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Lee-Poprocki H, Ritter AR, Upadhyay R, Perlow HK, Ayan AS, Cetnar AJ, Degnan M, Scharschmidt TJ, Mendel E, Blakaj DM, Thomas EM, Chakravarthy VB, Elder JB, Palmer JD. Novel Intrafraction Motion Tracking During Postoperative Spine Stereotactic Irradiation for a Patient With Carbon Fiber Fixation Hardware. Pract Radiat Oncol 2023; 13:510-516. [PMID: 37516957 DOI: 10.1016/j.prro.2023.06.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 07/31/2023]
Abstract
Carbon-fiber reinforced (CFR) polyetheretherketone hardware is an alternative to traditional metal hardware used for spinal fixation surgeries before postoperative radiation therapy for patients with spinal metastases. CFR hardware's radiolucency decreases metal artifact, improving visualization and accuracy of treatment planning. We present the first clinical use and proof of principle of CFR spinal hardware with tantalum markers used for successful tracking of intrafraction motion (IM) using Varian TrueBeam IMR (Intrafraction Motion Review) software module during postoperative spine stereotactic radiation. A 63-year-old woman with history of endometrial cancer presented with acute back pain. Imaging demonstrated pathologic T12 vertebral fracture with cord compression. She underwent T12 vertebrectomy with circumferential decompression and posterior instrumented T10-L2 fusion at our facility using CFR-polyetheretherketone hardware with tantalum screw markers followed by postoperative stereotactic body radiation therapy to 3000 cGy in 5 fractions delivered to T11-T12. Tantalum screw markers were used for IMR tracking. During irradiation, 260 kV images were acquired, and IMR software was able to identify and track markers. During the entire treatment, the IM motions were less than 3 mm. This is the first presented case of CFR spinal hardware with tantalum markers used for successful IMR tracking of IM during daily spine stereotactic treatment. Future work will be needed to improve workflow and create a spine-specific IMR protocol.
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Affiliation(s)
| | | | | | | | | | | | | | - Thomas J Scharschmidt
- Orthopedic Surgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | | | | | - Vikram B Chakravarthy
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
| | - James B Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
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Upadhyay R, Palmer JD, Perlow HK, Schoenhals J, Ghose J, Rajappa P, Blakaj DM, Beyer S, Grecula JC, Sim AJ, Hardesty D, Elder JB, Chakravarti A, Thomas EM, Raval R. Patient-Reported Cognitive Outcomes and Survival after Stereotactic Radiosurgery for 15 or More Brain Metastases. Int J Radiat Oncol Biol Phys 2023; 117:e153-e154. [PMID: 37784741 DOI: 10.1016/j.ijrobp.2023.06.977] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Overall survival (OS) in metastatic cancer patients has been improving with continued advancements, necessitating greater attention to treatment related toxicities. Patients with ≥ 15 brain metastases (BM) continue to be treated with whole brain radiation therapy (WBRT), despite poor neurocognitive outcomes. We analyzed our institutional experience of treating these patients with stereotactic radiosurgery (SRS), with the aim of evaluating safety, cognitive outcomes, and survival metrics. MATERIALS/METHODS Patients who received SRS for ≥ 15 BMs in 1-5 fractions from 2014-2022 using the previously described single isocenter multi-target technique were included. Cognitive outcomes were objectively evaluated using serial Patient-Reported Outcome Measurement Information System (PROMIS) scores. Kaplan-Meier method was used for survival analysis and log-rank test was used for intergroup comparisons. RESULTS A total of 118 patients underwent 124 courses of LINAC-based SRS. The mean and median number of lesions treated per patient was 24.8 and 20, respectively (range 15 - 94). Most common primary histologies were lung (47.6%), melanoma (21.0%), and breast (14.5%). The median SRS dose was 24 Gy (range 18 - 30 Gy) with 87.9% receiving 3 fraction SRS. At the time of SRS, 19.4% patients had received prior WBRT and 24.2% had received at least one prior SRS course. The rate of any grade radiation necrosis (RN) and ≥ grade 3 RN were 15.3% and 3.2% respectively. New onset seizures were seen in 2.4%, alopecia in 2.4%, and subjective cognitive decline in 4% of patients. Median follow-up by reverse Kaplan-Meier method was 17.8 months (m). Cognitive data was available for 38 patients. Mean PROMIS scores at baseline, 3m, 6m and 9m after SRS were 32.0, 31.6, 30.4 and 28.7 out of 40, respectively. When longitudinal trends were available, 25 of 31 patients had a stable or improved PROMIS score. The 12m local control was 97.6%. Cumulative incidence of distant intracranial failure was 79.2%. One year freedom from neurological death, leptomeningeal disease, and salvage WBRT were 85.6%, 87.6% and 71.7% respectively. Median OS from brain metastases diagnosis was 11.3m (95% CI 7.2m - 15.3m) overall, while it was 9.2m (6.5 - 11.8m) after excluding patients who had prior WBRT or SRS (n = 79). One-year survival was 40% from diagnosis and 38.7% from SRS. On Cox regression analysis, prior WBRT (p = 0.002), higher KPS (p = 0.050), systemic therapy after SRS (p<0.001), and controlled extracranial disease (p = 0.007) predicted for improved OS. CONCLUSION We present here the largest study evaluating SRS for patients with ≥ 15 BMs. We found that SRS was safe, had favorable cognitive outcomes, and comparable survival outcomes to contemporary studies evaluating WBRT in this patient population. Treatment-naïve patients had a median survival of > 6 months, long enough to benefit from cognitive sparing with SRS. Our study supports further randomized studies comparing SRS and memory avoidance WBRT approaches for patients with ≥ 15 BMs.
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Affiliation(s)
- R Upadhyay
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - J D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - H K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J Schoenhals
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - J Ghose
- The Ohio State University, Columbus, OH
| | - P Rajappa
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - D M Blakaj
- James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH
| | - S Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J C Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - A J Sim
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - D Hardesty
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J B Elder
- The James Cancer Hospital, Columbus, OH
| | - A Chakravarti
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - E M Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - R Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
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3
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Dibs K, Facer BD, Palmer JD, Pan J, Raval R, Thomas EM, Cochran ER, Beyer S, Grecula JC, Ayan AS, Zoller W, Christ D, Scharschmidt T, Elder JB, Bourekas E, Xu D, Chakravarthy V, Elguindy AN, Chakravarti A, Blakaj DM. Vertebral Compression Fracture Post Spine Stereotactic Body Radiotherapy: The Role of Vertebral Endplate. Int J Radiat Oncol Biol Phys 2023; 117:e99. [PMID: 37786229 DOI: 10.1016/j.ijrobp.2023.06.866] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Maintaining hydrostatic pressure -via Pascal's Principle- between vertebral bodies is essential to decrease the chance of vertebral compression fracture (VCF). Vertebral endplates (EP) play an essential role in this matter through maintaining the mechanical environment as well as the proper nutrition of avascular discs. The purpose of this study is to establish the correlation of VCF with disrupted EP by tumor involvement. MATERIALS/METHODS A retrospective analysis of de novo spine metastases treated with stereotactic body radiotherapy (SBRT) between 2013-2019. Patients (pts) with previous surgical intervention were excluded. VCF defined as new or progression of existing loss of vertebral body height. The vertebral EP region defined in relation to the vertebral body as superior EP vs inferior EP. Kaplan-Meier curves used to analyze the variables. A multivariate proportional hazard model used to assess the risk of all covariates. RESULTS A total of 111 pts were treated with SBRT with a median dose of 27 Gy (10-35 Gy). Median follow-up was 18 months (1.2-107). The median age was 60 years (24-87) and 59 were males (53%) and 52 were females (47%). The median body mass index (BMI) was 27 kg/m2 (16-47). Almost 9 pts diagnosed with osteoporosis prior radiation. Twelve pts received prolonged steroids. Twenty pts received bisphosphonate and 8 pts received denosumab. The median PTV was 50cc (8-465) and median Conformity Index was 1.05 (0.42-1.4). Almost 75% of pts received >95% of the dose covering 100% of the PTV. The most common histopathologies were renal cell carcinoma (25%), lung (13%) and breast (11%). Most of the pts (77%) had SINS score of 7 or less. 48 pts (43%) had either superior or inferior EP disruption secondary to the tumor at the time of radiation. Twenty pts (18%) had both superiorly and inferiorly disrupted EP. Around 20 pts (18%) developed VCF. The median time to VCF was 5.2 months (1.1-57.4). The one-year cumulative incidence of VCF was 18%. The 1-year cumulative incidence of VCF with either superiorly and/or inferiorly disrupted EP was 29% vs 6%, p value <0.001. The 1-year cumulative incidence of VCF with both superiorly and inferiorly disrupted EP was 57% vs 7% (p value <0.001). The median time to VCF was earlier in pts with both disrupted EP (2.4 months vs 5.7 months, p value <0.05). Other risk factors like SINS score of >7 and local recurrence (LR) associated with higher risk of VCF. On multivariate analysis, LR (HR 8.2 [CI 2.4-28, p- value <0.001]), tumor disrupting the EP (HR 4.5 [CI 1.3-16, p-value<0.018]) and SINS score of seven and above (HR 1.7 [CI 1.3-2.25, p-value <0.001]) correlated with the VCF risk. CONCLUSION In this retrospective analysis, tumor disrupting the EP, disease recurrence and high SINS score increased the risk of VCF. Cement augmentation either prophylactically or immediately following SBRT is currently being studied in a prospective trial within our institution.
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Affiliation(s)
- K Dibs
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - B D Facer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J Pan
- The Ohio State University Wexner Medical Center, Center for Biostatistics, Columbus, OH
| | - R Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - E M Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - E R Cochran
- The Ohio State University Hospital, Columbus, OH, United States
| | - S Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J C Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - A S Ayan
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - W Zoller
- The James Cancer Center, Ohio State University Wexner Medical Center, Columbus, OH
| | - D Christ
- The Ohio State University Wexner Medical Center, Department of Radiation Oncology, Columbus, OH
| | | | - J B Elder
- The James Cancer Hospital, Columbus, OH
| | - E Bourekas
- The Ohio State University Wexner Medical Center, Department of Neuroradiology, Columbus, OH
| | - D Xu
- Department of neurosurgery, The James Cancer Center, Ohio State University Wexner Medical Center, Columbus, OH
| | - V Chakravarthy
- Department of neurosurgery, The James Cancer Center, Ohio State University Wexner Medical Center, Columbus, OH
| | - A N Elguindy
- The James Cancer Center, Ohio State University Wexner Medical Center, Columbus, OH
| | - A Chakravarti
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - D M Blakaj
- James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH
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Dibs K, Palmer JD, Prasad RN, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Thomas E, Grecula J, Guiou M, Soghrati S, Tili E, Raval RR, Mendel E, Scharschmidt T, Elder JB, Lonser R, Chakravarti A, Blakaj DM. Feasibility, safety, and efficacy of circumferential spine stereotactic body radiotherapy. Front Oncol 2022; 12:912799. [PMID: 36505845 PMCID: PMC9727181 DOI: 10.3389/fonc.2022.912799] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background With advances in systemic therapy translating to improved survival in metastatic malignancies, spine metastases have become an increasingly common source of morbidity. Achieving durable local control (LC) for patients with circumferential epidural disease can be particularly challenging. Circumferential stereotactic body radiotherapy (SBRT) may offer improved LC for circumferential vertebral and/or epidural metastatic spinal disease, but prospective (and retrospective) data are extremely limited. We sought to evaluate the feasibility, toxicity, and cancer control outcomes with this novel approach to circumferential spinal disease. Methods We retrospectively identified all circumferential SBRT courses delivered between 2013 and 2019 at a tertiary care institution for post-operative or intact spine metastases. Radiotherapy was delivered to 14-27.5 Gy in one to five fractions. Feasibility was assessed by determining the proportion of plans for which ≥95% planning target volume (PTV) was coverable by ≥95% prescription dose. The primary endpoint was 1-year LC. Factors associated with increased likelihood of local failure (LF) were explored. Acute and chronic toxicity were assessed. Detailed dosimetric data were collected. Results Fifty-eight patients receiving 64 circumferential SBRT courses were identified (median age 61, KPS ≥70, 57% men). With a median follow-up of 15 months, the 12-month local control was 85% (eight events). Five and three recurrences were in the epidural space and bone, respectively. On multivariate analysis, increased PTV and uncontrolled systemic disease were significantly associated with an increased likelihood of LF; ≥95% PTV was covered by ≥95% prescription dose in 94% of the cases. The rate of new or progressive vertebral compression fracture was 8%. There were no myelitis events or any grade 3+ acute or late toxicities. Conclusions For patients with circumferential disease, circumferential spine SBRT is feasible and may offer excellent LC without significant toxicity. A prospective evaluation of this approach is warranted.
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Affiliation(s)
- Khaled Dibs
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Rahul N. Prasad
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric C. Bourekas
- Department of Radiology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniel Boulter
- Department of Radiology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ahmet S. Ayan
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - William S. Marras
- Department of Biomedical Engineering, Spine Research Institute, The Ohio State University, Columbus, OH, United States
| | - Prasath Mageswaran
- Department of Biomedical Engineering, Spine Research Institute, The Ohio State University, Columbus, OH, United States
| | - Evan Thomas
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Michael Guiou
- Department of Radiation Oncology, Green Bay Oncology, Green Bay, WI, United States
| | - Soheil Soghrati
- Department of Mechanical and Aerospace Engineering at the Ohio State University, Columbus, OH, United States
| | - Esmerina Tili
- Department of Anesthesiology, Ohio State College of Medicine, Columbus, OH, United States
| | - Raju R. Raval
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ehud Mendel
- Department of Neurosurgery, School of Medicine, Yale University, New Haven, CT, United States
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - James B. Elder
- Department of Neurosurgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Arnab Chakravarti
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States,*Correspondence: Dukagjin M. Blakaj,
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Perlow HK, Ho C, Matsui JK, Prasad RN, Klamer BG, Wang J, Damante M, Upadhyay R, Thomas E, Blakaj DM, Beyer S, Lonser R, Hardesty D, Raval RR, Prabhu R, Elder JB, Palmer JD. Comparing Pre-Operative Versus Post-Operative Single and Multi-Fraction Stereotactic Radiotherapy for Patients with Resectable Brain Metastases. Clin Transl Radiat Oncol 2022; 38:117-122. [PMID: 36420099 PMCID: PMC9676204 DOI: 10.1016/j.ctro.2022.11.004] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Pre-operative radiation therapy for brain metastases may reduce meningeal disease. Pre-operative radiation therapy for brain metastases may reduce radionecrosis. Fractionated radiation therapy for brain metastases may reduce local failure. Fractionated pre-operative radiation therapy requires prospective validation.
Background The standard treatment for patients with large brain metastases and limited intracranial disease is surgical resection and post-operative stereotactic radiosurgery (SRS). However, post-operative SRS still has elevated rates of local failure (LF) and is complicated by radiation necrosis (RN), and meningeal disease (MD). Pre-operative SRS may reduce the risk of RN and MD, while fractionated therapy may improve local control through delivering a higher biological effective dose. We hypothesize that pre-operative fractionated stereotactic radiation therapy (FSRT) will have less toxicity compared to patients who receive post-operative SRS or FSRT. Methods A multi-institutional analysis was conducted and included patients who had surgical resection and stereotactic radiation therapy to treat at least one brain metastasis. Pertinent demographic, clinical, radiation, surgical, and follow up data were collected for each patient. The primary outcome was a composite endpoint defined as patients with one of the following adverse events: 1) LF, 2) MD, and/or 3) Grade 2 or higher (symptomatic) RN. Results 279 patients were eligible for analysis. The median follow-up time was 9 months. 87 % of patients received fractionated treatment. 29 % of patients received pre-operative treatment. The composite endpoint incidences for post-operative SRS (n = 10), post-operative FSRT (n = 189), pre-operative SRS (n = 27), and pre-operative FSRT (n = 53) were 0 %, 17 %, 15 %, and 7.5 %, respectively. Conclusions In our study, the composite endpoint of 7.5% for pre-operative FSRT compares favorably to our post-operative FSRT rate of 17%. Pre-operative FSRT was observed to have low rates of LF, MD, and RN. Prospective validation is needed.
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Affiliation(s)
- Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cindy Ho
- Ohio State University School of Medicine, Columbus, OH, USA
| | | | - Rahul N. Prasad
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Brett G. Klamer
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Joshua Wang
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mark Damante
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Evan Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Russell Lonser
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Douglas Hardesty
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Roshan Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
- Southeast Radiation Oncology Group, Charlotte, NC, USA
| | - James B. Elder
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Corresponding author at: 460 W. 10 Avenue, Columbus, OH 43210, USA.
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6
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Dibs K, Blakaj DM, Prasad RN, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Thomas E, Lee H, Grecula J, Raval RR, Mendel E, Scharschmidt T, Lonser R, Chakravarti A, Elder JB, Palmer JD. Spine Stereotactic Body Radiotherapy to Three or More Contiguous Vertebral Levels. Front Oncol 2022; 12:912804. [PMID: 35756685 PMCID: PMC9213679 DOI: 10.3389/fonc.2022.912804] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background With survival improving in many metastatic malignancies, spine metastases have increasingly become a source of significant morbidity; achieving durable local control (LC) is critical. Stereotactic body radiotherapy (SBRT) may offer improved LC and/or symptom palliation. However, due to setup concerns, SBRT is infrequently offered to patients with ≥3 contiguous involved levels. Because data are limited, we sought to evaluate the feasibility, toxicity, and cancer control outcomes of spine SBRT delivered to ≥3 contiguous levels. Methods We retrospectively identified all SBRT courses delivered between 2013 and 2019 at a tertiary care institution for postoperative or intact spine metastases. Radiotherapy was delivered to 14-35 Gy in 1-5 fractions. Patients were stratified by whether they received SBRT to 1-2 or ≥3 contiguous levels. The primary endpoint was 1-year LC and was compared between groups. Factors associated with increased likelihood of local failure (LF) were explored. Acute and chronic toxicity was assessed. In-depth dosimetric data were collected. Results Overall, 165 patients with 194 SBRT courses were identified [54% were men, median age was 61 years, 93% had Karnofsky Performance Status (KPS) ≥70, and median follow-up was 15 months]. One hundred thirteen patients (68%) received treatment to 1-2 and 52 to 3-7 (32%) levels. The 1-year LC was 88% (89% for 1-2 levels vs. 84% for ≥3 levels, p = 0.747). On multivariate analysis, uncontrolled systemic disease was associated with inferior LC for patients with ≥3 treated levels. No other demographic, disease, treatment, or dosimetric variables achieved significance. Rates of new/progressive fracture were equivalent (8% vs. 9.5%, p = 0.839). There were no radiation-induced myelopathy or grade 3+ acute or late toxicities in either group. Coverage of ≥95% of the planning target volume with ≥95% prescription dose was similar between groups (96% 1-2 levels vs. 89% ≥3 levels, p = 0.078). Conclusions For patients with ≥3 contiguous involved levels, spine SBRT is feasible and may offer excellent LC without significant toxicity. Prospective evaluation is warranted.
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Affiliation(s)
- Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Rahul N Prasad
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric C Bourekas
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniel Boulter
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ahmet S Ayan
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - William S Marras
- Spine Research Institute, Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, OH, United States
| | - Prasath Mageswaran
- Spine Research Institute, Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, OH, United States
| | - Evan Thomas
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Hyeri Lee
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Raju R Raval
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Arnab Chakravarti
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - James B Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
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Palmer JD, Prasad RN, Fabian D, Wei L, Yildiz VO, Tan Y, Grecula J, Welliver M, Williams T, Elder JB, Raval R, Blakaj D, Haglund K, Bazan J, Kendra K, Arnett A, Beyer S, Liebner D, Giglio P, Puduvalli V, Chakravarti A, Wuthrick E. Phase I study of trametinib in combination with whole brain radiation therapy for brain metastases. Radiother Oncol 2022; 170:21-26. [DOI: 10.1016/j.radonc.2022.03.016] [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] [Received: 12/27/2021] [Revised: 03/15/2022] [Accepted: 03/25/2022] [Indexed: 11/25/2022]
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8
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Perlow HK, Yaney A, Yang M, Klamer B, Matsui J, Raval RR, Blakaj DM, Arnett A, Beyer S, Elder JB, Ammirati M, Lonser R, Hardesty D, Ong S, Giglio P, Pillainayagam C, Goranovich J, Grecula J, Chakravarti A, Gondi V, Brown PD, Palmer JD. Dose-escalated accelerated hypofractionation for elderly or frail patients with a newly diagnosed glioblastoma. J Neurooncol 2022; 156:399-406. [PMID: 35013838 DOI: 10.1007/s11060-021-03925-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 10/21/2021] [Accepted: 12/06/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND The standard of care for elderly glioblastoma patients is 40 Gy in 15 fraction radiotherapy with temozolomide (TMZ). However, this regimen has a lower biologic equivalent dose (BED) compared to the Stupp regimen of 60 Gy in 30 fractions. We hypothesize that accelerated hypofractionated radiation of 52.5 Gy in 15 fractions (BED equivalent to Stupp) will have superior survival compared to 40 Gy in 15 fractions. METHODS Elderly patients (≥ 65 years old) who received hypofractionated radiation with TMZ from 2010 to 2020 were included in this analysis. Overall survival (OS) and progression free survival were defined as the time elapsed between surgery/biopsy and death from any cause or progression. Baseline characteristics were compared between patients who received 40 and 52.5 Gy. Univariable and multivariable analyses were performed. RESULTS Sixty-six newly diagnosed patients were eligible for analysis. Thirty-nine patients were treated with 40 Gy in 15 fractions while twenty-seven were treated with 52.5 Gy in 15 fractions. Patients had no significant differences in age, sex, methylation status, or performance status. OS was superior in the 52.5 Gy group (14.1 months) when compared to the 40 Gy group (7.9 months, p = 0.011). Isoeffective dosing to 52.5 Gy was shown to be an independent prognostic factor for improved OS on multivariable analysis. CONCLUSIONS Isoeffective dosing to 52.5 Gy in 15 fractions was associated with superior OS compared to standard of care 40 Gy in 15 fractions. These hypothesis generating data support accelerated hypofractionation in future prospective trials.
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Affiliation(s)
- Haley K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Alexander Yaney
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Michael Yang
- Ohio State University School of Medicine, Columbus, OH, USA
| | - Brett Klamer
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | | | - Raju R Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - James B Elder
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mario Ammirati
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Russell Lonser
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Douglas Hardesty
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Shirley Ong
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Pierre Giglio
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Clement Pillainayagam
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Justin Goranovich
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville, Northwestern Medicine Proton Center, Warrenville, IL, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Cinic, Rochester, MN, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA.
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9
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Blakaj DM, Palmer JD, Dibs K, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Katzir M, Yildiz VO, Grecula J, Arnett A, Raval R, Scharschmidt T, Elder JB, Lonser R, Chakravarti A, Mendel E. Postoperative Stereotactic Body Radiotherapy for Spinal Metastasis and Predictors of Local Control. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa587_s126] [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: 11/15/2022] Open
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10
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Beyer S, Sebastian NT, Prasad RN, Chu J, Liu K, Madan K, Jiang W, Ghose J, Blakaj DM, Palmer JD, Eltobgy M, Otero J, Elder JB, Raval RR. Malignant ossifying fibromyxoid tumor of the brain treated with post-operative fractionated stereotactic radiation therapy: A case report and literature review. Surg Neurol Int 2021; 12:588. [PMID: 34992905 PMCID: PMC8720422 DOI: 10.25259/sni_827_2021] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/05/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Ossifying fibromyxoid tumor (OFMT) is a rare musculoskeletal soft-tissue neoplasm of uncertain histogenesis most frequently occurring in the lower extremities. Conventionally, considered benign, these tumors are often managed by surgical resection followed by surveillance. However, malignant OFMTs with an increased propensity for local recurrence and distant metastasis have been recently identified, and the role of adjuvant therapy in these more aggressive cases is unclear. Case Description: We present, to the best of our knowledge, the first reported case of a primary, malignant, and intracranial OFMT. A 29-year-old female presented with recurrent headaches secondary to a large mass in her right frontal lobe. She underwent gross total resection of the brain mass with final pathology consistent with malignant OFMT demonstrating high-risk features including increased cellularity, grade, and mitotic activity. Due to these high-risk features, she received postoperative fractionated stereotactic radiation therapy (FSRT) to the resection cavity, and to the best of our knowledge, she represents the only known patient with OFMT to be treated with adjuvant FSRT. She tolerated the adjuvant treatment well with no acute or late toxicities and remains disease-free over 5 ½ years after resection. Conclusion: Adjuvant FSRT appears to be a safe and efficacious approach for managing this rare intracranial disease presentation. We review this patient’s clinical course in the context of the literature to demonstrate the difficulties associated with accurate diagnosis of this rare tumor and the controversial role of adjuvant therapy in preventing disease recurrence in this patient population.
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Affiliation(s)
- Sasha Beyer
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio,
| | | | - Rahul Neal Prasad
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio,
| | - Jacqueline Chu
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio,
| | - Kevin Liu
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio,
| | - Kajal Madan
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio,
| | - William Jiang
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio,
| | - Jayeeta Ghose
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio,
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio,
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio,
| | - Mostafa Eltobgy
- Department of Neuropathology, The Ohio State University, Columbus, Ohio
| | - Jose Otero
- Department of Neuropathology, The Ohio State University, Columbus, Ohio
| | - James B. Elder
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio,
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11
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Blakaj DM, Palmer JD, Dibs K, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Katzir M, Yildiz VO, Grecula J, Arnett A, Raval R, Scharschmidt T, Elder JB, Lonser R, Chakravarti A, Mendel E. Postoperative Stereotactic Body Radiotherapy for Spinal Metastasis and Predictors of Local Control. Neurosurgery 2021; 88:1021-1027. [PMID: 33575784 DOI: 10.1093/neuros/nyaa587] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 05/20/2020] [Accepted: 11/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Spine surgery is indicated for select patients with mechanical instability, pain, and/or malignant epidural spinal cord compression, with or without neurological compromise. Stereotactic body radiotherapy (SBRT) is an option for durable local control (LC) for metastatic spine disease. OBJECTIVE To determine factors associated with LC and progression-free survival (PFS) for patients receiving postoperative stereotactic spine radiosurgery. METHODS We analyzed consecutive patients from 2013 to 2019 treated with surgical intervention followed by SBRT. Surgical interventions included laminectomy and vertebrectomy. SBRT included patients treated with 1 to 5 fractions of radiosurgery. We analyzed LC, PFS, overall survival (OS), and toxicity. Univariate and multivariate analyses were performed. RESULTS A total of 63 patients were treated with a median follow-up of 12.5 mo. Approximately 75% of patients underwent vertebrectomy and 25% underwent laminectomy. One-year cumulative incidence of local failure was 19%. LC was significantly improved for patients receiving radiosurgery ≤40 d from surgery compared to that for patients receiving radiosurgery ≥40 d from surgery, 94% vs 75%, respectively, at 1 yr (P = .03). Patients who received preoperative embolization had improved LC with 1-yr LC of 88% vs 76% for those who did not receive preoperative embolization (P = .037). Significant predictors for LC on multivariate analysis were time from surgery to radiosurgery, higher radiotherapy dose, and preoperative embolization. The 1-yr PFS and OS was 56% and 60%, respectively. CONCLUSION Postoperative radiosurgery has excellent and durable LC for spine metastasis. An important consideration when planning postoperative radiosurgery is minimizing delay from surgery to radiosurgery. Preoperative embolization and higher radiotherapy dose were associated with improved LC warranting further study.
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Affiliation(s)
- Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric C Bourekas
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Boulter
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ahmet S Ayan
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - William S Marras
- Spine Research Institute, College of Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Prasath Mageswaran
- Spine Research Institute, College of Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Miki Katzir
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Vedat O Yildiz
- Center for Biostatistics, College of Medicine Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Raju Raval
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James B Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ehud Mendel
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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12
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Sebastian NT, Glenn C, Hughes R, Raval R, Chu J, DiCostanzo D, Bell EH, Grecula J, Arnett A, Gondal H, McGregor J, Elder JB, Lonser R, Chakravarti A, Trifiletti D, Brown PD, Chan M, Palmer JD. Linear accelerator-based radiosurgery is associated with lower incidence of radionecrosis compared with gamma knife for treatment of multiple brain metastases. Radiother Oncol 2020; 147:136-143. [PMID: 32294607 DOI: 10.1016/j.radonc.2020.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 10/05/2019] [Revised: 02/22/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Gamma knife (GK) and linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) both offer excellent local control in the management of multiple brain metastases. The efficacy and toxicity of LINAC and GK SRS have not been directly compared in the modern era. We studied outcomes in patients treated with LINAC SRS and GK at two separate institutions. METHODS We identified patients treated with either LINAC or GK who were treated to ≥2 lesions and had available follow up. LINAC patients were treated using single-isocenter multitarget technique. We used Cox regression, Fine and Gray competing risks regression, and nearest neighbor propensity score matching to account for confounders and imbalance between cohorts. Kaplan-Meier curves were used to estimate overall survival and rates of radionecrosis. RESULTS We identified 391 patients who were treated in 537 courses to a total 2699 lesions (LINAC: 1014, GK: 1685). After propensity score matching, GK was associated with similar overall survival (HR = 0.86; 95% CI 0.59-1.24; p = 0.41) and higher rate of radionecrosis (HR = 3.83; 95% CI 1.66-8.84; p = 0.002) compared to LINAC. In a secondary propensity score matched analysis comparing radionecrosis in single-fraction LINAC and GK, GK remained associated with higher incidence of radionecrosis (HR = 4.42; 95% CI 1.28-15.29; p = 0.019). CONCLUSIONS In this multi-institutional study, we found similar overall survival with lower incidence of radionecrosis in patients treated with LINAC compared to GK SRS. These findings are hypothesis generating and should be validated in an independent cohort.
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Affiliation(s)
- Nikhil T Sebastian
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Chase Glenn
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Raju Raval
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Jacqueline Chu
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Dominic DiCostanzo
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Erica H Bell
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Hasan Gondal
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - John McGregor
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - James B Elder
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Russell Lonser
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA; Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA.
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13
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Cloughesy TF, Landolfi J, Vogelbaum MA, Ostertag D, Elder JB, Bloomfield S, Carter B, Chen CC, Kalkanis SN, Kesari S, Lai A, Lee IY, Liau LM, Mikkelsen T, Nghiemphu P, Piccioni D, Accomando W, Diago OR, Hogan DJ, Gammon D, Kasahara N, Kheoh T, Jolly DJ, Gruber HE, Das A, Walbert T. Durable complete responses in some recurrent high-grade glioma patients treated with Toca 511 + Toca FC. Neuro Oncol 2019; 20:1383-1392. [PMID: 29762717 DOI: 10.1093/neuonc/noy075] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Vocimagene amiretrorepvec (Toca 511) is an investigational gamma-retroviral replicating vector encoding cytosine deaminase that, when used in combination with extended-release 5-fluorocytosine (Toca FC), results preclinically in local production of 5-fluorouracil, depletion of immune-suppressive myeloid cells, and subsequent induction of antitumor immunity. Recurrent high-grade glioma (rHGG) patients have a high unmet need for effective therapies that produce durable responses lasting more than 6 months. In this setting, relapse is nearly universal and most responses are transient. Methods In this Toca 511 ascending-dose phase I trial (NCT01470794), HGG patients who recurred after standard of care underwent surgical resection and received Toca 511 injected into the resection cavity wall, followed by orally administered cycles of Toca FC. Results Among 56 patients, durable complete responses were observed. A subgroup was identified based on Toca 511 dose and entry requirements for the follow-up phase III study. In this subgroup, which included both isocitrate dehydrogenase 1 (IDH1) mutant and wild-type tumors, the durable response rate is 21.7%. Median duration of follow-up for responders is 35.7+ months. As of August 25, 2017, all responders remain in response and are alive 33.9+ to 52.2+ months after Toca 511 administration, suggesting a positive association of durable response with overall survival. Conclusions Multiyear durable responses have been observed in rHGG patients treated with Toca 511 + Toca FC in a phase I trial, and the treatment will be further evaluated in a randomized phase III trial. Among IDH1 mutant patients treated at first recurrence, there may be an enrichment of complete responders.
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Affiliation(s)
- Timothy F Cloughesy
- Departments of Neuro-Oncology and Neurosurgery, University of California, Los Angeles, California
| | - Joseph Landolfi
- New Jersey Neuroscience Institute, JFK Brain Tumor Center, Edison, New Jersey
| | | | | | - James B Elder
- Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Stephen Bloomfield
- New Jersey Neuroscience Institute, JFK Brain Tumor Center, Edison, New Jersey
| | - Bob Carter
- Moores Cancer Center, Department of Neurosciences, University of California, San Diego, California
| | - Clark C Chen
- Moores Cancer Center, Department of Neurosciences, University of California, San Diego, California
| | | | - Santosh Kesari
- Moores Cancer Center, Department of Neurosciences, University of California, San Diego, California
| | - Albert Lai
- Departments of Neuro-Oncology and Neurosurgery, University of California, Los Angeles, California
| | - Ian Y Lee
- Henry Ford Hospital, Detroit, Michigan
| | - Linda M Liau
- Departments of Neuro-Oncology and Neurosurgery, University of California, Los Angeles, California
| | | | - Phioanh Nghiemphu
- Departments of Neuro-Oncology and Neurosurgery, University of California, Los Angeles, California
| | - David Piccioni
- Moores Cancer Center, Department of Neurosciences, University of California, San Diego, California
| | | | | | | | | | - Noriyuki Kasahara
- Tocagen Inc., San Diego, California.,Departments of Cell Biology and Pathology, University of Miami, UM
| | | | | | | | - Asha Das
- Tocagen Inc., San Diego, California
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14
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Palmer JD, Sebastian NT, Chu J, DiCostanzo D, Bell EH, Grecula J, Arnett A, Blakaj DM, McGregor J, Elder JB, Lu L, Zoller W, Addington M, Lonser R, Chakravarti A, Brown PD, Raval R. Single-Isocenter Multitarget Stereotactic Radiosurgery Is Safe and Effective in the Treatment of Multiple Brain Metastases. Adv Radiat Oncol 2019; 5:70-76. [PMID: 32051892 PMCID: PMC7004936 DOI: 10.1016/j.adro.2019.08.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/14/2019] [Accepted: 08/22/2019] [Indexed: 12/20/2022] Open
Abstract
Purpose Multiple studies have reported favorable outcomes for stereotactic radiosurgery (SRS) in the treatment of limited brain metastases. An obstacle of SRS in the management of numerous metastases is the longer treatment time using traditional radiosurgery. Single-isocenter multitarget (SIMT) SRS is a novel technique that permits rapid therapy delivery to multiple metastases. There is a lack of clinical evidence regarding its efficacy and safety. We report the outcomes of patients treated with this technique. Methods and Materials We reviewed the records of patients with intact or resected brain metastases treated with SRS in 1 to 5 fractions using SIMT technique at our institution, with at least 1 available follow-up brain magnetic resonance imaging. Survival, disease control, and toxicity were evaluated using Cox regression, logistic regression, and Kaplan-Meier analysis. Results We identified 173 patients with 1014 brain metastases. Median follow up was 12.7 months. Median beam-on time was 4.1 minutes. The median dose to the brain was 219.4 cGy. Median overall survival and freedom from intracranial progression were 13.2 and 6.3 months, respectively. Overall survival did not differ between patients treated with greater than or less than 4 lesions (hazard ratio, 1.03; 95% confidence interval 0.66-1.61; P = .91). Actuarial 1- and 2-year local control were 99.0% and 95.1%, respectively. Rates of grade 2 and grade 3 or higher radionecrosis were 1.4% and 0.9%, respectively. Conclusions SIMT radiosurgery delivered in 1 to 5 fractions offers excellent local control and acceptable toxicity in the treatment of multiple intact and postoperative brain metastases. This technique should be evaluated prospectively.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio.,Department of Neurosurgery, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Nikhil T Sebastian
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Jacquline Chu
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Dominic DiCostanzo
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Erica H Bell
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - John McGregor
- Department of Neurosurgery, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - James B Elder
- Department of Neurosurgery, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Lanchun Lu
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Wesley Zoller
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Mark Addington
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Russell Lonser
- Department of Neurosurgery, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Raju Raval
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
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Wang JL, Hong CS, Henderson EY, Salma A, Heerema NA, Ray-Chaudhury A, Elder JB. Simultaneous supratentorial anaplastic and infratentorial low grade ependymomas with distinct genetic profiles. J Neurosurg Sci 2018; 62:526-529. [PMID: 29938482 DOI: 10.23736/s0390-5616.17.03941-8] [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: 11/08/2022]
Affiliation(s)
- Joshua L Wang
- Department of Neurological Surgery, Ohio State University Medical Center, Columbus, OH, USA
| | | | | | - Asem Salma
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Nyla A Heerema
- Department of Pathology, Ohio State University Medical Center, Columbus, OH, USA
| | - Abhik Ray-Chaudhury
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - James B Elder
- Department of Neurological Surgery, Ohio State University Medical Center, Columbus, OH, USA -
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Zuckerman SL, Kreines F, Powers A, Iorgulescu JB, Elder JB, Bilsky MH, Laufer I. Stabilization of Tumor-Associated Craniovertebral Junction Instability: Indications, Operative Variables, and Outcomes. Neurosurgery 2018; 81:251-258. [PMID: 28368478 DOI: 10.1093/neuros/nyx070] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 06/17/2016] [Accepted: 01/26/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Whether primary or metastatic, tumors of the craniovertebral junction (CVJ) are rare and challenging. OBJECTIVE To examine the surgical indications, operative variables, and outcomes in patients with tumors of the CVJ undergoing occipitocervical (OC) stabilization. METHODS A single-institution, retrospective case series was performed from a prospectively maintained spine database. Patients with primary or metastatic tumors of the CVJ who underwent OC stabilization were identified. Out of 46 patients who underwent OC fusion, 39 were for tumor. Paired t -tests and Wilcoxon rank-sum tests were performed to assess for postoperative changes. RESULTS Ten patients (26%) harbored primary tumors, and the remaining 29 (74%) had metastatic disease. Of the metastatic patients, 14 had a neurological deficit, 10 had severe neck pain, and 5 were deemed mechanically unstable. Postoperative visual analog pain scores were significantly reduced at all 3 follow-up times ( P < .001, 95% confidence interval [CI; 3.2, 6.0]; P = .001, 95% CI [2.6, 7.7]; P = .020, 95% CI [0.6, 5.5]). The percentage of patients who were ambulatory and neurologically improved or intact remained stable postoperatively with no significant declines. There were 2 perioperative mortalities (5%), and 13 patients (33%) experienced a major complication. CONCLUSIONS In patients with primary or metastatic tumor of the CVJ, OC stabilization using a cervical screw-rod system affixed to a midline-keel buttress plate, with or without posterior decompression, is a reliable method for CVJ stabilization in the oncologic setting. Improvement in pain and preservation of neurological function was seen.
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Affiliation(s)
- Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Fabiana Kreines
- Department of Neurosurgery, Memorial Sloan-Ketter-ing?Cancer Center, New?York, New?York
| | - Ann Powers
- Department of Neurosurgery, Memorial Sloan-Ketter-ing?Cancer Center, New?York, New?York
| | - J Bryan Iorgulescu
- Department of Pathology, Brigham and Women's Hospital, Boston, Mas-sachusetts
| | - James B Elder
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan-Ketter-ing Cancer Center, New York, New York.,Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan-Ketter-ing Cancer Center, New York, New York.,Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
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Goceri E, Goksel B, Elder JB, Puduvalli VK, Otero JJ, Gurcan MN. Quantitative validation of anti-PTBP1 antibody for diagnostic neuropathology use: Image analysis approach. Int J Numer Method Biomed Eng 2017; 33:10.1002/cnm.2862. [PMID: 28024117 PMCID: PMC5963259 DOI: 10.1002/cnm.2862] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 12/19/2016] [Accepted: 12/21/2016] [Indexed: 05/13/2023]
Abstract
Traditional diagnostic neuropathology relies on subjective interpretation of visual data obtained from a brightfield microscopy. This approach causes high variability, unsatisfactory reproducibility, and inability for multiplexing even among experts. These problems may affect patient outcomes and confound clinical decision-making. Also, standard histological processing of pathological specimens leads to auto-fluorescence and other artifacts, a reason why fluorescent microscopy is not routinely implemented in diagnostic pathology. To overcome these problems, objective and quantitative methods are required to help neuropathologists in their clinical decision-making. Therefore, we propose a computerized image analysis method to validate anti-PTBP1 antibody for its potential use in diagnostic neuropathology. Images were obtained from standard neuropathological specimens stained with anti-PTBP1 antibody. First, the noise characteristics of the images were modeled and images are de-noised according to the noise model. Next, images are filtered with sigma-adaptive Gaussian filtering for normalization, and cell nuclei are detected and segmented with a k-means-based deterministic approach. Experiments on 29 data sets from 3 cases of brain tumor and reactive gliosis show statistically significant differences between the number of positively stained nuclei in images stained with and without anti-PTBP1 antibody. The experimental analysis of specimens from 3 different brain tumor groups and 1 reactive gliosis group indicates the feasibility of using anti-PTBP1 antibody in diagnostic neuropathology, and computerized image analysis provides a systematic and quantitative approach to explore feasibility.
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Affiliation(s)
- Evgin Goceri
- Department of Computer Engineering, Engineering Faculty, Akdeniz University, Dumlupinar Boulevard, TR-07058, Antalya, Turkey
| | - Behiye Goksel
- Department of Pathology, Division of Neuropathology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - James B Elder
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, 43210, USA
| | - Vinay K Puduvalli
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, 43210, USA
| | - Jose J Otero
- Department of Pathology, Division of Neuropathology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Metin N Gurcan
- Department of Biomedical Informatics, Wexner Medical Center, The Ohio State University, Columbus, OH, 43210, USA
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Moulding HD, Elder JB, Lis E, Lovelock DM, Zhang Z, Yamada Y, Bilsky MH. Local disease control after decompressive surgery and adjuvant high-dose single-fraction radiosurgery for spine metastases. J Neurosurg Spine 2010; 13:87-93. [DOI: 10.3171/2010.3.spine09639] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Object
Adjuvant radiation following epidural spinal cord decompression for tumor is a powerful tool used to achieve local disease control and preserve neurological function. To the authors' knowledge, only 1 published report addresses adjuvant stereotactic radiosurgery after this procedure, but that study used significantly lower doses than are currently prescribed. The authors review their experience using high-dose single-fraction radiosurgery as a postoperative adjuvant following surgical decompression and instrumentation to assess long-term local tumor control, morbidity, and survival.
Methods
A retrospective chart review identified 21 patients treated with surgical decompression and instrumentation for high-grade, epidural, spinal cord compression from tumor, followed by single-fraction high-dose spinal radiosurgery (dose range 18–24 Gy, median 24 Gy). Spinal cord dose was limited to a cord maximal dose of 14 Gy. Tumor histologies, time between surgery and radiosurgery, time to local recurrence after radiosurgery as assessed by serial MR imaging, and time to death were determined. Competing risk analysis was used to evaluate these end points.
Results
In this series, 20 tumors treated (95%) were considered highly radioresistant to conventional external beam radiation. The planning target volume received a high dose (24 Gy) in 16 patients (76.2%), and a low dose (18 or 21 Gy) in 5 patients (23.8%). During the study, 15 (72%) of 21 patients died, and in all cases death was due to systemic progression as opposed to local failure. The median overall survival after radiosurgery was 310 days (range 37 days to not reached). One patient (4.8%) underwent repeat surgery for local failure and 2 patients (9.5%) underwent spine surgery for other reasons. Local control was maintained after radiosurgery in 17 (81%) of 21 patients until death or most recent follow-up, with an estimated 1-year local failure risk of 9.5%. Of the failures, 3 of 4 were noted in patients receiving low-dose radiosurgery, equaling an overall failure rate of 60% (3 of 5 patients) and a 1-year local failure estimated risk of 20%. Those patients receiving adjuvant stereotactic radiosurgery with a high dose had a 93.8% overall local control rate (15 of 16 patients), with a 1-year estimated failure risk of 6.3%. Competing risk analysis showed this to be a significant difference between radiosurgical doses. One patient experienced a significant radiation-related complication; there were no wound-related issues after radiosurgery.
Conclusions
Spine radiosurgery after surgical decompression and instrumentation for tumor is a safe and effective technique that can achieve local tumor control until death in the vast majority of patients. In this series, those patients who received a higher radiosurgical dose had a significantly better local control rate.
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Affiliation(s)
- Hugh D. Moulding
- 1St. Luke's Neurosurgical Associates, Bethlehem, Pennsylvania; and
- 2Departments of Neurosurgery,
| | | | | | | | | | - Yoshiya Yamada
- 6Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
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Elder JB, Hoh DJ, Liu CY, Wang MY. Postoperative continuous paravertebral anesthetic infusion for pain control in posterior cervical spine surgery: a case-control study. Neurosurgery 2010; 66:99-106; discussion 106-7. [PMID: 20173578 DOI: 10.1227/01.neu.0000349208.87863.b3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Patients who undergo posterior cervical spinal fusion procedures frequently experience significant postoperative pain. Use of a local anesthetic continuous infusion pump after surgery may improve these outcome variables. METHODS After posterior cervical spine fusion procedures, 25 consecutive patients received continuous infusion of 0.5% bupivacaine into the subfascial aspects of the wound via an elastomeric pump. Data were collected prospectively by third party assessment using standard nursing protocols. This included numeric pain scores and opiate use over the first 4 postoperative days (PODs), length of hospitalization, and complications. In a retrospective analysis, we compared each study patient to a control patient who did not receive the continuous infusion of bupivacaine. Demographic variables and surgical procedure were similar among matched cases. RESULTS Patients receiving continuous local anesthetic infusion used significantly less narcotics (P < .05) during the first 4 PODs: 24.4% on day 1, 34.1% on day 2, 53.5% on day 3, and 58.1% on day 4. A lower average pain score was observed among study patients on each POD (P < .05): 31.5% less on day 1, 13.0% on day 2, 24.0% on day 3, and 35.7% on day 4. Patients with the infusion device were discharged home earlier (POD 4.9 versus 6.7; P = .024) and demonstrated improvement in time to ambulation, first bowel movement, and discontinuation of the patient-controlled analgesia machine. No complications were associated with the device. CONCLUSION Patients with the local anesthetic continuous infusion device required less narcotics and reported lower pain scores than control patients on each of the first 4 PODs. These results suggest that continuous infusion of local anesthetic into the paravertebral tissue during the immediate postoperative period is a safe and effective technique that achieves lower pain scores and narcotic use and improves multiple postoperative outcome variables.
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Affiliation(s)
- James B Elder
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
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Affiliation(s)
- Michael L.J. Apuzzo
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - James B. Elder
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Charles Y. Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, and Division of Chemistry and Chemical Engineering, California Institute of Technology, Pasadena, California
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Farin A, Liu CY, Elder JB, Langmoen IA, Apuzzo MLJ. The biological restoration of central nervous system architecture and function: part 1-foundations and historical landmarks in contemporary stem cell biology. Neurosurgery 2009; 64:15-39; discussion 34. [PMID: 19145154 DOI: 10.1227/01.neu.0000337580.02706.dc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Since their discovery, stem cells have fascinated scientists with their ultimate potential: the ability to cure disease, repair altered physiology, and reverse neurological deficit. Stem cell science unquestionably promises to eliminate many of the tragic limitations contemporary medicine must acknowledge, and cloning may provide young cells for an aging population. Although it is widely believed that stem cells will transform the way medicine is practiced, therapeutic interventions using stem cell technology are still in their infancy. The 3 most common stem cell sources studied today are umbilical cord blood, bone marrow, and human embryos. Although cord blood is currently used to treat dozens of disorders and bone marrow stem cells have been used clinically since the 1960s, human embryonic stem cells have yet to be successfully applied to any disease. Undeniably, stem cell therapy has the potential to be one of the most powerful therapeutic options available. In this introductory article of a 5-part series on stem cells, we narrate the evolution of modern stem cell science, delineating major landmarks that will prove responsible for taking stem cell technology from the laboratory into revolutionary clinical applications: from the first milestone of identifying the mouse hematopoietic stem cell to the latest feats of producing pluripotent stem cells without embryos at all. In Part 2, we present the evidence demonstrating the certainty of adult mammalian neurogenesis; in Parts 3 and 4, we describe neurosurgical applications of stem cell technology; and in Part 5, we discuss the philosophical and ethical issues surrounding stem cell therapy, as well as future areas of exploration.
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Affiliation(s)
- Azadeh Farin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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Jabbour MN, Elder JB, Samuelson CG, Khashabi S, Hofman FM, Giannotta SL, Liu CY. ABERRANT ANGIOGENIC CHARACTERISTICS OF HUMAN BRAIN ARTERIOVENOUS MALFORMATION ENDOTHELIAL CELLS. Neurosurgery 2009; 64:139-46; discussion 146-8. [PMID: 19145162 DOI: 10.1227/01.neu.0000334417.56742.24] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
OBJECTIVE
To identify and characterize the phenotypic and functional differences of endothelial cells derived from cerebral arteriovenous malformations (AVM), as compared with endothelial cells derived from a normal brain.
METHODS
Isolated AVM brain endothelial cells and control brain endothelial cells were evaluated immunohistochemically for expression of the endothelial cell markers von Willebrand factor and CD31, as well as angiogenic factors including vascular endothelial growth factor A, interleukin-8, and endothelin-1. Vascular endothelial growth factor receptors 1 and 2 were also evaluated using immunohistochemistry techniques. Functional assays evaluated cell proliferation, cytokine production, tubule formation, and cell migration using the modified Boyden chamber technique.
RESULTS
Endothelial cells derived from AVMs expressed high levels of vascular endothelial growth factor A and significantly overexpressed the vascular endothelial growth factor receptors 1 and 2 (P < 0.05), as compared with control endothelial cells. In addition, comparison to control brain endothelial cells demonstrated that AVM brain endothelial cells proliferated faster, migrated more quickly, and produced aberrant tubule-like structures.
CONCLUSION
Endothelial cells derived from cerebral AVMs are highly activated cells overexpressing proangiogenic growth factors and exhibiting abnormal functions consistent with highly activated endothelial cells.
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Affiliation(s)
- Mark N. Jabbour
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - James B. Elder
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Shabnam Khashabi
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Florence M. Hofman
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Steven L. Giannotta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Charles Y. Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
- Division of Chemistry and Chemical Engineering, California Institute of Technology, Pasadena, California
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Abstract
This article presents an assessment of the power of ideas and their role in initiating change and progress. The enormous potential cascade effect is illustrated by examining the movement of Modernism in the arts. Next, the immense scope and capabilities of the modern scientific endeavor-with robotic space exploration at the scale of 10 meters at one extreme and the wonders of nanoscience at the scale of 10 m at the other-are examined. The attitudes and philosophies of neurological surgery are related to those involved in the Modernist movement and placed on the defined scale of contemporary scientific activity.
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Affiliation(s)
- Michael L J Apuzzo
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Abstract
ABSTRACT
INTRAOPERATIVE MANIPULATION TO correct scoliotic deformities relies upon spinal instrumentation for stabilization and fusion. However, novel strategies and innovative implant biotechnologies have emerged, applying natural growth and elongation of the immature spine for the treatment of scoliosis in young patients. In this work, we review the principles of growth modulation and the Hueter-Volkmann law as it applies to experimental models of scoliosis formation and correction. Current implant technologies, including shape memory alloy vertebral staples, growing rods, and vertical expandable titanium prosthetic ribs, are explored, with regards to implant design, surgical techniques, and clinical investigations. An exciting area of spinal implant technology is now becoming available to expand the surgical armamentarium for treating severe scoliotic deformity in young patients.
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Affiliation(s)
- Daniel J. Hoh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - James B. Elder
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael Y. Wang
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, Florida
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Hoh DJ, Larsen DW, Elder JB, Kim PE, Giannotta SL, Liu CY. Novel Use of an Endovascular Embolectomy Device for Retrograde Suction Decompression-Assisted Clip Ligation of a Large Paraclinoid Aneurysm: Technical Case Report. Oper Neurosurg (Hagerstown) 2008; 62:ONSE412-3; discussion ONSE413-4. [DOI: 10.1227/01.neu.0000326027.39467.88] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective:
Several different methodologies for proximal occlusion and retrograde suction decompression of large paraclinoid aneurysms have been reported previously. In this article, we describe the novel use of an endovascular embolectomy device (F.A.S.T. funnel catheter; Genesis Medical Interventional, Inc., Redwood City, CA) for temporary internal carotid artery occlusion and suction decompression of an intracranial aneurysm to facilitate surgical clip ligation. The combination of atraumatic occlusion technology and large lumen size makes this technique safer and easier.
Clinical Presentation:
A 53-year-old woman with progressive headaches underwent computed tomographic angiography, which revealed an unruptured large left paraclinoid aneurysm. Cerebral angiography confirmed the diagnosis. The patient did not tolerate a balloon test occlusion for therapeutic Hunterian internal carotid occlusion. The patient was subsequently taken to the operating room for a craniotomy and clip ligation of the aneurysm.
Intervention:
A standard left pterional craniotomy was performed with opening of the sylvian fissure and exposure of the left paraclinoid aneurysm. Intraoperative angiography with introduction of a new endovascular embolectomy device was performed. The device was deployed to achieve temporary occlusion of the cervical internal carotid artery, and aspiration through the central lumen allowed for retrograde suction decompression of the aneurysm. Collapse of the aneurysm through this technique permitted visualization of the aneurysmal neck with successful clip ligation.
Conclusion:
A new endovascular embolectomy device can be used to safely perform suction decompression of large paraclinoid aneurysms to facilitate clip ligation.
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Affiliation(s)
- Daniel J. Hoh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Donald W. Larsen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - James B. Elder
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Paul E. Kim
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Steven L. Giannotta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Charles Y. Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Abstract
Nanotechnology as a science has evolved from notions and speculation to emerge as a prominent combination of science and engineering that stands to impact innumerable aspects of technology. Medicine in general and neurosurgery in particular will benefit greatly in terms of improved diagnostic and therapeutic capabilities. The recent explosion in nanotechnology products, including diverse applications such as beauty products and medical contrast agents, has been accompanied by an ever increasing volume of literature. Recent articles from our institution provided an historical and scientific background of nanotechnology, with a purposeful focus on nanomedicine. Future applications of nanotechnology to neuroscience and neurosurgery were briefly addressed. The present article is the first of two that will further this discussion by providing specific details of current nanotechnology applications and research related to neuroscience and clinical neurosurgery. This article also provides relevant perspective in scale, history, economics, and toxicology. Topics of specific importance to developments or advances of technologies used by neuroscientists and neurosurgeons are presented. In addition, advances in the field of microelectromechanical systems technology are discussed. Although larger than nanoscale, microelectromechanical systems technologies will play an important role in the future of medicine and neurosurgery. The second article will discuss current nanotechnologies that are being, or will be in the near future, incorporated into the armamentarium of the neurosurgeon. The goal of these articles is to keep the neuroscience community abreast of current developments in nanotechnology, nanomedicine, and, in particular, nanoneurosurgery, and to present possibilities for future applications of nanotechnology. As applications of nanotechnology permeate all forms of scientific and medical research, clinical applications will continue to emerge. Physicians of the present and future must take an active role in shaping the design and research of nanotechnologies to ensure maximal clinical relevance and patient benefit.
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Affiliation(s)
- James B Elder
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
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Affiliation(s)
- James B. Elder
- Department of Neurological Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Charles Y. Liu
- Department of Neurological Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California
- Division of Chemistry and Chemical Engineering, California Institute of Technology, Pasadena, California
| | - Michael L.J. Apuzzo
- Department of Neurological Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California
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Abstract
✓Primary intraosseous meningiomas are a subtype of primary extradural meningiomas and constitute fewer than 2% of meningiomas overall, but they represent approximately two thirds of all extradural meningiomas. These types of meningiomas originate within the bones of the skull and thus can have a clinical presentation and radiographic differential diagnosis that is different from those for intradural meningiomas.
Primary intraosseous meningiomas are classified based on their location and histopathological characteristics. Treatment primarily involves resection with wide margins if possible. Very little literature exists regarding the use of adjuvant therapies such as radiation and chemotherapy for these tumors. In fact, the literature regarding primary intra-osseous meningiomas consists mostly of clinical case reports and case series. This literature is reviewed and summarized in this article.
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Affiliation(s)
| | | | - Chi-Shing Zee
- 3Radiology, University of Southern California, Los Angeles, California
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Elder JB. THIEME Atlas of Anatomy Series. Neurosurgery 2007. [DOI: 10.1227/01.neu.0000290923.01213.93] [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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Elder JB. Adams and Graham's Introduction to Neuropathology. Neurosurgery 2007. [DOI: 10.1227/01.neu.0000290925.85965.e8] [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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Anderson RCE, Anderson DE, Elder JB, Brown MD, Mandigo CE, Parsa AT, Goodman RR, McKhann GM, Sisti MB, Bruce JN. Lack of B7 expression, not human leukocyte antigen expression, facilitates immune evasion by human malignant gliomas. Neurosurgery 2007; 60:1129-36; discussion 1136. [PMID: 17538388 DOI: 10.1227/01.neu.0000255460.91892.44] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Lack of human leukocyte antigens and costimulatory molecules have been suggested as mechanisms by which human malignant gliomas avoid immune recognition and elimination. METHODS Using quantitative multiparameter flow cytometric analysis, tumor cells from patients with glioblastoma multiforme (n = 18) were examined ex vivo for the expression of human leukocyte antigen Class I and II molecules and the costimulatory molecules B7-1 and B7-2. They were compared with reactive astrocytes from peritumoral brain metastases (n = 7), and astrocytes removed during nontumor surgery (n = 5). RESULTS In contrast to the vast majority of solid peripheral human tumors, these results demonstrate that glioblastoma multiforme frequently express both human leukocyte antigen Class I and II molecules. Like most solid peripheral tumors, glioblastoma multiforme tumor cells express few or no B7 costimulatory molecules. Functional assays using heterogeneous ex vivo tumor preparations or pure populations of ex vivo tumor cells and microglia obtained using fluorescence-activated cell sorting indicate that CD4+ T-cells are activated by tumor cells only in the presence of exogenous B7 costimulation (provided by addition of soluble agonist anti-CD28 monoclonal antibody). CONCLUSION Thus, in contrast to many solid peripheral tumors, failure to present tumor antigens is not a likely impediment to immunotherapeutic strategies against malignant gliomas. Rather, immunotherapeutic strategies need to overcome low levels of B7 costimulation.
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Affiliation(s)
- Richard C E Anderson
- Department of Neurological Surgery, The Neurological Institute, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
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Abstract
Giant cell tumors of the bone are rare, locally aggressive lesions that primarily affect the epiphyses of long bones. These tumors can occur in the skull, principally in the sphenoid and temporal bones. Symptoms of these tumors depend on their site of origin but typically include headache, pain, visual field defects, and conductive hearing loss. Histologically, these tumors consist of three cell types: osteoclast-like multinucleated giant cells; round mononuclear cells resembling monocytes; and spindle-shaped, fibroblast-like stromal cells. Radiographically, the tumors appear osteolytic and radiolucent without a sclerotic border. These tumors typically present in the third to fourth decades of life and rarely occur in patients under 20 years of age. The small number of studies of giant cell tumors of the skull has focused on the adolescent and adult populations. The authors report two cases of giant cell tumors of the skull in pediatric patients. In the first case, a 2-year-old girl presented with swelling behind the right ear. In the second case, a 7-week-old girl presented with a mass within the external auditory canal. Both patients underwent metastatic workup and biopsy procedures before resection of the tumor. Both case reports contribute to the literature of giant cell tumors of the skull by describing this condition in pediatric patients. To the authors' knowledge, these cases represent the youngest two patients with giant cell tumors of the skull yet described.
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Affiliation(s)
- James B Elder
- Division of Neurosurgery, Childrens Hospital Los Angeles, Los Angeles, California 90033, USA.
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Bahar A, Whitby P, Holley S, Hoban PR, Elder JB, Deakin M, Hall C, Clayton RN, Williams GT, Farrell WE. Primary colorectal tumors fail to express the proapoptotic mediator PTAG and its reexpression augments drug-induced apoptosis. Genes Chromosomes Cancer 2006; 46:202-12. [PMID: 17117413 DOI: 10.1002/gcc.20401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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] [Indexed: 11/09/2022] Open
Abstract
Genes implicated in tumor evolution and progression, including those in apoptotic pathways, are associated with methylation-associated gene silencing in different tumor types. By exploiting differential methylation we recently isolated a novel pituitary tumor derived apoptosis gene (PTAG) that augments drug-induced apoptosis. The importance of PTAG was determined in other tumor types, and these studies show that the majority of primary colorectal tumors fail to express the PTAG gene, indicating an important role for PTAG in colorectal tumorigenesis. The effects of expression of PTAG were examined through stable transfection of the colorectal cell lines HCT116 and SW480. Expression of PTAG, per se, had no discernible effects on cell viability or cell kinetics. In contrast to these findings, in cells subject to drug challenges that engaged either a death-receptor mediated or mitochondrial pathway, all of the experiments indicated a role for PTAG in the intrinsic pathway of apoptosis. Loss of PTAG therefore contributes to a blunted apoptotic response and is likely to predispose cells toward malignant transformation and resistance to chemotherapeutic interventions.
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Affiliation(s)
- Adil Bahar
- Institute of Science and Technology in Medicine, School of Medicine, Keele University, Stoke on Trent, Staffordshire ST4 7QB, UK
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Abstract
Early diagnosis is central to proper management of primary central nervous system lymphomas (PCNSLs). Surgical intervention hinges on initial entertainment of a diagnosis of a PCNSL, based on acute neurological presentation and neuroimaging findings. Unless there is an urgent need for surgical decompression, a biopsy to obtain a diagnosis of PCNSL is the first step in surgical management. Repeated biopsy may be necessary in patients who have received preoperative steroid therapy. Patients with PCNSL may also present with leptomeningeal involvement, resulting in the need for an Ommaya reservoir for intrathecal chemotherapy. In cases in which hydrocephalus develops, placement of a ventriculoperitoneal shunt may be necessary. Two case studies are presented to highlight the role of surgical intervention in PCNSL.
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Affiliation(s)
- James B Elder
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
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Elder JB, Wang MY. Postoperative Continuous Paravertebral Anesthetic Infusion for Pain Control in Lumbar Spinal Fusion Surgery: A Case-control Study. Neurosurgery 2006. [DOI: 10.1227/01.neu.0000309903.90304.84] [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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Elder JB, Wang MY. Postoperative Continuous Paravertebral Anesthetic Infusion for Pain Control in Lumbar Spinal Fusion Surgery: A Case-control Study. Neurosurgery 2006. [DOI: 10.1227/00006123-200608000-00091] [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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Holley SL, Rajagopal R, Hoban PR, Deakin M, Fawole AS, Elder JB, Elder J, Smith V, Strange RC, Fryer AA. Polymorphisms in the glutathione S-transferase mu cluster are associated with tumour progression and patient outcome in colorectal cancer. Int J Oncol 2006; 28:231-6. [PMID: 16328000] [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: 05/05/2023] Open
Abstract
Glutathione S-transferase (GST) enzymes catalyse the detoxification of by-products of reactive oxygen species and are thus important in cellular defence mechanisms. The GSTs are polymorphic with allelic variants encoding isoforms with functional differences. GST polymorphism has been associated with susceptibility and clinical outcome in patients with cancer. In this retrospective cohort, we have investigated associations between common GSTM1, GSTM3 and GSTP1 polymorphisms with factors known to influence clinical out-come and patient survival in colorectal cancer. Significant linkage disequilibrium was demonstrated between GSTM1 and GSTM3 alleles (P< or =0.001). We identified no significant associations between the GSTP1(Ile105Val105) polymorphism and any clinical outcome parameters or patient survival. However significant associations were demonstrated with mu class GSTs. Those patients who were GSTM1 null presented less frequently with poorly-differentiated tumours (P=0.038). Furthermore, patients who were GSTM3 AA were less likely to present with advanced stage tumours (T-stage, P=0.036 and Dukes' classifications, P=0.012) or distant metastases (P=0.017) when examined alone. Upon further examination of the effect of linkage disequilibrium, we found that, in GSTM1 null individuals, GSTM3 AA (compared with other GSTM3 genotypes combined) had longer disease-free survival (HR=0.54, 95% CI 0.30-0.98, P=0.044). Thus, the GSTM3 AA genotype is associated with improved prognosis especially in those with GSTM1 null. Our findings suggest that the GST mu gene cluster mediates tumour characteristics and survival in patients with colorectal cancer.
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Affiliation(s)
- Sarah L Holley
- Human Genomics Research Group, Institute for Science and Technology in Medicine, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, Staffordshire ST4 7QB, UK.
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45
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Elder JB. Gastrointestinal Emergencies Volume 10, No. 1. Edited A. Torsoli. 232 × 160 mm. Pp. 260 + vii. Illustrated. 1981. Eastbourne: Holt—Saunders. £9·75. Br J Surg 2005. [DOI: 10.1002/bjs.1800681124] [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: 11/10/2022]
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Elder JB. Guide to house surgeons in the surgical unit. G. J. Fraenkel, J. Ludbrook and H. A. F. Dudley. Sixth edition. 150 × 120 mm. Pp. 203 + xii. Illustrated. 1978. London: Heinemann. £2.90. Br J Surg 2005. [DOI: 10.1002/bjs.1800660522] [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: 11/08/2022]
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47
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Elder JB. A textbook of surgical pathology. Sir Charles Illingworth and B. M. Dick. Twelfth Edition. 255 × 195 mm. Pp. 357. Illustrated. 1979. Edinburgh: Churchill Livingstone. £15·00. Br J Surg 2005. [DOI: 10.1002/bjs.1800670322] [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: 11/05/2022]
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Kmiot WA, Bramhall S, Elder JB. Life quality and psychological morbidity with an ileostomy. Br J Surg 2005. [DOI: 10.1002/bjs.1800800959] [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: 11/08/2022]
Affiliation(s)
- W A Kmiot
- Birmingham Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK
| | - S Bramhall
- Birmingham Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK
| | - J B Elder
- Department of Surgery, North Staffordshire Hospital Centre, Thornburrow Drive, Hartshill, Stoke–on–Trent ST4 7QB, UK
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Rajagopal R, Deakin M, Fawole AS, Elder JB, Elder J, Smith V, Strange RC, Fryer AA. Glutathione S -transferase T1 polymorphisms are associated with outcome in colorectal cancer. Carcinogenesis 2005; 26:2157-63. [PMID: 16051638 DOI: 10.1093/carcin/bgi195] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Colorectal cancer (CRC) remains a significant cause of mortality accounting for approximately 10% of all deaths from malignancy in the western world. Polymorphism in the glutathione S-transferase GSTT1 gene has been associated with CRC risk in some but not all studies. In this study, we examined associations between GSTT1 genotypes and CRC risk, and prognosis in 361 cases and 881 unrelated controls. GSTT1 null was associated with a small but significant increase in risk (P = 0.0006, odds ratio (OR) = 1.65, 95% confidence interval (CI) = 1.22-2.24). GSTT1 null was also associated with a significantly younger age at diagnosis (mean 65.2 years) compared with GSTT1 A (mean 67.6 years, P = 0.031). There were no significant associations between GSTT1 genotypes and clinical factors (e.g. Dukes stage, differentiation and tumour node metastasis classification) in the total case group. However, following stratification by age (<70 versus > or =70 years at diagnosis), in the patients diagnosed <70 years of age, GSTT1 null was more common in Dukes grade A/B tumours (P = 0.046), stage T1/T2 tumours (P = 0.053) and those with a pushing margin (P = 0.066). We also identified associations between GSTT1 null and increased prevalence of host lymphocyte response, particularly in the younger patients (P = 0.036). Furthermore, GSTT1 null was associated with improved survival in younger patients (P = 0.017, hazards ratio (HR) = 0.52, 95% CI = 0.31-0.89) but poorer survival in older patients (P = 0.017, HR = 1.89, 95% CI = 1.12-3.20). We proposed a model based on the dual functionality of GSTT1 to explain these contrasting results. We suggest that the null genotype is associated with improved immune response in younger patients, but poorer detoxification in older patients. These findings may also provide an explanation for the contrasting finding of other studies on the role of this gene in CRC.
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Affiliation(s)
- R Rajagopal
- Human Genomics Research Group, University of Keele, University Hospital of North Staffordshire, Stoke-on-Trent, Staffordshire, UK
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McCloud JM, Sivakumar R, Greenhough A, Elder J, Jones PW, Deakin M, Elder JB, Fryer AA, Hoban PR. p16INK4a polymorphism: associations with tumour progression in patients with sporadic colorectal cancer. Int J Oncol 2004; 25:1447-52. [PMID: 15492837] [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: 05/01/2023] Open
Abstract
Deregulated tumour expression of p16INK4a has previously been described in association with clinical progression in sporadic colorectal cancer patients (CRC). Furthermore, p16INK4a promoter hypermethylation leading to gene silencing has been shown to occur in advanced colorectal tumours and has been associated with patient survival. p16INK4a is polymorphic, with variant alleles being associated with tumour progression in melanoma. In this study we have examined p16INK4a polymorphism as a marker of tumour progression in sporadic CRC. Polymorphic sites G/A(442), C/G(500), and C/T(540), were studied, these alleles obeyed Hardy Weinberg equilibrium in a control group, but not in the CRC cases. G/A(442) and CG(500) alleles were in linkage disequilibrium in both cases and controls. In controls the C/T(540) alleles demonstrated no linkage with either other site, whilst an association was demonstrated between C/G(500) and C/T(540) alleles in the cases (p=0.011). Furthermore, the distribution of C/T(540) genotypes was different between the groups (p=0.002). Within the CRC cases, patients with the GG(442) genotype were more commonly associated with decreased tumour differentiation (p=0.018), advancing Dukes' stage (p=0.006) and T-stage (p=0.007) than patients with the GA(442) and AA(442) genotypes. Patients with the CC(500) genotype were more commonly associated with decreased tumour differentiation (p=0.012), advancing Dukes' stage (p=0.015), and N-stage (p=0.031). No associations between patient C/T(540) genotype and clinical prognostic parameters were found. An analysis of patient tumour expression with p16INK4a genotype revealed patients with the CC(500) genotype were more commonly associated with reduced tumour p16 expression (p=0.046). In summary our data indicate that p16INK4a polymorphism is associated with tumour progression in patients with sporadic CRC.
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Affiliation(s)
- Jonathan M McCloud
- Human Genomics Research Group, Institute for Science and Technology in Medicine, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
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