Brain and Brain Stem Necrosis After Reirradiation for Recurrent Childhood Primary Central Nervous System Tumors: A PENTEC Comprehensive Review

PURPOSE

Reirradiation is increasingly used in children and adolescents/young adults (AYA) with recurrent primary central nervous system tumors. The Pediatric Normal Tissue Effects in the Clinic (PENTEC) reirradiation task force aimed to quantify risks of brain and brain stem necrosis after reirradiation.

METHODS AND MATERIALS

A systematic literature search using the PubMed and Cochrane databases for peer-reviewed articles from 1975 to 2021 identified 92 studies on reirradiation for recurrent tumors in children/AYA. Seventeen studies representing 449 patients who reported brain and brain stem necrosis after reirradiation contained sufficient data for analysis. While all 17 studies described techniques and doses used for reirradiation, they lacked essential details on clinically significant dose-volume metrics necessary for dose-response modeling on late effects. We, therefore, estimated incidences of necrosis with an exact 95% CI and qualitatively described data. Results from multiple studies were pooled by taking the weighted average of the reported crude rates from individual studies.

RESULTS

Treated cancers included ependymoma (n = 279 patients; 7 studies), medulloblastoma (n = 98 patients; 6 studies), any CNS tumors (n = 62 patients; 3 studies), and supratentorial high-grade gliomas (n = 10 patients; 1 study). The median interval between initial and reirradiation was 2.3 years (range, 1.2-4.75 years). The median cumulative prescription dose in equivalent dose in 2-Gy fractions (EQD22; assuming α/β value = 2 Gy) was 103.8 Gy (range, 55.8-141.3 Gy). Among 449 reirradiated children/AYA, 22 (4.9%; 95% CI, 3.1%-7.3%) developed brain necrosis and 14 (3.1%; 95% CI, 1.7%-5.2%) developed brain stem necrosis with a weighted median follow-up of 1.6 years (range, 0.5-7.4 years). The median cumulative prescription EQD22 was 111.4 Gy (range, 55.8-141.3 Gy) for development of any necrosis, 107.7 Gy (range, 55.8-141.3 Gy) for brain necrosis, and 112.1 Gy (range, 100.2-117 Gy) for brain stem necrosis. The median latent period between reirradiation and the development of necrosis was 5.7 months (range, 4.3-24 months). Though there were more events among children/AYA undergoing hypofractionated versus conventionally fractionated reirradiation, the differences were not statistically significant (P = .46).

CONCLUSIONS

Existing reports suggest that in children/AYA with recurrent brain tumors, reirradiation with a total EQD22 of about 112 Gy is associated with an approximate 5% to 7% incidence of brain/brain stem necrosis after a median follow-up of 1.6 years (with the initial course of radiation therapy being given with conventional prescription doses of ≤2 Gy per fraction and the second course with variable fractionations). We recommend a uniform approach for reporting dosimetric endpoints to derive robust predictive models of late toxicities following reirradiation.

Brainstem toxicity after proton or photon therapy in children and young adults with localized intracranial ependymoma: A French retrospective study

BACKGROUND AND PURPOSE

Ependymoma is the third most frequent childhood braintumor. Standard treatment is surgery followed by radiation therapy including proton therapy (PBT). Retrospective studies have reported higher rates of brainstem injury after PBT than after photon therapy (XRT). We report a national multicenter study of the incidence of brainstem injury after XRT versus PBT, and their correlations with dosimetric data.

MATERIAL AND METHODS

We included all patients aged < 25 years who were treated with PBT or XRT for intracranial ependymoma at five French pediatric oncology reference centers between 2007 and 2020. We reviewed pre-irradiation MRI, follow-up MRIs over the 12 months post-treatment and clinical data.

RESULTS

Of the 83 patients, 42 were treated with PBT, 37 with XRT, and 4 with both (median dose: 59.4 Gy, range: 53‑60). No new or progressive symptomatic brainstem injury was found. Four patients presented asymptomatic radiographic changes (punctiform brainstem enhancement and FLAIR hypersignal), with median onset at 3.5 months (range: 3.0‑9.4) after radiation therapy, and median offset at 7.6 months (range: 3.7‑7.9). Two had been treated with PBT, one with XRT, and one with mixed XRT-PBT. Prescribed doses were 59.4, 55.8, 59.4 and 54 Gy.

CONCLUSION

Asymptomatic radiographic changes occurred in 4.8% of patients with ependymoma in a large national series. There was no correlation with dose or technique. No symptomatic brainstem injury was identified.

Effects of light intensity and dual light intensity choice on plasma corticosterone, central serotonergic and dopaminergic activities in birds, Gallus gallus

Light intensity plays an important role in the regulation of growth, behavior, reproduction, and welfare of avian species. Light intensity preference behavior has been suggested to be involved in welfare of birds. This study aims to investigate the effects of different light intensity and dual light intensity choice (DLIC) lighting program on plasma corticosterone (CORT), and tryptophan hydroxylase 2 (TPH2, the rate-limiting enzyme of serotonin biosynthesis) and tyrosine hydroxylase (TH, the rate-limiting enzyme of dopamine biosynthesis) gene expression in the brainstem of male chickens. Day old broilers were housed in two commercial houses, and placed in 24 pens. All the treatment groups were provided with 23 h light (L) /1 h dark (D) and 30 lx (lx) light intensity during the first week and then 18L:6D (10 lx) from day 7 to 14. Blood and brain were sampled at 14 days of age (10 lx) before the onset of light treatments. On day 15, four treatments (2, 10, 20, and 100 lx), and DLIC treatment (2/20 lx) were initiated. Samples were collected on days 15, 16, 17, 30 and 41. TPH2 expression in the dorsal raphe nucleus (DRN) and caudal raphe nucleus (CRN) of brainstem, and TPH2 and TH expression in ventral tegmental areas (VTN) of the midbrain were determined by qPCR. Results showed that bright light and DLIC lighting program temporarily attenuated plasma CORT, suggesting the short-term stress attenuating effect of bright light and DLIC lighting program. Differential TPH2 expression in the DRN and CRN observed in the DLIC birds indicate a significant effect of DLIC lighting program on the serotonergic activity in the avian brainstem. At the 41 days of age, the significant downregulation of TPH2 and TH expression occurred in the VTA of DLIC treated birds compared to the other group of birds. Taken together, temporal and spatial regulation of TPH2 and TH expression by DLIC lighting program indicate that compensatory regulation of serotonergic and dopaminergic activities might be involved in the light intensity preference behavior of birds, suggesting a possible beneficial effect of the DLIC lighting program on broiler welfare.

The impact of proton LET/RBE modeling and robustness analysis on base-of-skull and pediatric craniopharyngioma proton plans relative to VMAT

Purpose: Pediatric craniopharyngioma, adult base-of-skull sarcoma and chordoma cases are all regarded as priority candidates for proton therapy. In this study, a dosimetric comparison between volumetric modulated arc therapy (VMAT) and intensity modulated proton therapy (IMPT) was first performed. We then investigated the impact of physical and biological uncertainties. We assessed whether IMPT plans remained dosimetrically superior when such uncertainty estimates were considered, especially with regards to sparing organs at risk (OARs).Methodology: We studied 10 cases: four chondrosarcoma, two chordoma and four pediatric craniopharyngioma. VMAT and IMPT plans were created according to modality-specific protocols. For IMPT, we considered (i) variable RBE modeling using the McNamara model for different values of (α/β)x, and (ii) robustness analysis with ±3 mm set-up and 3.5% range uncertainties.Results: When comparing the VMAT and IMPT plans, the dosimetric advantages of IMPT were clear: IMPT led to reduced integral dose and, typically, improved CTV coverage given our OAR constraints. When physical robustness analysis was performed for IMPT, some uncertainty scenarios worsened the CTV coverage but not usually beyond that achieved by VMAT. Certain scenarios caused OAR constraints to be exceeded, particularly for the brainstem and optical chiasm. However, variable RBE modeling predicted even more substantial hotspots, especially for low values of (α/β)x. Variable RBE modeling often prompted dose constraints to be exceeded for critical structures.Conclusion: For base-of-skull and pediatric craniopharyngioma cases, both physical and biological robustness analyses should be considered for IMPT: these analyses can substantially affect the sparing of OARs and comparisons against VMAT. All proton RBE modeling is subject to high levels of uncertainty, but the clinical community should remain cognizant possible RBE effects. Careful clinical and imaging follow-up, plus further research on end-of-range RBE mitigation strategies such as LET optimization, should be prioritized for these cohorts of proton patients.

National Cancer Institute Workshop on Proton Therapy for Children: Considerations Regarding Brainstem Injury

PURPOSE

Proton therapy can allow for superior avoidance of normal tissues. A widespread consensus has been reached that proton therapy should be used for patients with curable pediatric brain tumor to avoid critical central nervous system structures. Brainstem necrosis is a potentially devastating, but rare, complication of radiation. Recent reports of brainstem necrosis after proton therapy have raised concerns over the potential biological differences among radiation modalities. We have summarized findings from the National Cancer Institute Workshop on Proton Therapy for Children convened in May 2016 to examine brainstem injury.

METHODS AND MATERIALS

Twenty-seven physicians, physicists, and researchers from 17 institutions with expertise met to discuss this issue. The definition of brainstem injury, imaging of this entity, clinical experience with photons and photons, and potential biological differences among these radiation modalities were thoroughly discussed and reviewed. The 3 largest US pediatric proton therapy centers collectively summarized the incidence of symptomatic brainstem injury and physics details (planning, dosimetry, delivery) for 671 children with focal posterior fossa tumors treated with protons from 2006 to 2016.

RESULTS

The average rate of symptomatic brainstem toxicity from the 3 largest US pediatric proton centers was 2.38%. The actuarial rate of grade ≥2 brainstem toxicity was successfully reduced from 12.7% to 0% at 1 center after adopting modified radiation guidelines. Guidelines for treatment planning and current consensus brainstem constraints for proton therapy are presented. The current knowledge regarding linear energy transfer (LET) and its relationship to relative biological effectiveness (RBE) are defined. We review the current state of LET-based planning.

CONCLUSIONS

Brainstem injury is a rare complication of radiation therapy for both photons and protons. Substantial dosimetric data have been collected for brainstem injury after proton therapy, and established guidelines to allow for safe delivery of proton radiation have been defined. Increased capability exists to incorporate LET optimization; however, further research is needed to fully explore the capabilities of LET- and RBE-based planning.

Brainstem dose is associated with patient-reported acute fatigue in head and neck cancer radiation therapy

BACKGROUND AND PURPOSE

Radiation (RT) dose to the central nervous system (CNS) has been implicated as a contributor to treatment-related fatigue in head and neck cancer (HNC) patients undergoing radiation therapy (RT). This study evaluates the association of RT dose to CNS structures with patient-reported (PRO) fatigue scores in a population of HNC patients.

MATERIALS AND METHODS

At pre-RT (baseline), 6th week of RT, and 1-month post-RT time points, Multidimensional Fatigue Inventory (MFI-20) scores were prospectively obtained from 124 patients undergoing definitive treatment for HNC. Medulla, pons, midbrain, total brainstem, cerebellum, posterior fossa, and pituitary dosimetry were evaluated using summary statistics and dose-volume histograms, and associations with MFI-20 scores were analyzed.

RESULTS

Maximum dose (Dmax) to the brainstem and medulla was significantly associated with MFI-20 scores at 6th week of RT and 1-month post-RT time points, after controlling for baseline scores (p<0.05). Each 1Gy increase in medulla Dmax resulted in an increase in total MFI-20 score over baseline of 0.30 (p=0.026), and 0.25 (p=0.037), at the 6th week of RT and 1-month post-RT, respectively. Each 1Gy increase in brainstem Dmax resulted in an increase in total MFI-20 score over baseline of 0.30 (p=0.027), and 0.25 (p=0.037) at the 6th week of RT, 1-month post-RT, respectively. Statistically significant associations were not found between dosimetry for the other CNS structures and MFI-20 scores.

CONCLUSIONS

In this analysis of PRO fatigue scores from a population of patients undergoing definitive RT for HNC, maximum dose to the brainstem and medulla was associated with a significantly increased risk of acute patient fatigue.

Fully automated, comprehensive knowledge-based planning for stereotactic radiosurgery: Preclinical validation through blinded physician review

PURPOSE

As knowledge-based planning (KBP) attempts to augment and potentially supplant manual treatment planning, it is imperative to ensure any implementation maintains or improves overall plan quality in any disease site. The purpose of this study was to demonstrate the overall quality of KBP-driven automated stereotactic radiosurgery (SRS) treatment planning using blinded physician comparison and determine systematic factors predictive of physician plan preference to guide future KBP refinement.

METHODS AND MATERIALS

Automated noncoplanar volume modulated arc therapy KBP routines were developed for 199 plans across 3 clinical SRS scenarios: isolated lesions (isolated), lesions closely abutting (<3 cm) organs at risk (involved), and single-isocenter multiple metastases (multimet). Overall plan quality and preference were assessed via blinded review of the plans by two SRS physicians. Quantitative quality metrics were also compared to determine systematic differences in the treatment plans. Multiple parameters were investigated as predictors of KBP plan selection.

RESULTS

For the isolated, involved, and multimet scenarios, the KBP plans were considered to be superior or equivalent to clinical plans 86.7% (91/105), 81.1% (43/53), and 78.1% (32/41) of the time, respectively. All investigated quality metrics were equivalent or indicated more sparing for all KBP plans. The only nondosimetric predictor was planning target volume in the isolated (P = .02) and involved (P = .05) groups. The dosimetric predictors for the isolated group were gradient measure and heterogeneity index (both P < .01). In the multimet category, the only significant dosimetric predictor was interlesion dose (P = .01).

CONCLUSIONS

The fully automated KBP SRS plans were equivalent or superior to previously treated plans in 83.4% (166/199) of cases. In clinical implementation, geometric features found to be predictive of KBP performance can be used to identify plans where KBP results might benefit from further refinement, whereas dosimetric predictive features could be used to further refine KBP optimization priorities.

Preliminary analysis of the sequential simultaneous integrated boost technique for intensity-modulated radiotherapy for head and neck cancers

The aim of this study was to compare three strategies for intensity-modulated radiotherapy (IMRT) for 20 head-and-neck cancer patients. For simultaneous integrated boost (SIB), doses were 66 and 54 Gy in 30 fractions for PTVboost and PTVelective, respectively. Two-phase IMRT delivered 50 Gy in 25 fractions to PTVelective in the First Plan, and 20 Gy in 10 fractions to PTVboost in the Second Plan. Sequential SIB (SEQ-SIB) delivered 55 Gy and 50 Gy in 25 fractions, respectively, to PTVboost and PTVelective using SIB in the First Plan and 11 Gy in 5 fractions to PTVboost in the Second Plan. Conformity indexes (CIs) (mean ± SD) for PTVboost and PTVelective were 1.09 ± 0.05 and 1.34 ± 0.12 for SIB, 1.39 ± 0.14 and 1.80 ± 0.28 for two-phase IMRT, and 1.14 ± 0.07 and 1.60 ± 0.18 for SEQ-SIB, respectively. CI was significantly highest for two-phase IMRT. Maximum doses (Dmax) to the spinal cord were 42.1 ± 1.5 Gy for SIB, 43.9 ± 1.0 Gy for two-phase IMRT and 40.3 ± 1.8 Gy for SEQ-SIB. Brainstem Dmax were 50.1 ± 2.2 Gy for SIB, 50.5 ± 4.6 Gy for two-phase IMRT and 47.4 ± 3.6 Gy for SEQ-SIB. Spinal cord Dmax for the three techniques was significantly different, and brainstem Dmax was significantly lower for SEQ-SIB. The compromised conformity of two-phase IMRT can result in higher doses to organs at risk (OARs). Lower OAR doses in SEQ-SIB made SEQ-SIB an alternative to SIB, which applies unconventional doses per fraction.

Can mobile phone emissions affect auditory functions of cochlea or brain stem?

PROBLEMS ADDRESSED:

Despite their abundant spread, mobile phones are suspected by a major share of the population to cause adverse effects on health and welfare. The ear as the sense organ next to the individual device has rarely been Investigated for short-term effects in this regard. In a previous article, we could not prove any impact on the vestibular part of the inner ear. Our present examinations are concerned with the question whether mobile phone emissions could affect cochlear or auditory brain stem functions.

METHODS AND MEASURES:

In 12 healthy test persons with normal hearing, auditory brain stem reflexes recordings were performed before, during, and after exposure to electromagnetic emissions by standardized mobile phone devices. Two modes of electromagnetic emissions fields were administered: pulsed and continuous. For acoustic stimulation simultaneous to field exposure, special “plug-in” earphones had to be used.

RESULTS:

No impact on auditory brain stem reflexes recordings in terms of absolute and interpeak latencies could be found.

CLINICAL SIGNIFICANCE:

Together with the results of a previous article concerned with the vestibular part of the inner ear, we can state that there are no adverse effects of mobile phone emissions on the ear function, at least on a short-term range. Of course, any long-term effects cannot be excluded by our study.

Effects of chronic exposure to electromagnetic waves on the auditory system

CONCLUSION

The results support that chronic electromagnetic field exposure may cause damage by leading to neuronal degeneration of the auditory system.

OBJECTIVES

Numerous researches have been done about the risks of exposure to the electromagnetic fields that occur during the use of these devices, especially the effects on hearing. The aim of this study is to evaluate the effects of the electromagnetic waves emitted by the mobile phones through the electrophysiological and histological methods.

METHODS

Twelve adult Wistar albino rats were included in the study. The rats were divided into two groups of six rats. The study group was exposed to the electromagnetic waves over a period of 30 days. The control group was not given any exposure to the electromagnetic fields. After the completion of the electromagnetic wave application, the auditory brainstem responses of both groups were recorded under anesthesia. The degeneration of cochlear nuclei was graded by two different histologists, both of whom were blinded to group information.

RESULTS

The histopathologic and immunohistochemical analysis showed neuronal degeneration signs, such as increased vacuolization in the cochlear nucleus, pyknotic cell appearance, and edema in the group exposed to the electromagnetic fields compared to the control group. The average latency of wave in the ABR was similar in both groups (p > 0.05).

Temozolomide in the treatment of newly diagnosed diffuse brainstem glioma in children: a broken promise?

BACKGROUND

The purpose of this study was to assess the efficacy and toxicity of radiotherapy (RT) with concurrent temozolomide (TMZ) chemotherapy followed by adjuvant TMZ in children with diffuse intrinsic pontine glioma (DIPG).

METHODS

Patients younger than 18 years with newly diagnosed DIPG were enrolled. Children were treated with focal RT along with concurrent daily TMZ. Four weeks after completing the initial RT-TMZ schedule, adjuvant TMZ was given every 28 days up to 12 cycles or progression disease.

RESULTS

Fifteen children with a median age of 9 years were enrolled. Fourteenth out of the 15 patients completed the chemoradiotherapy. The toxicity associated with TMZ was primarily haematopoietic. At a median follow-up of 15 months 13 children had died and 2 children were alive with progressive disease. No patient experienced complete response (CR). The median time to progression was 7.15 months.

CONCLUSION

Chemoradiotherapy with TMZ followed by adjuvant TMZ did not improve the poor prognosis associated with DIPG in children.

Incidence and dosimetric parameters of pediatric brainstem toxicity following proton therapy

BACKGROUND

Proton therapy offers superior low and intermediate radiation dose distribution compared with photon-based radiation for brain and skull base tumors; yet tissue within and adjacent to the target volume may receive a comparable radiation dose. We investigated the tolerance of the pediatric brainstem to proton therapy and identified prognostic variables.

MATERIAL AND METHODS

All patients < 18 years old with tumors of the brain or skull base treated from 2007 to 2013 were reviewed; 313 who received > 50.4 CGE to the brainstem were included in this study. Brainstem toxicity was graded according to the NCI Common Terminology Criteria for Adverse Events v4.0.

RESULTS

The three most common histologies were ependymoma, craniopharyngioma, and low-grade glioma. Median patient age was 5.9 years (range 0.5-17.9 years) and median prescribed dose was 54 CGE (range 48.6-75.6 CGE). The two-year cumulative incidence of toxicity was 3.8% ± 1.1%. The two-year cumulative incidence of grade 3 + toxicity was 2.1% ± 0.9%. Univariate analysis identified age < 5 years, posterior fossa tumor location and specific dosimetric parameters as factors associated with an increased risk of toxicity.

CONCLUSION

Utilization of current national brainstem dose guidelines is associated with a low risk of brainstem toxicity in pediatric patients. For young patients with posterior fossa tumors, particularly those who undergo aggressive surgery, our data suggest more conservative dosimetric guidelines should be considered.

Late neurological sequelae due to brainstem irradiation for an assumed glioma

PURPOSE

There is ongoing discussion whether radiotherapy might be beneficial in the treatment of intracranial cavernomas, however long-term sequelae due to brainstem irradiation may exist.

CASE REPORT

The case of a 72-year-old female is reported who received radiotherapy in the pre-MRI era due to a suspected intra-axial pontine lesion. Later on she developed severe trigeminal neuropathy and an MRI was performed 27 years after irradiation of the brainstem. On these images a large cavernous malformation with signs of multiple haemorrhages instead of the pontine glioma was seen accompanied by a substantial atrophy of brainstem structures.

CONCLUSION

This case impressively demonstrates the long-term outcome of brainstem irradiation and reflects that cavernomas do not respond to radiotherapy.

Clinical management and outcome of histologically verified adult brainstem gliomas in Switzerland: a retrospective analysis of 21 patients

Because of low incidence, mixed study populations and paucity of clinical and histological data, the management of adult brainstem gliomas (BSGs) remains non-standardized. We here describe characteristics, treatment and outcome of patients with exclusively histologically confirmed adult BSGs. A retrospective chart review of adults (age >18 years) was conducted. BSG was defined as a glial tumor located in the midbrain, pons or medulla. Characteristics, management and outcome were analyzed. Twenty one patients (17 males; median age 41 years) were diagnosed between 2004 and 2012 by biopsy (n = 15), partial (n = 4) or complete resection (n = 2). Diagnoses were glioblastoma (WHO grade IV, n = 6), anaplastic astrocytoma (WHO grade III, n = 7), diffuse astrocytoma (WHO grade II, n = 6) and pilocytic astrocytoma (WHO grade I, n = 2). Diffuse gliomas were mainly located in the pons and frequently showed MRI contrast enhancement. Endophytic growth was common (16 vs. 5). Postoperative therapy in low-grade (WHO grade I/II) and high-grade gliomas (WHO grade III/IV) consisted of radiotherapy alone (three in each group), radiochemotherapy (2 vs. 6), chemotherapy alone (0 vs. 2) or no postoperative therapy (3 vs. 1). Median PFS (24.1 vs. 5.8 months; log-rank, p = 0.009) and mOS (30.5 vs. 11.5 months; log-rank, p = 0.028) was significantly better in WHO grade II than in WHO grade III/IV tumors. Second-line therapy considerably varied. Histologically verification of adult BSGs is feasible and has an impact on postoperative treatment. Low-grade gliomas can simple be followed or treated with radiotherapy alone. Radiochemotherapy with temozolomide can safely be prescribed for high-grade gliomas without additional CNS toxicities.

The error estimate for contouring the brainstem in radiotherapy of head and neck cancer: a multi-center study from north China

PURPOSE

To analyze the error in contouring the brainstem for patients with head and neck cancer who underwent radiotherapy (RT) based on computed tomography (CT) and magnetic resonance (MR) images.

METHODS

20 patients with brain tumor and 17 patients with nasopharyngeal cancer (NPC) were randomly selected. Each patient underwent MR and CT scanning. For each patient, one observer contoured the brainstem on CT and MR images 10 times, and 10 observers from 5 centers delineated the brainstem on CT and MR images only one time. The inter- and intra-observers volume and outline variations were compared.

RESULTS

The volumes of brainstem contoured by inter and intra-observers on CT and MR images were similar (p>0.05). The reproducibility of contouring brainstem on MR images was better than that on CT images (p<0.05) for both inter- and intra-observer variability. The inter- and intra-observer variability for contouring the brainstem on CT images reached mean values of 0.81±0.05 (p>0.05) and of 0.85±0.05 (p>0.05), respectively, while on MR images the respective values were 0.90±0.05 (p>0.05) and 0.92±0.04 (p>0.05).

CONCLUSION

Contouring the brainstem on MR images was more accurate and reproducible than that on CT images. Precise information might be more helpful for the patients whose lesion were closed to brainstem.

Comparison of 3D anatomical dose verification and 2D phantom dose verification of IMRT/VMAT treatments for nasopharyngeal carcinoma

BACKGROUND

The two-dimensional phantom dose verification (2D-PDV) using hybrid plan and planar dose measurement has been widely used for IMRT treatment QA. Due to the lack of information about the correlations between the verification results and the anatomical structure of patients, it is inadequate in clinical evaluation. A three-dimensional anatomical dose verification (3D-ADV) method was used in this study to evaluate the IMRT/VMAT treatment delivery for nasopharyngeal carcinoma and comparison with 2D-PDV was analyzed.

METHODS

Twenty nasopharyngeal carcinoma (NPC) patients treated with IMRT/VMAT were recruited in the study. A 2D ion-chamber array was used for the 2D-PDV in both single-gantry-angle composite (SGAC) and multi-gantry-angle composite (MGAC) verifications. Differences in the gamma pass rate between the 2 verification methods were assessed. Based on measurement of irradiation dose fluence, the 3D dose distribution was reconstructed for 3D-ADV in the above cases. The reconstructed dose homogeneity index (HI), conformity index (CI) of the planning target volume (PTV) were calculated. Gamma pass rate and deviations in the dose-volume histogram (DVH) of each PTV and organ at risk (OAR) were analyzed.

RESULTS

In 2D-PDV, the gamma pass rate (3%, 3 mm) of SGAC (99.55% ± 0.83%) was significantly higher than that of MGAC (92.41% ± 7.19%). In 3D-ADV, the gamma pass rates (3%, 3 mm) were 99.75% ± 0.21% in global, 83.82% ± 16.98% to 93.71% ± 6.22% in the PTVs and 45.12% ± 32.78% to 98.08% ± 2.29% in the OARs. The maximum HI increment in PTVnx was 19.34%, while the maximum CI decrement in PTV1 and PTV2 were -32.45% and -6.93%, respectively. Deviations in dose volume of PTVs were all within ±5%. D2% of the brainstem, spinal cord, left/right optic nerves, and the mean doses to the left/right parotid glands maximally increased by 3.5%, 6.03%, 31.13%/26.90% and 4.78%/4.54%, respectively.

CONCLUSION

The 2D-PDV and global gamma pass rate might be insufficient to provide an accurate assessment for the complex NPC IMRT operation. In contrast, the 3D-ADV is superior in clinic-related quality assurance offering evaluation of organ specific pass rate and dose-volume deviations.

Statistical assessment of proton treatment plans under setup and range uncertainties

PURPOSE

To evaluate a method for quantifying the effect of setup errors and range uncertainties on dose distribution and dose-volume histogram using statistical parameters; and to assess existing planning practice in selected treatment sites under setup and range uncertainties.

METHODS AND MATERIALS

Twenty passively scattered proton lung cancer plans, 10 prostate, and 1 brain cancer scanning-beam proton plan(s) were analyzed. To account for the dose under uncertainties, we performed a comprehensive simulation in which the dose was recalculated 600 times per given plan under the influence of random and systematic setup errors and proton range errors. On the basis of simulation results, we determined the probability of dose variations and calculated the expected values and standard deviations of dose-volume histograms. The uncertainties in dose were spatially visualized on the planning CT as a probability map of failure to target coverage or overdose of critical structures.

RESULTS

The expected value of target coverage under the uncertainties was consistently lower than that of the nominal value determined from the clinical target volume coverage without setup error or range uncertainty, with a mean difference of -1.1% (-0.9% for breath-hold), -0.3%, and -2.2% for lung, prostate, and a brain cases, respectively. The organs with most sensitive dose under uncertainties were esophagus and spinal cord for lung, rectum for prostate, and brain stem for brain cancer.

CONCLUSIONS

A clinically feasible robustness plan analysis tool based on direct dose calculation and statistical simulation has been developed. Both the expectation value and standard deviation are useful to evaluate the impact of uncertainties. The existing proton beam planning method used in this institution seems to be adequate in terms of target coverage. However, structures that are small in volume or located near the target area showed greater sensitivity to uncertainties.

Dosimetric and delivery characterizations of full-arc and half-arc volumetric-modulated arc therapy for maxillary cancer

We compared the efficiency and accuracy of full-arc and half-arc volumetric-modulated arc therapy (VMAT) delivery for maxillary cancer. Plans for gantry rotation angles of 360° and 180° (full-arc and half-arc VMAT) were created for six maxillary cancer cases with the Monaco treatment planning system, and delivered using an Elekta Synergy linear accelerator. Full-arc and half-arc VMAT were compared with regard to homogeneity index (HI), conformity index (CI), mean dose to normal brain, total monitor units (MU), delivery times, root mean square (r.m.s.) gantry accelerations (°/s(2)), and r.m.s. gantry angle errors (°). The half-arc VMAT plans achieved comparable HI and CI to the full-arc plans. Mean doses to the normal brain and brainstem with the half-arc VMAT plans were on average 16% and 17% lower than those with the full-arc VMAT plans. For other organs at risk (OARs), no significant DVH differences were observed between plans. Half-arc VMAT resulted in 11% less total MU and 20% shorter delivery time than the full-arc VMAT, while r.m.s. gantry acceleration and r.m.s. gantry angle error during half-arc VMAT delivery were 30% and 23% less than those during full-arc VMAT delivery, respectively. Furthermore, the half-arc VMAT plans were comparable with the full-arc plans regarding dose homogeneity and conformity in maxillary cancer, and provided a statistical decrease in mean dose to OAR, total MU, delivery time and gantry angle error. Half-arc VMAT plans may be a suitable treatment option in radiotherapy for maxillary cancer.

Intensity-modulated radiotherapy for nasopharyngeal carcinoma: improvement of the therapeutic ratio with helical tomotherapy vs segmental multileaf collimator-based techniques

OBJECTIVES

The aim of the study was to compare differences in dosimetric, clinical and quality-of-life end points among patients treated with helical tomotherapy (HT) and segmental multileaf collimator (SMLC)-based intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma.

METHODS

From June 2005 to August 2009, 30 consecutive patients were treated with IMRT for nasopharyngeal carcinoma to a dose of 70 Gy. 14 patients (47%) were treated using HT and 16 (53%) were treated using SMLC-based IMRT. 28 patients (93%) received concurrent chemotherapy. The patients were evenly balanced between the two radiotherapy groups with respect to clinical and pathological characteristics. Median follow-up was 30 months (range, 6-62 months).

RESULTS

The 2-year estimates of overall survival, local-regional control and progression-free survival were 81%, 87% and 82%, respectively. There were no significant differences in any of these end points with respect to IMRT technique (p>0.05 for all). Dosimetric analysis revealed that patients treated by HT had significantly improved salivary sparing with respect to mean dose (27.3 vs 34.1 Gy, p=0.03) and volume receiving greater than or equal to 30 Gy (31.7% vs 47.3%, p=0.01) to the contralateral (spared) parotid gland. The incidence of Grade 3+ late xerostomia was 13 and 7% among patients treated with SMLC-based IMRT and HT, respectively (p=0.62). The corresponding proportion of patients who subjectively reported "too little" or "no" saliva at final follow-up was 38% and 7%, respectively (p=0.04).

CONCLUSION

The superior dosimetric outcome observed with HT appeared to translate into moderately improved clinical outcomes with respect to salivary sparing. Prospective trials are needed to validate this gain in the therapeutic ratio.

A dosimetric comparison between Gamma Knife and CyberKnife treatment plans for trigeminal neuralgia

OBJECT

The Leksell Gamma Knife and the Accuray CyberKnife systems have been used in the radio surgical treatment of trigeminal neuralgia. The 2 techniques use different delivery methods and different treatment parameters. In the past, CyberKnife treatments have been associated with an increased incidence of treatment-related complications, such as facial numbness. The goal of this study was to develop a method for planning a CyberKnife treatment for trigeminal neuralgia that would reproduce the dosimetric characteristics of a Gamma Knife plan. A comparison between Gamma Knife and CyberKnife treatment plans obtained with this method is presented.

METHODS

Five patients treated using the Gamma Knife Perfexion Unit were selected for this study. All patients underwent CT cisternography to accurately identify the position of the trigeminal nerve. The Gamma Knife plans used either one 4-mm-diameter collimator or two coincident 4-mm collimators (one open and one with sector blocking) placed at identical isocenter coordinates. A maximum local dose of 80 Gy was prescribed. Critical structures and representative isodose lines were outlined in GammaPlan and exported to the CyberKnife treatment planning platform. CyberKnife treatments were developed using the 5-mm-diameter cone and the trigeminal node set, which provides an effective collimation diameter of 4 mm at the isocenter. The 60-Gy isodose volume imported from GammaPlan was used as the target in the CyberKnife plans. The CyberKnife treatments were optimized to achieve target dose and critical structure sparing similar to the Gamma Knife plans. Isocentric and nonisocentric delivery techniques were investigated. Treatment plans were compared in terms of dosimetric characteristics, delivery, and planning efficiency.

RESULTS

CyberKnife treatments using the 5-mm cone and the trigeminal node set can closely reproduce the dose distribution of Gamma Knife plans. CyberKnife isocentric and nonisocentric plans provide comparable results. The average length of the trigeminal nerve receiving a dose of 60 Gy was 4.5, 4.5, and 4.4 mm for Gamma Knife, nonisocentric CyberKnife, and isocentric CyberKnife, respectively. However, minimizing the dose to the critical structures was more difficult with the CyberKnife and required the use of tuning structures. In addition, the dose fall off away from the target was steeper in Gamma Knife plans, probably due to the larger number of beams (192 beams for perfexion vs ~ 100 beams for cyberknife). While the treatment time with the cyberknife is generally shorter, the planning time is significantly longer.

CONCLUSIONS

CyberKnife radiosurgical parameters can be optimized to mimic the dose distribution of Gamma Knife plans. However, Gamma Knife plans result in superior sparing of critical structures (brainstem, temporal lobe,and cranial nerves VII and VIII) and in steeper dose fall off away from the target. The clinical significance of these effects is unknown. (DOI: 10.3171/2010.8.GKS101002)

Skull base chordomas: efficacy of surgery followed by carbon ion radiotherapy

BACKGROUND

Skull base chordomas are challenging to treat because of their invasive nature, critical location, and aggressive recurrence. We report the effectiveness of combined radical skull base surgery with carbon ion radiotherapy for treating skull base chordomas.

METHODS

Between November 1996 and August 2007, 32 patients (12 males and 20 females; mean age at initial presentation 41.4 years, range, 10-75 years) with skull base chordomas underwent 59 operations. Sub-total resection (resection of >90% of the pre-operative tumour volume) was achieved in 24 out of 59 (40.7%) operations. After surgical excision, 9/32 (28.1%) patients underwent adjuvant carbon ion radiotherapy. The patients were followed up for a mean period of 36.3 months (range, 3-93 months) from the initial presentation.

FINDINGS

Fifty percent of the patients had to be re-treated due to tumour regrowth during the follow-up period. Thus far, 3 patients have died from the neoplasms. The overall 7 year survival rate of 9 patients who underwent carbon ion radiotherapy was 85.7%. The rate was higher compared to that of others (76.4%). The 3 year recurrence free survival rates of carbon ion therapy treated group was 70.0%, being higher than that of the other groups treated with radiotherapy or untreated (57.1%, and 7.1% respectively). Log-rank analysis showed a significant difference in the recurrence free survival rates between the group treated with adjunctive carbon ion radiotherapy and the untreated group (P = 0.001146).

CONCLUSIONS

Surgical removal of the tumour around the brainstem and the optic nerve combined with post-operative carbon ion radiotherapy will improve the survival rate and quality of life of patients with complicated skull base chordomas.

Adverse radiation effects after Gamma Knife Surgery in relation to dose and volume

INTRODUCTION

The relationship between target volume and adverse radiation effects (AREs) at low prescription doses requires elucidation. The development of AREs in three series of patients treated in the Gamma Knife is analysed in relation to prescription dose and target volume.

MATERIALS AND METHODS

There were three groups. In group 1, there were of 275 patients with meningiomas; in group 2, 132 patients with vestibular schwannomas; and in group 3, 107 patients with arteriovenous malformations (AVMs). The minimum follow-up for each group was more than 24 months. All patients were followed up at six monthly intervals. The patients with tumours received a prescription dose of 12 Gy, which was varied to protect normal structures but not in relation to tumour volume per se. The desired AVM prescription dose was 25 Gy, but this was also reduced to protect normal structures and to keep the total dose within certain pre-defined limits. All AREs refer to intra-parenchymal increased perilesional T2 signal on MR irrespective of clinical correlation.

RESULTS

There was no relationship between tumour volume and the development of ARE in the tumour groups. There was a highly significant relationship between target volume and the development of ARE for the AVMs with their much higher dose. Radiation-induced clinical trigeminal and facial nerve deficits with both vestibular schwannomas and meningiomas were always associated with an increased T2 signal in the neighbouring brainstem parenchyma.

CONCLUSIONS

The relationship between target volume and the risk of adverse radiation effects may not apply with lower prescription doses. Individual radiosensitivity may explain why a minority suffer AREs unrelated to target volume. It is possible that radiation-induced brainstem parenchymal damage with concomitant cranial nerve deficits may be commoner after radiosurgery than is usually thought. If tumour control with lower doses is adequate, radiosurgery could be safely considered for larger targets associated with a high risk from microsurgery.

A treatment planning comparison of combined photon-proton beams versus proton beams-only for the treatment of skull base tumors

PURPOSE

To compare treatment planning between combined photon-proton planning (CP) and proton planning (PP) for skull base tumors, so as to assess the potential limitations of CP for these tumors.

METHODS AND MATERIALS

Plans for 10 patients were computed for both CP and PP. Prescribed dose was 67 cobalt Gray equivalent (CGE) for PP; 45 Gy (photons) and 22 CGE (protons) for CP. Dose-volume histograms (DVHs) were calculated for gross target volume (GTV), clinical target volume (CTV), normal tissues (NT), and organs at risk (OARs) for each plan. Results were analyzed using DVH parameters, inhomogeneity coefficient (IC), and conformity index (CI).

RESULTS

Mean doses delivered to the GTVs and CTVs with CP (65.0 and 61.7 CGE) and PP (65.3 and 62.2 Gy CGE) were not significantly different (p > 0.1 and p = 0.72). However, the dose inhomogeneity was drastically increased with CP, with a mean significant incremental IC value of 10.5% and CP of 6.8%, for both the GTV (p = 0.01) and CTV (p = 0.04), respectively. The CI(80%) values for the GTV and CTV were significantly higher with PP compared with CP. Compared with CP, the use of protons only led to a significant reduction of NT and OAR irradiation, in the intermediate-to-low dose (< or =80% isodose line) range.

CONCLUSIONS

These results suggest that the use of CP results in levels of target dose conformation similar to those with PP. Use of PP significantly reduced the tumor dose inhomogeneity and the delivered intermediate-to-low dose to NT and OARs, leading us to conclude that this treatment is mainly appropriate for tumors in children.

Effects of hypomagnetic field on noradrenergic activities in the brainstem of golden hamster

Previous studies found that elimination of the geomagnetic field (GMF) interferes with the normal brain functions, but the underlying mechanism remains unknown. The present study examined the effects of long-term exposures to a near-zero magnetic environment on the noradrenergic activities in the brainstem of golden hamsters. Both the content of norepinephrine (NE) and the density of NE-immunopositive neurons in the tissue decreased significantly after the treatment, and the effects could be progressive with time. These variations may substantially contribute to behavioral and mood disorders reported in other studies when animals are shielded from the GMF.

Effect of beam channel plugging on the outcome of gamma knife radiosurgery for trigeminal neuralgia

PURPOSE

We studied the influence of using plugs for brainstem protection during gamma knife radiosurgery (GKR) of trigeminal neuralgia (TN), with special emphasis on irradiation doses delivered to the trigeminal nerve, pain outcomes, and incidence of trigeminal dysfunction.

METHODS AND MATERIALS

A GKR procedure for TN using an anterior cisternal target and a maximum dose of 90 Gy was performed in 109 patients. For 49 patients, customized beam channel blocking (plugs) were used to reduce the dose delivered to the brainstem. We measured the mean and integrated radiation doses delivered to the trigeminal nerve and the clinical course of patients treated with and without plugs.

RESULTS

We found that blocking increases the length of trigeminal nerve exposed to high-dose radiation, resulting in a significantly higher mean dose to the trigeminal nerve. Significantly more of the patients with blocking achieved excellent pain outcomes (84% vs. 62%), but with higher incidences of moderate and bothersome trigeminal nerve dysfunction (37% mild/10% bothersome with plugs vs. 30% mild/2% bothersome without).

CONCLUSIONS

The use of plugs to protect the brainstem during GKR treatment for TN increases the dose of irradiation delivered to the intracisternal trigeminal nerve root and is associated with an important increase in the incidence of trigeminal nerve dysfunction. Therefore, beam channel blocking should be avoided for 90 Gy-GKR of TN.

Mice expressing constitutively active Gsalpha exhibit stimulus encoding deficits similar to those observed in schizophrenia patients

People with schizophrenia display sensory encoding deficits across a broad range of electrophysiological and behavioral measures, suggesting fundamental impairments in the ability to transduce the external environment into coherent neural representations. This inability to create basic components of complex stimuli interferes with a high fidelity representation of the world and likely contributes to cognitive deficits. The current study evaluates the effects of constitutive forebrain activation of the G(s)alpha G-protein subunit on auditory threshold and gain using acoustic brainstem responses and cortically generated N40 event-related potentials to assess the role of cyclic AMP signaling in sensory encoding. Additionally, we examine the ability of pharmacological treatments that mimic (amphetamine) or ameliorate (haloperidol) positive symptoms of schizophrenia to test the hypothesis that the encoding deficits observed in G(s)alpha transgenic mice can be normalized with treatment. We find that G(s)alpha transgenic mice have decreased amplitude of cortically generated N40 but normal acoustic brainstem response amplitude, consistent with forebrain transgene expression and a schizophrenia endophenotype. Transgenic mice also display decreased stimulus intensity response (gain) in both acoustic brainstem response and N40, indicating corticofugal influence on regions that lack transgene expression. N40 deficits in transgenic animals were ameliorated with low dose haloperidol and reversed with higher dose, suggesting dopamine D2 receptor-linked Gi activity contributes to the impairment. Consistent with this hypothesis, we recreated the G(s)alpha transgenic deficit in wild type animals using the indirect dopamine agonist amphetamine. This transgenic model of sensory encoding deficits provides a foundation for identifying biochemical contributions to sensory processing impairments associated with schizophrenia.

Activation of alpha7 acetylcholine receptors augments stimulation-induced hippocampal theta oscillation

In the septohippocampal formation alpha7 nicotinic receptors (alpha7 nAChRs) are predominantly expressed by neurons well positioned to modulate hippocampal theta oscillation, such as GABAergic interneurons in the hippocampus, and by both GABAergic and cholinergic septal neurons. In the present experiments, we evaluated the efficacy of the recently developed selective alpha7 nAChR agonist PNU-282987 on hippocampal theta oscillation in anaesthetized rats. This compound shows high affinity for the rat alpha7 nAChRs (Ki = 26 nM) but a negligible activity at other nAChRs. Systemic administration of PNU-282987 significantly enhanced the power (by 40%) of hippocampal theta oscillation induced by electrical stimulation of the brainstem reticular formation. In contrast, the amnesic and muscarinic receptor antagonist scopolamine significantly decreased the power (by 68%) of the stimulation-induced theta oscillation. Given the connection between hippocampal theta oscillation and cognitive processes, it is proposed that precognitive actions of alpha7 nAChR agonists could be mediated, at least in part, by modulation of hippocampal oscillatory activity.

Mapping radiation dose distribution on the fractional anisotropy map: applications in the assessment of treatment-induced white matter injury

We describe a method to map whole brain radiation dose distribution on to diffusion tensor MR (DT-MR) fractional anisotropy (FA) images and illustrate its applications for studying dose-effect relationships and regional susceptibility in two childhood medulloblastoma survivors. To determine the FA changes voxel-by-voxel in white matter, the post-treatment follow-up FA maps were coregistered to baseline pre-treatment FA maps and automatic segmentation for white matter was carried out. DeltaFA maps representing relative FA change in white matter were hence generated for visual inspection and quantitative analysis. The radiation dose distribution, calculated from radiotherapy plan and exported as images, was coregistered to baseline FA images. DT-MR imaging and processing noise was small with root mean square value of 1.49% for mean DeltaFA. We evaluated the mean DeltaFA changes of regions-of-interest according to radiation dose regions to provide an estimate of the dose-response and found increasing reduction in mean DeltaFA with increasing radiation dose up to 45 Gy after which there was a reversal in the mean FA trend and mean FA approached baseline value. We also found more severe mean FA reduction in the frontal lobes compared to the parietal lobes despite the same radiation dose, suggesting regional susceptibility in the frontal lobe, and mean FA increase in the brainstem after radiation in both patients. We conclude that the method described may be useful in estimating dose-effect relationships and studying regional susceptibility of the brain to radiation in medulloblastoma survivors.

Transcranial magnetic stimulation as trigger of dystonic attacks in a patient affected by paroxysmal kinesigenic dyskinesia

A 22-year-old patient presented with attacks of paroxysmal dystonia characterised by involuntary and uncontrollable movements affecting lower and upper limbs with sustained turning or twisting of the trunk. These motor paroxysms were induced by voluntary movements and lasted between 10 and 15 s with a frequency of 1-5 attacks per day. Transcranial magnetic stimulation of the motor cortex was found to induce motor paroxysms very similar to the spontaneous attacks. To evaluate motor cortex and brainstem excitability immediately after and between the attacks, a neurophysiological study was performed.

[MRI for oligodendrogliomas]

MRI has dramatically improved the management of cerebral tumors and consequently oligodendrogliomas. T1 and T2-weighted images and gadolinium enhancement are very useful for tumor detection and characterization. Tumor enhancement is of a great prognostic value because it is highly predictive of high-grade oligodendroglioma. Three-dimensional MR images provide, with high precision, the anatomical location and the relationships with functional structures (motor and language areas). The recent technical progress in MRI and the use of diffusion images in the screening of tumors lead to a better definition of the lesion. Comparative analysis of MRI images is helpful to detect eventual relapse and adverse effects of treatment.

Thermophysiological responses of human volunteers to whole body RF exposure at 220 MHz

Since 1994, our research has demonstrated how thermophysiological responses are mobilized in human volunteers exposed to three radio frequencies, 100, 450, and 2450 MHz. A significant gap in this frequency range is now filled by the present study, conducted at 220 MHz. Thermoregulatory responses of heat loss and heat production were measured in six adult volunteers (five males, one female, aged 24-63 years) during 45 min whole body dorsal exposures to 220 MHz radio frequency (RF) energy. Three power densities (PD = 9, 12, and 15 mW/cm(2) [1 mW/cm(2) = 10 W/m(2)], whole body average normalized specific absorption rate [SAR] = 0.045 [W/kg]/[mW/cm(2)] = 0.0045 [W/kg]/[W/m(2)]) were tested at each of three ambient temperatures (T(a) = 24, 28, and 31 degrees C) plus T(a) controls (no RF). Measured responses included esophageal (T(esoph)) and seven skin temperatures (T(sk)), metabolic rate (M), local sweat rate, and local skin blood flow (SkBF). Derived measures included heart rate (HR), respiration rate, and total evaporative water loss (EWL). Finite difference-time domain (FDTD) modeling of a seated 70 kg human exposed to 220 MHz predicted six localized "hot spots" at which local temperatures were also measured. No changes in M occurred under any test condition, while T(esoph) showed small changes (< or =0.35 degrees C) but never exceeded 37.3 degrees C. As with similar exposures at 100 MHz, local T(sk) changed little and modest increases in SkBF were recorded. At 220 MHz, vigorous sweating occurred at PD = 12 and 15 mW/cm(2), with sweating levels higher than those observed for equivalent PD at 100 MHz. Predicted "hot spots" were confirmed by local temperature measurements. The FDTD model showed the local SAR in deep neural tissues that harbor temperature-sensitive neurons (e.g., brainstem, spinal cord) to be greater at 220 than at 100 MHz. Human exposure at both 220 and 100 MHz results in far less skin heating than occurs during exposure at 450 MHz. However, the exposed subjects thermoregulate efficiently because of increased heat loss responses, particularly sweating. It is clear that these responses are controlled by neural signals from thermosensors deep in the brainstem and spinal cord, rather than those in the skin.

Is NMDA receptor activation essential for the production of locomotor-like activity in the neonatal rat spinal cord?

Previous work has established that in vitro bath application of N-methyl-D-aspartic acid (NMDA) promotes locomotor activity in a variety of vertebrate preparations including the neonatal rat spinal cord. In addition, NMDA receptor activation gives rise to active membrane properties that are postulated to contribute to the generation or stabilization of locomotor rhythm. However, earlier studies yielded conflicting evidence as to whether NMDA receptors are essential in this role. Therefore in this study, we examined the effect of NMDA receptor blockade, using D-2-amino-5-phosphono-valeric acid (AP5), on locomotor-like activity in the in vitro neonatal rat spinal cord. Locomotor-like activity was induced using 5-hydroxytryptamine (5-HT), acetylcholine, combined 5-HT and NMDA receptor activation, increased K(+) concentration, or electrical stimulation of the brain stem and monitored using suction electrode recordings of left and right lumbar ventral root discharge. We also studied the effect on locomotor capacity of selectively suppressing NMDA receptor-mediated active membrane properties; this was achieved by removing Mg(2+) ions from the bath, which in turn abolishes voltage-sensitive blockade of the NMDA receptor channel. The results show that, although NMDA receptor activation may seem essential for locomotor network operation under some experimental conditions, locomotor-like rhythms can nevertheless be generated in the presence of AP5 if spinal cord circuitry is exposed to appropriate levels of non-NMDA receptor-dependent excitation. Therefore neither NMDA receptor-mediated nonlinear membrane properties nor NMDA receptor activation in general is universally essential for locomotor network activation in the in vitro neonatal rat spinal cord.

Stimulation of the parapyramidal region of the neonatal rat brain stem produces locomotor-like activity involving spinal 5-HT7 and 5-HT2A receptors

Locomotion can be induced in rodents by direct application 5-hydroxytryptamine (5-HT) onto the spinal cord. Previous studies suggest important roles for 5-HT7 and 5-HT2A receptors in the locomotor effects of 5-HT. Here we show for the first time that activation of a discrete population of 5-HT neurons in the rodent brain stem produces locomotion and that the evoked locomotion requires 5-HT7 and 5-HT2A receptors. Cells localized in the parapyramidal region (PPR) of the mid-medulla produced locomotor-like activity as a result of either electrical or chemical stimulation, and PPR-evoked locomotor-like activity was blocked by antagonists to 5-HT2A and 5-HT7 receptors located on separate populations of neurons concentrated in different rostro-caudal regions. 5-HT7 receptor antagonists blocked locomotor-like activity when applied above the L3 segment; 5-HT2A receptor antagonists blocked locomotor-like activity only when applied below the L2 segment. 5-HT7 receptor antagonists decreased step cycle duration, consistent with an action on neurons involved in the rhythm-generating function of the central pattern generator (CPG) for locomotion. 5-HT2A antagonists reduced the amplitude of ventral root activity with only small effects on step cycle duration, suggesting an action directly on cells involved in the output stage of the pattern generator for locomotion, including motoneurons and premotor cells. Experiments with selective antagonists show that dopaminergic (D1, D2) and noradrenergic (alpha1, alpha2) receptors are not critical for PPR-evoked locomotor-like activity.

Subtype Composition and Responses of Respiratory Neurons in the Pre-Bötzinger Region to Pulmonary Afferent Inputs in Dogs

The brain stem pre-Bötzinger complex (pre-BC) plays an important role in respiratory rhythm generation. However, it is not clear what function each subpopulation of neurons in the pre-BC serves. The purpose of the present studies was to identify neuronal subpopulations of the canine pre-BC and to characterize the neuronal responses of subpopulations to experimentally imposed changes in inspiratory (I) and expiratory (E) phase durations. Lung inflations and electrical stimulation of the cervical vagus nerve were used to produce changes in respiratory phase timing via the Hering-Breuer reflex. Multibarrel micropipettes were used to record neuronal activity and for pressure microejection in decerebrate, paralyzed, ventilated dogs. The pre-BC region was functionally identified by eliciting tachypneic phrenic neural responses to localized microejections of dl-homocysteic acid. Antidromic stimulation and spike-triggered averaging techniques were used to identify bulbospinal and cranial motoneurons, respectively. The results indicate that the canine pre-BC region consists of a heterogeneous mixture of propriobulbar I and E neuron subpopulations. The neuronal responses to ipsi-, contra-, and bilateral pulmonary afferent inputs indicated that I and E neurons with decrementing patterns were the only neurons with responses consistently related to phase duration. Late-I neurons were excited, but most other types of I neurons were inhibited or unresponsive. E neurons with augmenting or parabolic discharge patters were inhibited by ipsilateral inputs but excited by contra- and bilateral inputs. Late-E neurons were more frequently encountered and were inhibited by ipsi- and bilateral inputs, but excited by contralateral inputs. The results suggest that only a limited number of neuron subpopulations may be involved in rhythmogenesis, whereas many neuron types may be involved in motor pattern generation.

Age effect on far field potentials from the brain stem after transcutaneous vagus nerve stimulation

Recently, a new electrophysiological method for the assessment of vagus nerve function in the brainstem has been proposed in healthy participants. Before this procedure may be applied to patients with neurodegenerative diseases, its feasibility in elderly healthy participants and a possible age effect on the measurement have to be investigated. The vagus sensory evoked potentials (VSEP) after transcutaneous electric stimulation of the sensory auricular branch of the vagus nerve have been assessed in healthy younger and elderly participants. VSEP measured as far field potentials probably originating in vagus nuclei in the brainstem were recorded in 20 of 22 younger as well as in 39 of 43 elderly healthy participants. Latencies were significantly longer in the elderly as compared to the younger participants, while no clear age effects on amplitudes were identified. These results indicate that the assessment of VSEP is feasible also in elderly healthy participants. This is a prerequisite for testing this method in elderly patients with neurodegenerative diseases like Alzheimer and Parkinson disease as a noninvasive tool to detect an affection of the brainstem nuclei of the vagus nerve early in their course.

[Magnetic resonance imaging manifestations of radiation injury in brain stem and cervical spinal cord of nasopharyngeal carcinoma patients after radiotherapy]

BACKGROUND & OBJECTIVE

It is very important to diagnose the radiation injury in brain stem and cervical spinal cord of patients with nasopharyngeal carcinoma (NPC) after radiotherapy. Magnetic resonance imaging (MRI) manifestations of radiation encephalopathy have been widely reported, while those of radiation injury in brain stem and cervical spinal cord have been seldom reported. This study was to analyze the MRI characteristics of radiation injury in brain stem and cervical spinal cord of patients with NPC after radiotherapy.

METHODS

MRI was performed in 60 NPC patients 6 months to 5 years after radiotherapy. The imaging sequences included T(1)-weighted image (T(1)WI), T2-weighted image (T(2)WI), fluid attenuated inversion recovery (FLAIR). All patients received T(1)WI contrast-enhanced scanning.

RESULTS

Of the 60 patients, 6 had lesions in cervical spinal cord, 54 had lesions in brain stem. Of the 54 cases of radiation injury in brain stem, most lesions located in pons (20 cases), basis pons and medulla oblongata (26 cases), others located in mesencephalon (3 cases), medulla oblongata (5 cases). All lesions showed hypo- or iso-intense signal on T(1)WI, and hyper-intense signal on T(2)WI. After contrast-enhanced scanning, 11 cases (18.3%) had no enhancement; 49 (81.7%) markedly enhanced with 21 cases (42.9%) of homogenous patchy enhancement, and 28 cases (57.1%) of hetergenerous ringed and patchy enhancement.

CONCLUSION

MRI shows clearly the radiation injury in brain stem and cervical spinal cord of NPC patients after radiotherapy.

Gamma knife surgery for trigeminal neuralgia: Outcome, imaging, and brainstem correlates

PURPOSE

To review our results with gamma knife surgery (GKS) in the treatment of trigeminal neuralgia (TN), and to determine whether pain relief, medication usage, and the development of facial numbness are affected by trigeminal nerve compression, MRI imaging quality, or brainstem radiation dose.

METHODS AND MATERIALS

One hundred twelve patients with TN refractory to medical or surgical management were treated at the University of Maryland Gamma Knife Center between June 1996 and July 2001. Patients were treated using a 4-mm shot to the trigeminal nerve, at a point 2-4 mm anterior to the root entry zone of the nerve into the pons. The median dose prescribed was 75 Gy (range, 60-80 Gy). T1- and T2-weighted, axial, 1.5-mm-thick MRI images were obtained using three-dimensional gradient echo acquisition after contrast injection for treatment planning. MRI images were evaluated for imaging quality (i.e., the adequacy of visualization of the affected prepontine trigeminal nerve), the presence of trigeminal nerve compression, and the brainstem dose. Follow-up data were obtained via telephone interviews, and patients were asked to rate their pre-GKS and post-GKS pain using the Barrow Neurological Institute (BNI) Pain Intensity Scale. Patients were also asked about side effects from GKS and were asked to rate any facial numbness on the BNI Facial Numbness Scale. Medication use, time to pain response, and duration of relief were also evaluated.

RESULTS

Ninety-six patients who had follow-up data were included in the analysis. Eighty-six patients (89.6%) responded to GKS with an improvement in BNI pain class. Ten patients (10.4%) were found to have an MRI of poor quality, 30 (31.3%) fair quality, and 56 (58.3%) good quality. Forty-two (43.8%) received 10% of the maximal dose to the brainstem edge, whereas 54 (56.2%) received 20%. Eleven (11.5%) patients were found to have obvious nerve compression by MRI. Imaging quality (p = 0.1863), presence of compression (p = 0.1147), and brainstem dose (p = 0.3168) did not correlate with treatment response. There was also no correlation between these variables (MRI quality, compression, and brainstem dose) and medication use (p = 0.5372, p = 0.0913, p = 0.6832, respectively). Facial numbness was the only side effect experienced. Thirteen patients reported varying degrees of facial numbness, but there was no correlation between imaging quality (p = 0.0600), brainstem dose (p = 0.6773), and presence of compression (p = 0.5785) with the development of facial numbness.

CONCLUSIONS

Gamma knife surgery is effective in the treatment of TN and has a favorable side effect profile. Treatment response and the development of facial numbness do not correlate with MRI imaging quality, presence of nerve compression, or radiation dose to the brainstem.

Brain stem evoked response to forward and reversed speech in humans

Speech stimuli played in reverse are perceived as unfamiliar and alien-sounding, even though phoneme duration and fundamental voicing frequency are preserved. Although language perception ultimately resides in the neocortex, the brain stem plays a vital role in processing auditory information, including speech. The present study measured brain stem frequency-following responses (FFR) evoked by forward and reverse speech stimuli recorded from electrodes oriented horizontally and vertically to measure signals with putative origins in auditory nerve and rostral brain stem, respectively. The vertical FFR showed increased amplitude due to forward speech. It is concluded that familiar phonological and prosodic properties of forward speech selectively activate central brain stem neurons.

Imaging of the guinea pig cochlea following round window gadolinium application

Precise, non-invasive determination of the aetiology and site of pathology of inner ear disorders is difficult. The aim of this study was to describe an alternative method for inner ear visualization, based on local application of the paramagnetic contrast agent gadolinium. Using a 4.7 T MRI scanner, high contrast images of all four cochlear turns were obtained 3.5 h after placing gadolinium on the round window membrane. Gadolinium cleared from the cochlea within 96 h. Auditory brainstem response measurements performed on a separate group of animals showed no significant threshold shifts after the application, indicating that gadolinium is non-toxic to the guinea pig cochlea.

Les contraintes aux organes à risque en radiothérapie par modulation d'intensité des cancers ORL

Constraint definitions in intensity modulated radiation therapy is a key point factor during the treatment planning process. In literature some data are available about dose constraints and volumes according to the tissue architectures. Following ICRU recommendations, organs at risk organized in a parallel structure could receive an acceptably small proportion of high dose component. Mean dose and dose volume histogram is a most convenient tool for incorporating such constraints. Organs described as a serial structure are supposed to receive less than the given maximum dose, directly linked to the occurrence of complications. Dmax is the best way to describe such events. These constraints are new tools in radiation therapy, available for optimizing the dose distribution in target volume, sparing the organs at risk to protect the organ function or at least decreasing the late functional damages like xerostomia. It is necessary to define with accuracy gross target volumes and clinical target volume with available radio-anatomical guidelines before introducing current constraints on each volume in the inverse dosimetry. The management of these constraints remains under the responsibility of the clinicians. A permanent compromise has to be chosen between homogeneity of the dose distribution in the target volume and the probability of preserving functions of organs at risk.

Effects of spatial attention on the brain stem frequency-following potential

Can spatial attention or orienting affect human auditory information processing as peripheral as on the brain stem level? More specifically, is the reduction of the latency of the frequency-following potential (FFP; an evoked lower brain stem response) that we described in an earlier Neuroreport article really specifically attention-related? Here we demonstrate that, indeed, exogenous intramodal (auditory) spatial orienting, but not a transient modulation of general arousal, reduced the latency of the FFP by 27 micros; there were no effects on the FFP-amplitude. Although it might seem small, this reduction may be relevant in spatial hearing. We conclude that under certain conditions spatial attention can affect auditory information processing already on the brain stem level.

Selective source blocking for Gamma Knife radiosurgery of trigeminal neuralgia based on analytical dose modelling

We have developed an automatic critical region shielding (ACRS) algorithm for Gamma Knife radiosurgery of trigeminal neuralgia. The algorithm selectively blocks 201 Gamma Knife sources to minimize the dose to the brainstem while irradiating the root entry area of the trigeminal nerve with 70-90 Gy. An independent dose model was developed to implement the algorithm. The accuracy of the dose model was tested and validated via comparison with the Leksell GammaPlan (LGP) calculations. Agreements of 3% or 3 mm in isodose distributions were found for both single-shot and multiple-shot treatment plans. After the optimized blocking patterns are obtained via the independent dose model, they are imported into the LGP for final dose calculations and treatment planning analyses. We found that the use of a moderate number of source plugs (30-50 plugs) significantly lowered (approximately 40%) the dose to the brainstem for trigeminal neuralgia treatments. Considering the small effort involved in using these plugs, we recommend source blocking for all trigeminal neuralgia treatments with Gamma Knife radiosurgery.

Radiotherapy of small intracranial tumours with different advanced techniques using photon and proton beams: a treatment planning study

BACKGROUND AND PURPOSE

The potential benefits and limitations of five different radiation techniques, 3D conformal radiotherapy (3DCRT), stereotactic arc therapy (SRS/T), intensity modulated radiotherapy with photons (IMRT), and radiotherapy with protons (spot scanning (SSp) or passive scattering (PSp)), have been assessed using comparative treatment planning methods in a cohort of patients presenting with 'benign' brain tumours.

MATERIAL AND METHODS

Plans for five acoustic neurinomas, five meningiomas, and two pituitary adenomas were computed for all modalities using computed tomography (CT) scans to delineate planning target volume and organs at risk (OARs) and to predict dose distributions. Dose-volume histograms were used for physical and simple biological evaluation.

RESULTS

Proton techniques were shown to be superior to all photon approaches for the irradiation of small brain lesions in terms of target dose uniformity and conformity and in terms of sparing OARs. No major differences were observed between the results of the photon techniques, which were generally good for target coverage. Minimum target doses ranged from 81% with SRS/T to 93% with IMRT. The volume receiving more than 95% of the dose ranged from 95% (SRS/T) to 99% (PSp). No clear patterns of coverage dependence upon target shape were observed. Maximum brain stem irradiation ranged from 60% with IMRT to 26% with protons and the conformity index from 4.4 with IMRT to 2.5 with protons. Considering the rather long life expectancy of the patients suffering from meningiomas, neurinomas, and pituitary adenomas, the most important aspect to be considered, other than target coverage, is toxicity and in the long term, the possibility of secondary tumour induction. Considering these aspects, proton irradiation should be the irradiation technique of choice, when available. If not, IMRT, or even 3DCRT, techniques can provide an acceptable compromise, even without recurring to unconventional treatments like SRS/T, which require complex installations and high machine occupancy.

Comparison of treatment plans using intensity-modulated radiotherapy and three-dimensional conformal radiotherapy for paranasal sinus carcinoma

PURPOSE

To compare intensity-modulated radiotherapy (IMRT) treatment planning with three-dimensional conformal radiotherapy (3D-CRT) planning for paranasal sinus carcinoma.

MATERIALS AND METHODS

Treatment plans using traditional 3-field technique, 3D-CRT planning, and inverse planning IMRT were developed for a case of paranasal sinus cancer requiring adjuvant radiotherapy. Plans were compared with respect to dose conformality, dose-volume histograms, doses to critical normal tissues, and ease of treatment delivery.

RESULTS

The inverse-planned IMRT technique was more conformal around the tumor target volume than conventional techniques. The dose-volume histograms demonstrated significantly better critical normal-tissue sparing with the IMRT plans, while able to deliver a minimum dose of 60 Gy to the clinical tumor volume and 70 Gy to the gross tumor volume. Acute toxicities in our analysis were minimal.

CONCLUSIONS

IMRT planning provided improved tumor target coverage when compared to 3D-CRT treatment planning. There was significant sparing of optic structures and other normal tissues, including the brainstem. Inverse planning IMRT provided the best treatment for all paranasal sinus carcinomas, but required stringent immobilization criteria. Further studies are needed to establish the true clinical advantage of this modality.

[Dynamics of changes in the heparin-binding activity of rat brain proteins after fractionated exposure to ionizing radiation of low intensity]

In experiment on white rats it was shown that fractionated exposure to 1 sGy/day during 25 days is followed by the directed change in the total heparin-binding activity of proteins in the rat brain (both in males and in females) with maximum deviation from control by the 7th day after accumulation of a total dose of 25 sGy. The diverse in hemisphere cortex and hippocampus were different from those in brain trunk regions and cerebellum. It is supposed that a thin overturning of the intercellular and "cell-matrix" interactions in CNS modulates compensation and adaptation processes under chronic X-ray irradiation with a small dose of low intensity due to regulation of the free/bound heparansulphate correlation.