago, Chicago, Illinois
| | - Gerald Grant
- 12Department of Neurosurgery, Stanford University, Palo Alto, California
| | - Nalin Gupta
- 13Department of Neurosurgery, University of California at San Francisco, San Francisco, California
| | - Kurtis I Auguste
- 13Department of Neurosurgery, University of California at San Francisco, San Francisco, California
| | - Dimitrios C Nikas
- 14Department of Neurosurgery, University of Illinois, Chicago, Illinois
| | - Michael Vassilyadi
- 15Department of Neurosurgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Carrie R Muh
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Nicholas M Wetjen
- 16Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; and
| | - Sandi K Lam
- 17Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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McDowell MM, Blatt JE, Deibert CP, Zwagerman NT, Tempel ZJ, Greene S. Predictors of mortality in children with myelomeningocele and symptomatic Chiari type II malformation. J Neurosurg Pediatr 2018; 21:587-596. [PMID: 29570035 DOI: 10.3171/2018.1.peds17496] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chiari malformation type II (CM-II) in myelomeningocele is associated with a significant rate of mortality and poor outcome. Death is frequently heralded by the onset or progression of neurological symptoms. The authors sought to identify predictors of poor outcome and mortality within the myelomeningocele population at Children's Hospital of Pittsburgh. METHODS A retrospective chart and radiology review was performed on all infants who underwent primary closure of a myelomeningocele defect at Children's Hospital of Pittsburgh between the years of 1995 and 2015. Preoperative symptoms and signs leading to CM-II decompression, as well as operative details and postoperative changes in these symptoms and signs, were investigated in detail and correlated to outcome. Poor outcome was defined as death, stridor, or ventilator dependence. Deceased patients were separately assessed within this subgroup. RESULTS Thirty-two (21%) of 153 patients were found to have symptomatic CM-II. Of the 32 patients meeting inclusion criteria, 12 (38%) had poor outcomes. Eight patients (25%) died since initial presentation; 5 of these patients (16% of the overall cohort) died within the 1st year of life and 3 (9%) died during adolescence. Seven (88%) of the 8 patients who died had central apnea on presentation (p = 0.001) and 7 (44%) of the 16 patients who developed symptoms in the first 3 months of life died, compared with 1 (6.3%) of 16 who developed symptoms later in childhood (p = 0.04). The median Apgar score at 1 minute was 4.5 for patients who died and 8 for surviving patients (p = 0.006). The median diameter of the myelomeningocele defect was 5.75 cm for patients who died and 5 for those who survived (p = 0.01). The anatomical level of defect trended toward higher levels in patients who died, with 4 patients in that group having an anatomical level at L-2 or higher compared with 5 of the surviving patients (p = 0.001). The median initial head circumference for the 5 patients dying in the 1st year of life was 41.5 cm, versus 34 cm for all other patients (p = 0.01). CONCLUSIONS CM-II in spina bifida is associated with a significant mortality rate even when surgical intervention is performed. Death is more frequent in symptomatic patients presenting prior to 1 year of age. Late deaths are associated with symptom progression despite aggressive surgical and medical intervention. In this patient cohort, death was more likely in patients with symptomatic presentation during the first 3 months of life, low Apgar scores, large myelomeningocele defects, early central apnea, and large head circumference at birth.
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Affiliation(s)
- Michael M McDowell
- 1Department of Neurological Surgery and the.,2Children's Hospital of Pittsburgh Division of Pediatric Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Jason E Blatt
- 3Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | | | | | | | - Stephanie Greene
- 1Department of Neurological Surgery and the.,2Children's Hospital of Pittsburgh Division of Pediatric Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
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Panesar SS, Yeh FC, Deibert CP, Fernandes-Cabral D, Rowthu V, Celtikci P, Celtikci E, Hula WD, Pathak S, Fernández-Miranda JC. A diffusion spectrum imaging-based tractographic study into the anatomical subdivision and cortical connectivity of the ventral external capsule: uncinate and inferior fronto-occipital fascicles. Neuroradiology 2017; 59:971-987. [PMID: 28721443 DOI: 10.1007/s00234-017-1874-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/27/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE The inferior fronto-occipital fasciculus (IFOF) and uncinate fasciculus (UF) are major fronto-capsular white matter pathways. IFOF connects frontal areas of the brain to parieto-occipital areas. UF connects ventral frontal areas to anterior temporal areas. Both fascicles are thought to subserve higher language and emotion roles. Controversy pertaining to their connectivity and subdivision persists in the literature, however. METHODS High-definition fiber tractography (HDFT) is a non-tensor tractographic method using diffusion spectrum imaging data. Its major advantage over tensor-based tractography is its ability to trace crossing fiber pathways. We used HDFT to investigate subdivisions and cortical connectivity of IFOF and UF in 30 single subjects and in an atlas comprising averaged data from 842 individuals. A per-subject aligned, atlas-based approach was employed to seed fiber tracts and to study cortical terminations. RESULTS For IFOF, we observed a tripartite arrangement corresponding to ventrolateral, ventromedial, and dorsomedial frontal origins. IFOF volume was not significantly lateralized to either hemisphere. UF fibers arose from ventromedial and ventrolateral frontal areas on the left and from ventromedial frontal areas on the right. UF volume was significantly lateralized to the left hemisphere. The data from the averaged atlas was largely in concordance with subject-specific findings. IFOF connected to parietal, occipital, but not temporal, areas. UF connected predominantly to temporal poles. CONCLUSION Both IFOF and UF possess subdivided arrangements according to their frontal origin. Our connectivity results indicate the multifunctional involvement of IFOF and UF in language tasks. We discuss our findings in context of the tractographic literature.
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Affiliation(s)
- Sandip S Panesar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Fang-Cheng Yeh
- Department of Psychology, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Christopher P Deibert
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Fernandes-Cabral
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vijayakrishna Rowthu
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pinar Celtikci
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emrah Celtikci
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William D Hula
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Sudhir Pathak
- Learning Research and Development Center, Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Juan C Fernández-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Deibert CP, Gandhoke GS, Paschel EE, Gerszten PC. A Longitudinal Cohort Investigation of the Development of Symptomatic Adjacent Level Compression Fractures Following Balloon-assisted Kyphoplasty in a Series of 726 Patients. Pain Physician 2016; 19:E1167-E1172. [PMID: 27906947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Balloon-assisted kyphoplasty (BAK) is a well-accepted treatment for symptomatic vertebral compression fractures (VCF) secondary to osteoporosis. Some have raised a concern of an increased incidence of adjacent fractures due to alterations in spine biomechanics after cement augmentation. The incidence of subsequent VCFs following BAK is poorly understood. The aim of this study was to investigate the timing, location, and incidence of new VCFs following BAK and to identify risk factors associated specifically with the occurrence of new adjacent level fractures. OBJECTIVES The study was performed to determine the incidence of symptomatic subsequent adjacent and remote level compression fractures in a cohort of patients undergoing BAK. STUDY DESIGN Longitudinal cohort investigation at an academic medical center and a central referral center for VCFs. SETTING A consecutive single surgeon series of 726 patients with osteoporotic compression fractures. METHODS A prospectively collected cohort of 726 patients who underwent BAK between 2001 and 2014 for osteoporotic VCFs was evaluated. Seventy-seven patients were identified who underwent a second BAK for a new compression fracture and were include in the present series. The indication for BAK treatment was pain unresponsive to non-surgical management for all cases. Variables were recorded for each patient, including the time between index and subsequent fracture, fracture level, and number of initial fractures as well as with tobacco use, body mass index (BMI), and chronic steroid use. RESULTS Seventy-seven of 726 patients (10.6%) underwent a second BAK procedure on average 350 days following the initial procedure (range 21 to 2,691 days). Third and fourth procedures were less common, treated in 11 and 3 patients, respectively. Forty-eight of 77 patients (62%) suffered a fracture at a level immediately adjacent to the index level at mean time of 256 days. Remote level fractures were treated at a mean time of 489 days, but no statistical difference was noted. There was no statistically significant difference between tobacco use, BMI, and chronic steroid use between patients suffering from remote and adjacent level VCFs. LIMITATIONS This was not a population based study, and the true incidence of subsequent fractures after BAK might be underestimated by this analysis. CONCLUSIONS Symptomatic compression fractures after BAK are relatively uncommon and may occur long after the initial kyphoplasty procedure. Only half of subsequent fractures occur immediately adjacent to the initially treated level; the others occur remotely. Patients with a single symptomatic thoracic or lumbar fracture suffered from remote and adjacent level fractures equally. In contrast, all patients who suffered both a thoracic and lumbar fracture at the same time had a second fracture at an adjacent level. Specific risk factors for remote versus adjacent level fractures could not be determined. Key words: Balloon kyphoplasty, cement augmentation, osteoporosis, vertebral compression fracture, adjacent level fracture, vertebroplasty.
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Affiliation(s)
- Christopher P Deibert
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gurpreet S Gandhoke
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Erin E Paschel
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Peter C Gerszten
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Greene S, Lee PS, Deibert CP, Tempel ZJ, Zwagerman NT, Florio K, Bonfield CM, Emery SP. The impact of mode of delivery on infant neurologic outcomes in myelomeningocele. Am J Obstet Gynecol 2016; 215:495.e1-495.e11. [PMID: 27242203 DOI: 10.1016/j.ajog.2016.05.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 05/17/2016] [Accepted: 05/20/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Controversy exists regarding the optimal route of delivery for fetuses who are diagnosed prenatally with myelomeningocele. Current recommendations are based partly on antiquated studies with questionable methods. All studies that have been published to date suffer from nonstandardized outcome measures, selection bias, and small sample size. The larger studies are >15 years old. OBJECTIVE The purpose of this study was to provide information for evidence-based decision-making regarding the impact of route of delivery on motor outcomes for pediatric patients with prenatally were diagnosed myelomeningocele in a well-defined retrospective cohort. STUDY DESIGN Medical records were reviewed retrospectively for all neonates who had been diagnosed with a myelomeningocele at birth from 1995-2015 within the University of Pittsburgh Medical Center system, as identified through the Children's Hospital of Pittsburgh Neurosurgery Department operative database. Records were matched with maternal records with the use of the Center for Assistance in Research that used eRecord. Data from 72 maternal-neonatal pairs were analyzed for multiple variables. The primary outcome measure was the difference between the functional and anatomic motor levels in the child at the age of 2 years, stratified by mode of delivery and presence or absence of labor. The sample size necessary to detect a difference between the groups with power of 0.8 and significance of .05 was calculated to be 52 subjects total (26 per group). RESULTS Functional levels were slightly better than predicted by anatomic levels for all pediatric patient groups, regardless of mode of delivery or presence of labor. Anatomic levels were slightly lower (better), and defects were smaller for those infants who underwent vaginal delivery or a trial of labor, likely attributable to selection bias. Attempts to correct for this selection bias did not change the results. No other outcomes that were analyzed were associated significantly with mode of delivery or presence of labor. CONCLUSION No benefit to motor function from delivery by cesarean section or avoidance of labor was demonstrated statistically in this mother-infant cohort.
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Affiliation(s)
- Stephanie Greene
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Philip S Lee
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christopher P Deibert
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Zachary J Tempel
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nathan T Zwagerman
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Karen Florio
- Department of Ultrasound and Maternal-Fetal Medicine, Magee Women's Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christopher M Bonfield
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stephen P Emery
- Department of Ultrasound and Maternal-Fetal Medicine, Magee Women's Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Foster KA, Deibert CP, Choi PA, Gardner PA, Tyler-Kabara EC, Engh JA. Endoscopic third ventriculostomy as adjunctive therapy in the treatment of low-pressure hydrocephalus in adults. Surg Neurol Int 2016; 7:26. [PMID: 27069743 PMCID: PMC4802992 DOI: 10.4103/2152-7806.178522] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 10/29/2015] [Indexed: 11/07/2022] Open
Abstract
Background: Treatment of low-pressure hydrocephalus (LPH) may require prolonged external ventricular drainage (EVD) at sub-zero pressures to reverse ventriculomegaly. Endoscopic third ventriculostomy (ETV) has been used in the treatment of noncommunicating hydrocephalus; however, indications for ETV are expanding. Methods: Patients with the diagnosis of LPH as defined by the Pang and Altschuler criteria who underwent sub-zero drainage treatment over an 8-year period were included. Patients were divided into two cohorts based on whether or not ETV was employed during their treatment. Time from EVD placement to internalization of shunt was recorded for both groups; time from ETV to placement of shunt was recorded for the patients undergoing ETV. Results: Sixteen adult patients with LPH were managed with sub-zero drainage method. Ten (62.5%) patients did not undergo ETV and the average time from first ventriculostomy to shunting was 73 days (range 14–257 days). Six (37.5%) patients underwent ETV during the course of their treatment; average time from initial ventriculostomy to shunt was 114 days (range 0–236 days) (P = 0.16). Time from development of LPH to ETV ranged from 28 days to 6.5 months. In the ETV group, of the 4 patients who underwent shunting, the average time to shunting following ETV was 15.25 days. Conclusions: ETV can be used successfully in the management of refractory LPH to decrease the duration of EVD.
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Affiliation(s)
- Kimberly A Foster
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christopher P Deibert
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Phillip A Choi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Elizabeth C Tyler-Kabara
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Johnathan A Engh
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Deibert CP, Engh JA. Picroside II as a Novel Inhibitor of Apoptosis After Cerebral Ischemia in Rats. Neurosurgery 2015; 77:N17. [DOI: 10.1227/01.neu.0000467295.18386.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Deibert CP, Gandhoke GS, Forsythe RM, Moossy JJ. Surgical Site Infection 18 Months Following Intrathecal Pump Placement Secondary to an Asymptomatic Bowel Injury. Pain Pract 2015; 15:E69-71. [DOI: 10.1111/papr.12314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 03/31/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Christopher P. Deibert
- Department of Neurological Surgery; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania U.S.A
| | - Gurpreet S. Gandhoke
- Department of Neurological Surgery; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania U.S.A
| | - Raquel M. Forsythe
- Department of Trauma and General Surgery; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania U.S.A
| | - John J. Moossy
- Department of Neurological Surgery; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania U.S.A
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Chen SH, Grandhi R, Deibert CP, Jovin TG, Gardner PA, Ducruet AF. Coil herniation following intra-arterial verapamil infusion for the treatment of cerebral vasospasm: Case report and literature review. Interv Neuroradiol 2015; 21:184-7. [PMID: 25934655 DOI: 10.1177/1591019915581990] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Complications associated with intra-arterial infusion of vasodilator agents for the treatment of vasospasm associated with a ruptured cerebral aneurysm are extremely rare. We present the case of a patient who developed left lower extremity monoplegia following intra-arterial infusion of verapamil for treatment of diffuse cerebral vasospasm, 6 days after initially undergoing treatment of a ruptured right A1-2 junction aneurysm. A repeat angiogram following this intra-arterial vasodilator treatment demonstrated a coil loop which had herniated into the right A2 artery. Herein, we describe a previously unreported complication which occurred following intra-arterial pharmacologic vasospasm treatment, review the existing literature, and suggest potential causes and treatment options.
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Affiliation(s)
| | - Ramesh Grandhi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Christopher P Deibert
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Tudor G Jovin
- Department of Neurology, University of Pittsburgh Medical Center; Pittsburgh, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Andrew F Ducruet
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
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Deibert CP, Zussman BM, Engh JA. Focused Ultrasound With Microbubbles Increases Temozolomide Delivery in U87 Transfected Mice. Neurosurgery 2015; 76:N22-3. [DOI: 10.1227/01.neu.0000462700.20586.94] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Deibert CP, Zussman BM, Engh JA. A novel mechanism of oncogenesis in type 3 and 4 medulloblastomas. Neurosurgery 2014; 75:N16-7. [PMID: 25406623 DOI: 10.1227/01.neu.0000457196.94533.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Zussman BM, Deibert CP, Engh JA. A Previously Unrecognized Mechanism for Communication Between the Hematopoietic System and the Brain. Neurosurgery 2014; 75:N22-3. [DOI: 10.1227/01.neu.0000454763.29872.6b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Gandhoke GS, Deibert CP, Paschel E, Gerszten PC. SAFETY AND EFFICACY OF BALLOON KYPHOPLASTY FOR COMPRESSION FRACTURES IN THE VERY ELDERLY. Cureus 2014. [DOI: 10.7759/cureus.161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Deibert CP, Kondziolka D. Stereotactic radiosurgery used to manage a meningioma filling the posterior two-thirds of the superior sagittal sinus. J Neurosurg 2013; 119:1156-8. [PMID: 23991841 DOI: 10.3171/2013.7.jns13623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intrinsic meningiomas of the superior sagittal sinus pose a significant technical challenge, particularly in the posterior two-thirds of the sinus. Resection is curative but frequently is not possible because of the involvement of critical vascular structures. Here, the authors present the case of a 49-year-old woman with a recurrent meningioma located exclusively in the posterior two-thirds of the sagittal sinus. The patient was treated with a margin dose of 12 Gy and a maximum dose of 24 Gy to the length of the tumor, which measured 16 cm. Five years after treatment, the tumor remains stable and the patient is symptom free. This case demonstrates the unique role that stereotactic radiosurgery can play in the management of meningiomas that are surgically unresectable and have no accepted form of treatment. To the authors' knowledge, 16 cm also represents the longest segment of tumor treated using stereotactic radiosurgery.
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Affiliation(s)
- Christopher P Deibert
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
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Grandhi R, Deibert CP, Pirris SM, Lembersky B, Mintz AH. Simultaneous Muir-Torre and Turcot's syndrome: A case report and review of the literature. Surg Neurol Int 2013; 4:52. [PMID: 23646262 PMCID: PMC3640225 DOI: 10.4103/2152-7806.110512] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 02/08/2013] [Indexed: 11/29/2022] Open
Abstract
Background: Muir-Torre syndrome (MTS) is an autosomal dominant syndrome characterized by neoplasms of the sebaceous gland or keratoacanthomas, in addition to visceral malignancies. Cerebral neoplasms in patients with hereditary nonpolyposis colorectal cancer (HNPCC) or familial adenomatous polyposis suffer from Turcot's syndrome. Genetic mutations in MutS homolog (MSH)-2, MutL homolog (MLH)-1, and MutS homolog (MSH)-6 DNA mismatch repair genes are the most common in MTS with MSH-2 being the most predominant. In HNPCC MLH-1 and MSH-2 mutations are approximately equal in prevalence. Case Description: We present the case of a 58-year-old male with a prior history of being treated for colonic adenocarcinoma and skin lesions leading to a diagnosis of MTS. The patient later developed a World Health Organization (WHO) grade 4 glioma requiring surgical resection. Pathology revealed mutations in MSH-2 and MSH-6 mismatch repair genes. Conclusions: This case represents the first report of Turcot's and MTS with extensive molecular testing on the cerebral neoplasm demonstrating a molecular relationship between Turcot's and MTS and only the second published report of simultaneous Turcot's and MTS.
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Affiliation(s)
- Ramesh Grandhi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Arango JI, Deibert CP, Brown D, Bell M, Dvorchik I, Adelson PD. Posttraumatic seizures in children with severe traumatic brain injury. Childs Nerv Syst 2012; 28:1925-9. [PMID: 22843174 DOI: 10.1007/s00381-012-1863-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 07/10/2012] [Indexed: 01/30/2023]
Abstract
PURPOSE Traumatic brain injury (TBI) remains a leading cause of childhood death and disability worldwide. Seizures are a common complication of TBI and they are particularly common in pediatric populations. The proper management of children sustaining severe TBI is still controversial. Our study aims to share our experience contributing to build evidence for better care. METHODS Retrospective chart review was performed on individuals ages 0 to <18 who presented to a level 1 trauma center during a 10-year period with the diagnosis of severe TBI. Data analyzed included patient's demographics, event information, clinical and radiological presentation, management, and midterm follow-up. Presence of seizures was tracked through EEG monitoring, staff witnessing, or guardian referral. RESULTS The incidence of early posttraumatic seizures (EPTS) observed in our population (19 %) exceeds those previously reported. Such findings likely reflect the importance of close monitoring including EEG. An association between the presence of EPTS and the development of late posttraumatic seizures (LPTS) was evidenced (p=0.001; 95 % CI 2.2, 16.5), while this association should not be assumed as a measure of causality, it should be considered for the management of patients presenting EPTS. Non-accidental trauma and young age were identified as independent predictors for the development of seizures. CONCLUSIONS Seizures are a common complication of severe TBI among children aged 0-3 years. Given the detrimental effects that seizures produce on the injured brain, close observation and appropriate monitoring with EEG are essential for the management of children sustaining severe TBI.
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Affiliation(s)
- Jorge I Arango
- Department of Neurosurgery and Neuroscience Research, Barrow Neurological Institute at Phoenix Children's Hospital, Ambulatory Building B, 1919 East Thomas Road, Phoenix, AZ 85016, USA
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