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Song KH, Ge X, Engelbach J, Rich KM, Ackerman JJH, Garbow JR. Deuterium Magnetic Resonance Spectroscopy Quantifies Tumor Fraction in a Mouse Model of a Mixed Radiation Necrosis / GL261-Glioblastoma Lesion. Mol Imaging Biol 2024; 26:173-178. [PMID: 37516675 DOI: 10.1007/s11307-023-01837-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE Distinguishing recurrent brain tumor from treatment effects, including late time-to-onset radiation necrosis (RN), presents an on-going challenge in post-treatment imaging of neuro-oncology patients. Experiments were performed in a novel mouse model that recapitulates the relevant clinical histologic features of recurrent glioblastoma growing in a RN environment, the mixed tumor/RN model. The goal of this work was to apply single-voxel deuterium (2H) magnetic resonance spectroscopy (MRS), in concert with administration of deuterated glucose, to determine if the metabolic signature of aerobic glycolysis (Warburg effect: glucose → lactate in the presence of O2), a distinguishing characteristic of proliferating tumor, provides a quantitative readout of the tumor fraction (percent) in a mixed tumor/RN lesion. PROCEDURES 2H MRS employed the SPin-ECho full-Intensity Acquired Localized (SPECIAL) MRS pulse sequence and outer volume suppression at 11.74 T. For each subject, a single 2H MRS voxel was placed over the mixed lesion as defined by contrast enhanced (CE) 1H T1-weighted MRI. Following intravenous administration of [6,6-2H2]glucose (Glc), 2H MRS monitored the glycolytic conversion to [3,3-2H2]lactate (Lac) and glutamate + glutamine (Glu + Gln = Glx). RESULTS Based on previous work, the tumor fraction of the mixed lesion was quantified as the ratio of tumor volume, defined by 1H magnetization transfer experiments, vs. the total mixed-lesion volume. Metabolite 2H MR spectral-amplitude values were converted to metabolite concentrations using the natural-abundance semi-heavy water (1HO2H) resonance as an internal concentration standard. The 2H MR-determined [Lac] / [Glx] ratio was strongly linearly correlated with tumor fraction in the mixed lesion (n = 9), Pearson's r = 0.87, and 77% of the variation in the [Lac] / [Glx] ratio was due to tumor percent r2 = 0.77. CONCLUSIONS This preclinical study supports the proposal that 2H MR could occupy a well-defined secondary role when standard-of-care 1H imaging is non-diagnostic regarding tumor presence and/or response to therapy.
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Affiliation(s)
- Kyu-Ho Song
- Department of Radiology, Biomedical MR Center, Washington University, 660 South Euclid Avenue, MO 63110, St. Louis, MO, Mail Stop Code: MSC 8227-0082-02, USA
| | - Xia Ge
- Department of Radiology, Biomedical MR Center, Washington University, 660 South Euclid Avenue, MO 63110, St. Louis, MO, Mail Stop Code: MSC 8227-0082-02, USA
| | - John Engelbach
- Department of Radiology, Biomedical MR Center, Washington University, 660 South Euclid Avenue, MO 63110, St. Louis, MO, Mail Stop Code: MSC 8227-0082-02, USA
| | - Keith M Rich
- Department of Neurosurgery, Washington University, St. Louis, MO, USA
| | - Joseph J H Ackerman
- Department of Radiology, Biomedical MR Center, Washington University, 660 South Euclid Avenue, MO 63110, St. Louis, MO, Mail Stop Code: MSC 8227-0082-02, USA
- Department of Chemistry, Washington University, St. Louis, MO, USA
- Department of Internal Medicine, Washington University, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University, MO, St. Louis, USA
| | - Joel R Garbow
- Department of Radiology, Biomedical MR Center, Washington University, 660 South Euclid Avenue, MO 63110, St. Louis, MO, Mail Stop Code: MSC 8227-0082-02, USA.
- Alvin J. Siteman Cancer Center, Washington University, MO, St. Louis, USA.
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Johnson GW, Mian AY, Dahiya S, Rich KM, Chicoine MR, Limbrick DD. Cystic dissemination of choroid plexus papilloma: illustrative cases. J Neurosurg Case Lessons 2022; 4:CASE22360. [PMID: 36377129 PMCID: PMC9664240 DOI: 10.3171/case22360] [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] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Choroid plexus papillomas are benign tumors of the choroid plexus. Although typically focal, they can metastasize. Rarely, patients may present with numerous cystic lesions throughout the craniospinal axis. OBSERVATIONS The authors present three cases of pathologically confirmed fourth ventricular World Health Organization (WHO) grade 1 choroid plexus papillomas presenting with numerous cystic lesions throughout the craniospinal axis. Two cases were treated with only resection of the fourth ventricular mass; one was treated with a partial cyst fenestration. During follow-up, there was only mild interval growth of the cystic lesions over time, and all patients remained asymptomatic from their cystic lesions. The authors summarize five additional cases of cystic dissemination in the published literature and discuss hypotheses for the pathophysiology of this rare presentation. LESSONS Choroid plexus papillomas may present with numerous, widely disseminated cystic lesions within the craniospinal axis. Thus, the authors recommend preoperative and routine imaging of the entire neuroaxis in patients with choroid plexus tumors, regardless of WHO grade. Although the role of adjuvant therapy and cyst fenestration in the treatment of these lesions remains unclear, watchful waiting may be indicated, especially in asymptomatic patients, because the lesions often demonstrate slow, if any, growth over time.
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Affiliation(s)
| | | | - Sonika Dahiya
- Pathology, Washington University School of Medicine, St. Louis, Missouri; and
| | | | - Michael R. Chicoine
- Department of Neurosurgery, University of Missouri School of Medicine, Columbia, Missouri
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3
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Yahanda AT, Rich KM, Dacey RG, Zipfel GJ, Dunn GP, Dowling JL, Smyth MD, Leuthardt EC, Limbrick DD, Honeycutt J, Sutherland GR, Jensen RL, Evans J, Chicoine MR. Survival After Resection of Newly-Diagnosed Intracranial Grade II Ependymomas: An Initial Multicenter Analysis and the Logistics of Intraoperative Magnetic Resonance Imaging. World Neurosurg 2022; 167:e757-e769. [PMID: 36028106 DOI: 10.1016/j.wneu.2022.08.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 08/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To identify factors, including the use of intraoperative magnetic resonance imaging (iMRI), impacting overall survival (OS) and progression-free survival (PFS) after resections of newly diagnosed intracranial grade II ependymomas performed across 4 different institutions. METHODS Analyses of a multicenter mixed retrospective/prospective database assessed the impact of patient, treatment, and tumor characteristics on OS and PFS. iMRI workflow and logistics were also outlined. RESULTS Forty-three patients were identified (mean age 25.4 years, mean follow-up 52.8 months). The mean OS was 52.8 ± 44.7 months. Univariate analyses failed to identify prognostic factors associated with OS, likely due to relatively shorter follow-up time for this less aggressive glioma subtype. The mean PFS was 43.7 ± 39.8 months. Multivariate analyses demonstrated that gross-total resection was associated with prolonged PFS compared to both subtotal resection (STR) (P = 0.005) and near-total resection (P = 0.01). Infratentorial location was associated with improved PFS compared to supratentorial location (P = 0.04). Log-rank analyses of Kaplan-Meier survival curves showed that increasing extent of resection (EOR) led to improved OS specifically for supratentorial tumors (P = 0.02) and improved PFS for all tumors (P < 0.001). Thirty cases (69.8%) utilized iMRI, of which 12 (27.9%) involved additional resection after iMRI. Of these, 8/12 (66.7%) resulted in gross-total resection, while 2/12 (16.7%) were near-total resection and 2/12 (16.7%) were subtotal resection. iMRI was not an independent prognosticator of PFS (P = 0.72). CONCLUSIONS Greater EOR and infratentorial location were associated with increased PFS for grade II ependymomas. Greater EOR was associated with longer OS only for supratentorial tumors. A longer follow-up is needed to establish prognostic factors for this cohort, including use of iMRI.
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Affiliation(s)
- Alexander T Yahanda
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Gavin P Dunn
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Joshua L Dowling
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Matthew D Smyth
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Eric C Leuthardt
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - John Honeycutt
- Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Garnette R Sutherland
- Department of Neurological Surgery, University of Calgary School of Medicine, Calgary, Alberta, Canada
| | - Randy L Jensen
- Department of Neurological Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John Evans
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Ge X, Song KH, Engelbach JA, Yuan L, Gao F, Dahiya S, Rich KM, Ackerman JJH, Garbow JR. Distinguishing Tumor Admixed in a Radiation Necrosis (RN) Background: 1H and 2H MR With a Novel Mouse Brain-Tumor/RN Model. Front Oncol 2022; 12:885480. [PMID: 35712497 PMCID: PMC9196939 DOI: 10.3389/fonc.2022.885480] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose Distinguishing radiation necrosis (RN) from recurrent tumor remains a vexing clinical problem with important health-care consequences for neuro-oncology patients. Here, mouse models of pure tumor, pure RN, and admixed RN/tumor are employed to evaluate hydrogen (1H) and deuterium (2H) magnetic resonance methods for distinguishing RN vs. tumor. Furthermore, proof-of-principle, range-finding deuterium (2H) metabolic magnetic resonance is employed to assess glycolytic signatures distinguishing RN vs. tumor. Materials and Methods A pipeline of common quantitative 1H MRI contrasts, including an improved magnetization transfer ratio (MTR) sequence, and 2H magnetic resonance spectroscopy (MRS) following administration of 2H-labeled glucose, was applied to C57BL/6 mouse models of the following: (i) late time-to-onset RN, occurring 4–5 weeks post focal 50-Gy (50% isodose) Gamma Knife irradiation to the left cerebral hemisphere, (ii) glioblastoma, growing ~18–24 days post implantation of 50,000 mouse GL261 tumor cells into the left cerebral hemisphere, and (iii) mixed model, with GL261 tumor growing within a region of radiation necrosis (1H MRI only). Control C57BL/6 mice were also examined by 2H metabolic magnetic resonance. Results Differences in quantitative 1H MRI parametric values of R1, R2, ADC, and MTR comparing pure tumor vs. pure RN were all highly statistically significant. Differences in these parameter values and DCEAUC for tumor vs. RN in the mixed model (tumor growing in an RN background) are also all significant, demonstrating that these contrasts—in particular, MTR—can effectively distinguish tumor vs. RN. Additionally, quantitative 2H MRS showed a highly statistically significant dominance of aerobic glycolysis (glucose ➔ lactate; fermentation, Warburg effect) in the tumor vs. oxidative respiration (glucose ➔ TCA cycle) in the RN and control brain. Conclusions These findings, employing a pipeline of quantitative 1H MRI contrasts and 2H MRS following administration of 2H-labeled glucose, suggest a pathway for substantially improving the discrimination of tumor vs. RN in the clinic.
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Affiliation(s)
- Xia Ge
- Department of Radiology, Washington University, Saint Louis, MO, United States
| | - Kyu-Ho Song
- Department of Radiology, Washington University, Saint Louis, MO, United States
| | - John A Engelbach
- Department of Radiology, Washington University, Saint Louis, MO, United States
| | - Liya Yuan
- Department of Neurosurgery, Washington University, Saint Louis, MO, United States
| | - Feng Gao
- Department of Surgery, Washington University, Saint Louis, MO, United States
| | - Sonika Dahiya
- Division of Neuropathology, Department of Pathology and Immunology, Washington University, Saint Louis, MO, United States
| | - Keith M Rich
- Department of Neurosurgery, Washington University, Saint Louis, MO, United States
| | - Joseph J H Ackerman
- Department of Radiology, Washington University, Saint Louis, MO, United States.,Alvin J. Siteman Cancer Center, Washington University, Saint Louis, MO, United States.,Department of Internal Medicine, Washington University, Saint Louis, MO, United States.,Department of Chemistry, Washington University, Saint Louis, MO, United States
| | - Joel R Garbow
- Department of Radiology, Washington University, Saint Louis, MO, United States.,Alvin J. Siteman Cancer Center, Washington University, Saint Louis, MO, United States
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Beaumont TL, Limbrick DD, Patel B, Chicoine MR, Rich KM, Dacey RG. Surgical management of colloid cysts of the third ventricle: a single-institution comparison of endoscopic and microsurgical resection. J Neurosurg 2022; 137:1-9. [PMID: 35148502 DOI: 10.3171/2021.11.jns211317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/30/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Colloid cysts of the third ventricle are histologically benign lesions that can cause obstructive hydrocephalus and death. Historically, colloid cysts have been removed by open microsurgical approaches. More recently, minimally invasive endoscopic and port-based techniques have offered decreased complications and length of stay, with improved patient satisfaction. METHODS A single-center retrospective analysis of patients with colloid cysts who underwent surgery at a large tertiary care hospital was performed. The cohort was assessed based on the surgical approach, comparing endoscopic resection to open microsurgical resection. The primary endpoint was rate of perioperative complications. Univariate analysis was used to assess several procedure-related variables and the cost of treatment. Multivariate analysis was used to assess predictors of perioperative complications. Total inpatient cost for each case was extracted from the health system financial database. RESULTS The study included 78 patients with colloid cysts who underwent resection either via an endoscopic approach (n = 33) or through a craniotomy (n = 45) with an interhemispheric-transcallosal or transcortical-transventricular approach. Nearly all patients were symptomatic, and half had obstructive hydrocephalus. Endoscopic resection was associated with reduced operative time (3.2 vs 4.9 hours, p < 0.001); lower complication rate (6.1% vs 33.1%, p = 0.009); reduced length of stay (4.1 vs 8.9 days, p < 0.001); and improved discharge to home (100% vs 75.6%, p = 0.008) compared to microsurgical resection. Coagulated residual cyst wall remnants were more common after endoscopic resection (63.6% vs 19.0%, p < 0.001) although this was not associated with a significantly increased rate of reoperation for recurrence. The mean follow-up was longer in the microsurgical resection group (3.1 vs 4.9 years, p = 0.016). The total inpatient cost of endoscopic resection was, on average, one-half (47%) that of microsurgical resection. When complications were encountered, the total inpatient cost of microsurgical resection was 4 times greater than that of endoscopic resection where no major complications were observed. The increased cost-effectiveness of endoscopic resection remained during reoperation. CONCLUSIONS Endoscopic resection of colloid cysts of the third ventricle offers a significant reduction in perioperative complications when compared to microsurgical resection. Endoscopic resection optimizes nearly all procedure-related variables compared to microsurgical resection, and reduces total inpatient cost by > 50%. However, endoscopic resection is associated with a significantly increased likelihood of residual coagulated cyst wall remnants that could increase the rate of reoperation for recurrence. Taken together, endoscopic resection represents a safe and effective minimally invasive approach for removal of colloid cysts.
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Shah AS, Yahanda AT, Sylvester PT, Evans J, Dunn GP, Jensen RL, Honeycutt J, Cahill DP, Sutherland GR, Oswood M, Shah M, Abram SR, Rich KM, Dowling JL, Leuthardt EC, Dacey RG, Kim AH, Zipfel GJ, Limbrick DD, Smyth MD, Leonard J, Chicoine MR. Using Histopathology to Assess the Reliability of Intraoperative Magnetic Resonance Imaging in Guiding Additional Brain Tumor Resection: A Multicenter Study. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa338_s074] [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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7
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Cooper GS, Shankar B, Rich KM, Ratna NN, Alam MJ, Singh N, Kadiyala S. Can fruit and vegetable aggregation systems better balance improved producer livelihoods with more equitable distribution? World Dev 2021; 148:105678. [PMID: 34866757 PMCID: PMC8520944 DOI: 10.1016/j.worlddev.2021.105678] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 05/03/2023]
Abstract
The need for food systems to generate sustainable and equitable benefits for all is a global imperative. However, whilst ample evidence exists linking smallholder farmer coordination and aggregation (i.e. the collective transport and marketing of produce on behalf of multiple farmers) to improved market participation and farmer incomes, the extent to which interventions that aim to improve farmer market engagement may co-develop equitable consumer benefits remains uncertain. This challenge is pertinent to the horticultural systems of South Asia, where the increasing purchasing power of urban consumers, lengthening urban catchments, underdeveloped rural infrastructures and inadequate local demands combine to undermine the delivery of fresh fruits and vegetables to smaller, often rural or semi-rural markets serving nutritionally insecure populations. To this end, we investigate the potential for aggregation to be developed to increase fruit and vegetable delivery to these neglected smaller markets, whilst simultaneously improving farmer returns. Using an innovative system dynamics modelling approach based on an aggregation scheme in Bihar, India, we identify potential trade-offs between outcomes relating to farmers and consumers in smaller local markets. We find that changes to aggregation alone (i.e. scaling-up participation; subsidising small market transportation; mandating quotas for smaller markets) are unable to achieve significant improvements in smaller market delivery without risking reduced farmer participation in aggregation. Contrastingly, combining aggregation with the introduction of market-based cold storage and measures that boost demand improves fruit and vegetable availability significantly in smaller markets, whilst avoiding farmer-facing trade-offs. Critically, our study emphasises the benefits that may be attained from combining multiple nutrition-sensitive market interventions, and stresses the need for policies that narrow the fruit and vegetable cold storage deficits that exist away from more lucrative markets in developing countries. The future pathways and policy options discovered work towards making win-win futures for farmers and disadvantaged consumers a reality.
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Affiliation(s)
- G S Cooper
- Institute for Sustainable Food and Department of Geography, University of Sheffield, Sheffield, United Kingdom
| | - B Shankar
- Institute for Sustainable Food and Department of Geography, University of Sheffield, Sheffield, United Kingdom
| | - K M Rich
- Ferguson College of Agriculture, Oklahoma State University, Stillwater, OK, USA
- International Livestock Research Institute (ILRI), West Africa Regional Office, Dakar, Senegal
| | - N N Ratna
- Department of Global Value Chain & Trade, Faculty of Agribusiness and Commerce, Lincoln University, Christchurch, New Zealand
| | - M J Alam
- Department of Agribusiness and Marketing, Bangladesh Agricultural University (BAU), Mymensingh, Bangladesh
| | - N Singh
- Digital Green, North India Office, New Delhi, India
| | - S Kadiyala
- Department for Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
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Mitchell KT, Younce JR, Norris SA, Tabbal SD, Dowling JL, Rich KM, Perlmutter JS, Ushe M. Bilateral Subthalamic Nucleus Deep Brain Stimulation in Elderly Patients With Parkinson Disease: A Case-Control Study. Neurosurgery 2021. [DOI: 10.1093/neuros/opaa049_s143] [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: 11/12/2022] Open
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9
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Enahoro D, Bahta S, Mensah C, Oloo S, Rich KM. Current and future trade in livestock products. REV SCI TECH OIE 2021; 40:395-411. [PMID: 34542107 DOI: 10.20506/rst.40.2.3232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Rising per capita consumption, economic growth, and urbanisation, particularly in developing countries, have been driving an increased global demand for food. These changing socio-economic trends, which have greatly influenced changes in dietary patterns globally and, more specifically, have increased consumption of livestock products in developing countries, are expected to endure and to place new pressures on livestock-sector infrastructure and the delivery of veterinary services. This paper summarises current trade in meat and presents plausible projections for the future. It highlights the impact of animal disease on trade and considers the effect of ongoing disease outbreaks, particularly the outbreaks of African swine fever and COVID-19, on current and future trade dynamics. The authors analysed published statistics on the demand for, and international trade in, livestock products at national and regional levels and made projections of the same up to 2050, generated from an integrated model of the global agricultural and food system. The resulting analyses identified patterns of trade consistent with growing populations, increasing incomes and changing diets in developing countries. The analyses also pointed to slow expansion of livestock production, and the impacts of countries' disease status on livestock trade. For most of the livestock products analysed, economic model projections indicate increased consolidation of production and exports among a few countries. Marked increases in the trade in livestock products suggest a changing role for Veterinary Services in facilitating trade and extension in the years to come.
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Garbow JR, Johanns TM, Ge X, Engelbach JA, Yuan L, Dahiya S, Tsien CI, Gao F, Rich KM, Ackerman JJH. Irradiation-Modulated Murine Brain Microenvironment Enhances GL261-Tumor Growth and Inhibits Anti-PD-L1 Immunotherapy. Front Oncol 2021; 11:693146. [PMID: 34249742 PMCID: PMC8263916 DOI: 10.3389/fonc.2021.693146] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 04/09/2021] [Accepted: 06/02/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Clinical evidence suggests radiation induces changes in the brain microenvironment that affect subsequent response to treatment. This study investigates the effect of previous radiation, delivered six weeks prior to orthotopic tumor implantation, on subsequent tumor growth and therapeutic response to anti-PD-L1 therapy in an intracranial mouse model, termed the Radiation Induced Immunosuppressive Microenvironment (RI2M) model. Method and Materials C57Bl/6 mice received focal (hemispheric) single-fraction, 30-Gy radiation using the Leksell GammaKnife® Perfexion™, a dose that does not produce frank/gross radiation necrosis. Non-irradiated GL261 glioblastoma tumor cells were implanted six weeks later into the irradiated hemisphere. Lesion volume was measured longitudinally by in vivo MRI. In a separate experiment, tumors were implanted into either previously irradiated (30 Gy) or non-irradiated mouse brain, mice were treated with anti-PD-L1 antibody, and Kaplan-Meier survival curves were constructed. Mouse brains were assessed by conventional hematoxylin and eosin (H&E) staining, IBA-1 staining, which detects activated microglia and macrophages, and fluorescence-activated cell sorting (FACS) analysis. Results Tumors in previously irradiated brain display aggressive, invasive growth, characterized by viable tumor and large regions of hemorrhage and necrosis. Mice challenged intracranially with GL261 six weeks after prior intracranial irradiation are unresponsive to anti-PD-L1 therapy. K-M curves demonstrate a statistically significant difference in survival for tumor-bearing mice treated with anti-PD-L1 antibody between RI2M vs. non-irradiated mice. The most prominent immunologic change in the post-irradiated brain parenchyma is an increased frequency of activated microglia. Conclusions The RI2M model focuses on the persisting (weeks-to-months) impact of radiation applied to normal, control-state brain on the growth characteristics and immunotherapy response of subsequently implanted tumor. GL261 tumors growing in the RI2M grew markedly more aggressively, with tumor cells admixed with regions of hemorrhage and necrosis, and showed a dramatic loss of response to anti-PD-L1 therapy compared to tumors in non-irradiated brain. IHC and FACS analyses demonstrate increased frequency of activated microglia, which correlates with loss of sensitivity to checkpoint immunotherapy. Given that standard-of-care for primary brain tumor following resection includes concurrent radiation and chemotherapy, these striking observations strongly motivate detailed assessment of the late effects of the RI2M on tumor growth and therapeutic efficacy.
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Affiliation(s)
- Joel R Garbow
- Department of Radiology, Washington University, Saint Louis, MO, United States.,Alvin J. Siteman Cancer Center, Washington University, Saint Louis, MO, United States
| | - Tanner M Johanns
- Department of Internal Medicine, Washington University, Saint Louis, MO, United States.,Alvin J. Siteman Cancer Center, Washington University, Saint Louis, MO, United States
| | - Xia Ge
- Department of Radiology, Washington University, Saint Louis, MO, United States
| | - John A Engelbach
- Department of Radiology, Washington University, Saint Louis, MO, United States
| | - Liya Yuan
- Department of Neurosurgery, Washington University, Saint Louis, MO, United States
| | - Sonika Dahiya
- Division of Neuropathology, Department of Pathology and Immunology, Washington University, Saint Louis, MO, United States
| | - Christina I Tsien
- Department of Radiation Oncology, Washington University, Saint Louis, MO, United States
| | - Feng Gao
- Department of Surgery, Washington University, Saint Louis, MO, United States
| | - Keith M Rich
- Department of Neurosurgery, Washington University, Saint Louis, MO, United States
| | - Joseph J H Ackerman
- Department of Radiology, Washington University, Saint Louis, MO, United States.,Alvin J. Siteman Cancer Center, Washington University, Saint Louis, MO, United States.,Department of Internal Medicine, Washington University, Saint Louis, MO, United States.,Department of Chemistry, Washington University, Saint Louis, MO, United States
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11
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Mitchell KT, Younce JR, Norris SA, Tabbal SD, Dowling JL, Rich KM, Perlmutter JS, Ushe M. Bilateral Subthalamic Nucleus Deep Brain Stimulation in Elderly Patients With Parkinson Disease: A Case-Control Study. Oper Neurosurg (Hagerstown) 2021; 19:234-240. [PMID: 32259239 DOI: 10.1093/ons/opaa049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 06/20/2019] [Accepted: 01/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Subthalamic nucleus deep brain stimulation (STN DBS) is an effective adjunctive therapy for Parkinson disease. Studies have shown improvement of motor function but often exclude patients older than 75 yr. OBJECTIVE To determine the safety and effectiveness of STN DBS in patients 75 yr and older. METHODS A total of 104 patients (52 patients >75 yr old, 52 patients <75 yr old) with STN DBS were paired and retrospectively analyzed. The primary outcome was change in Unified Parkinson Disease Rating Scale (UPDRS) subscale III at 1 yr postoperatively, OFF medication. Secondary outcomes were changes in UPDRS I, II, and IV subscales and levodopa equivalents. Complications and all-cause mortality were assessed at 30 d and 1 yr. RESULTS Both cohorts had significant improvements in UPDRS III at 6 mo and 1 yr with no difference between cohorts. Change in UPDRS III was noninferior to the younger cohort. The cohorts had similar worsening in UPDRS I at 1 yr, no change in UPDRS II, similar improvement in UPDRS IV, and similar levodopa equivalent reduction. There were similar numbers of postoperative intracerebral hemorrhages (2/52 in each cohort, more severe in the older cohort) and surgical complications (4/52 in each cohort), and mortality in the older cohort was similar to an additional matched cohort not receiving DBS. CONCLUSION STN DBS provides substantial motor benefit and reduction in levodopa equivalents with a low rate of complications in older patients, which is also noninferior to the benefit in younger patients. STN DBS remains an effective therapy for those over 75 yr.
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Affiliation(s)
- Kyle T Mitchell
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - John R Younce
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Scott A Norris
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.,Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Samer D Tabbal
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.,Department of Neurology, American University of Beirut, Beirut, Lebanon
| | - Joshua L Dowling
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joel S Perlmutter
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.,Department of Radiology, Washington University School of Medicine, St. Louis, Missouri.,Department of Neuroscience, Washington University School of Medicine, St. Louis, Missouri.,Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri.,Program in Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri
| | - Mwiza Ushe
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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12
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Shah AS, Yahanda AT, Sylvester PT, Evans J, Dunn GP, Jensen RL, Honeycutt J, Cahill DP, Sutherland GR, Oswood M, Shah M, Abram SR, Rich KM, Dowling JL, Leuthardt EC, Dacey RG, Kim AH, Zipfel GJ, Limbrick DD, Smyth MD, Leonard J, Chicoine MR. Using Histopathology to Assess the Reliability of Intraoperative Magnetic Resonance Imaging in Guiding Additional Brain Tumor Resection: A Multicenter Study. Neurosurgery 2020; 88:E49-E59. [PMID: 32803226 DOI: 10.1093/neuros/nyaa338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/31/2019] [Accepted: 05/24/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Intraoperative magnetic resonance imaging (iMRI) is a powerful tool for guiding brain tumor resections, provided that it accurately discerns residual tumor. OBJECTIVE To use histopathology to assess how reliably iMRI may discern additional tumor for a variety of tumor types, independent of the indications for iMRI. METHODS A multicenter database was used to calculate the odds of additional resection during the same surgical session for grade I to IV gliomas and pituitary adenomas. The reliability of iMRI for identifying residual tumor was assessed using histopathology of tissue resected after iMRI. RESULTS Gliomas (904/1517 cases, 59.6%) were more likely than pituitary adenomas (176/515, 34.2%) to receive additional resection after iMRI (P < .001), but these tumors were equally likely to have additional tissue sent for histopathology (398/904, 44.4% vs 66/176, 37.5%; P = .11). Tissue samples were available for resections after iMRI for 464 cases, with 415 (89.4%) positive for tumor. Additional resections after iMRI for gliomas (361/398, 90.7%) were more likely to yield additional tumor compared to pituitary adenomas (54/66, 81.8%) (P = .03). There were no significant differences in resection after iMRI yielding histopathologically positive tumor between grade I (58/65 cases, 89.2%; referent), grade II (82/92, 89.1%) (P = .98), grade III (72/81, 88.9%) (P = .95), or grade IV gliomas (149/160, 93.1%) (P = .33). Additional resection for previously resected tumors (122/135 cases, 90.4%) was equally likely to yield histopathologically confirmed tumor compared to newly-diagnosed tumors (293/329, 89.0%) (P = .83). CONCLUSION Histopathological analysis of tissue resected after use of iMRI for grade I to IV gliomas and pituitary adenomas demonstrates that iMRI is highly reliable for identifying residual tumor.
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Affiliation(s)
- Amar S Shah
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - John Evans
- Washington University School of Medicine, St. Louis, Missouri
| | - Gavin P Dunn
- Washington University School of Medicine, St. Louis, Missouri
| | - Randy L Jensen
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | | | | | - Mark Oswood
- University of Minnesota, Minneapolis, Minnesota.,Allina Health, Minneapolis, Minnesota
| | - Mitesh Shah
- Goodman Campbell and Indiana University, Indianapolis, Indiana
| | | | - Keith M Rich
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Ralph G Dacey
- Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Matthew D Smyth
- Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey Leonard
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
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13
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Kennedy WR, DeWees TA, Acharya S, Mahmood M, Knutson NC, Goddu SM, Kavanaugh JA, Mitchell TJ, Rich KM, Kim AH, Leuthardt EC, Dowling JL, Dunn GP, Chicoine MR, Perkins SM, Huang J, Tsien CI, Robinson CG, Abraham CD. Internal dose escalation associated with increased local control for melanoma brain metastases treated with stereotactic radiosurgery. J Neurosurg 2020:1-7. [PMID: 33307528 DOI: 10.3171/2020.7.jns192210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 07/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The internal high-dose volume varies widely for a given prescribed dose during stereotactic radiosurgery (SRS) to treat brain metastases (BMs). This may be altered during treatment planning, and the authors have previously shown that this improves local control (LC) for non-small cell lung cancer BMs without increasing toxicity. Here, they seek to identify potentially actionable dosimetric predictors of LC after SRS for melanoma BM. METHODS The records of patients with unresected melanoma BM treated with single-fraction Gamma Knife RS between 2006 and 2017 were reviewed. LC was assessed on a per-lesion basis, defined as stability or a decrease in lesion size. Outcome-oriented approaches were utilized to determine optimal dichotomization for dosimetric variables relative to LC. Univariable and multivariable Cox regression analysis was implemented to evaluate the impact of collected parameters on LC. RESULTS Two hundred eighty-seven melanoma BMs in 79 patients were identified. The median age was 56 years (range 31-86 years). The median follow-up was 7.6 months (range 0.5-81.6 months), and the median survival was 9.3 months (range 1.3-81.6 months). Lesions were optimally stratified by volume receiving at least 30 Gy (V30) greater than or equal to versus less than 25%. V30 was ≥ and < 25% in 147 and 140 lesions, respectively. For all patients, 1-year LC was 83% versus 66% for V30 ≥ and < 25%, respectively (p = 0.001). Stratifying by volume, lesions 2 cm or less (n = 215) had 1-year LC of 82% versus 70% (p = 0.013) for V30 ≥ and < 25%, respectively. Lesions > 2 to 3 cm (n = 32) had 1-year LC of 100% versus 43% (p = 0.214) for V30 ≥ and < 25%, respectively. V30 was still predictive of LC even after controlling for the use of immunotherapy and targeted therapy. Radionecrosis occurred in 2.8% of lesions and was not significantly associated with V30. CONCLUSIONS For a given prescription dose, an increased internal high-dose volume, as indicated by measures such as V30 ≥ 25%, is associated with improved LC but not increased toxicity in single-fraction SRS for melanoma BM. Internal dose escalation is an independent predictor of improved LC even in patients receiving immunotherapy and/or targeted therapy. This represents a dosimetric parameter that is actionable at the time of treatment planning and warrants further evaluation.
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Affiliation(s)
| | - Todd A DeWees
- 2Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, Arizona; and
| | - Sahaja Acharya
- 3Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | | | | | | | | | - Keith M Rich
- 4Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- 4Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Eric C Leuthardt
- 4Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua L Dowling
- 4Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gavin P Dunn
- 4Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R Chicoine
- 4Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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14
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Andruska N, Kennedy WR, Bonestroo L, Anderson R, Huang Y, Robinson CG, Abraham C, Tsien C, Knutson N, Rich KM, Spencer C, Huang J. Dosimetric predictors of symptomatic radiation necrosis after five-fraction radiosurgery for brain metastases. Radiother Oncol 2020; 156:181-187. [PMID: 33310010 DOI: 10.1016/j.radonc.2020.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/28/2020] [Accepted: 12/01/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND To identify factors predictive of developing symptomatic radiation necrosis (sRN) among patients with either intact or resected brain metastases undergoing five-fraction stereotactic radiosurgery (5fSRS). METHODS Multi-institutional retrospective review of 117 brain metastases from 83 patients treated with 5fSRS. The cumulative incidence of sRN and predictors of sRN were calculated using Gray's competing risks and Cox regression. RESULTS The median dose of 5fSRS was 30 Gy (range: 25-40), and 21 lesions (18%) had prior SRS. After a median follow-up of 10.3 months (range: 3-52), the cumulative sRN incidence was 15%, with a median time to sRN of 6.9 months (range: 1.8-31.7). sRN incidence was significantly higher among the lesions treated with prior SRS: hazard ratio (HR): 7.48 [95% confidence interval: 2.57-21.8]. Among lesions without prior SRS, higher volume of uninvolved brain receiving 25 Gy (BrainV25; HR: 1.07 [1.02-1.12]) and 30 Gy (BrainV30; HR: 1.07 [1.01-1.33]) were the most significant factors associated with sRN. Similar results were also observed among the patients with prior SRS. For lesions without prior SRS, BrainV25 > 16 cm3 (HR: 11.7 [1.47-93.3]) and BrainV30 > 10 cm3 (HR: 7.08 [1.52-33.0]) were associated with significantly higher risk of sRN. At two years, the sRN incidence was 21% if violating either dosimetric threshold and 2% if violating neither (p = .007). CONCLUSION BrainV25 and BrainV30 are significant dosimetric predictors of sRN of brain metastases treated with 5fSRS. In the absence of prior SRS, maintaining BrainV25Gy < 16 cm3 and BrainV30Gy < 10 cm3 may minimize sRN risk.
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Affiliation(s)
- Neal Andruska
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, USA.
| | - William R Kennedy
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, USA
| | - Liberty Bonestroo
- Delbert Day Cancer Institute, Phelps County Regional Medical Center, Rolla, USA
| | - Rebecca Anderson
- Delbert Day Cancer Institute, Phelps County Regional Medical Center, Rolla, USA
| | - Yi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, USA
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, USA
| | - Christopher Abraham
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, USA
| | - Christina Tsien
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, USA
| | - Nels Knutson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, USA
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, USA
| | - Christopher Spencer
- Delbert Day Cancer Institute, Phelps County Regional Medical Center, Rolla, USA
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, USA.
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15
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Yahanda AT, Shah AS, Sylvester P, Evans J, Dunn GP, Jensen RL, Honeycutt JH, Cahill DP, Sutherland GR, Oswood MC, Shah MV, Abram SR, Rich KM, Dowling JL, Leuthardt EC, Dacey RG, Kim AH, Zipfel GJ, Limbrick DD, Smyth MD, Leonard JR, Chicoine MR. Using Histopathology to Assess the Reliability With Which Intraoperative MRI Identifies Residual Brain Tumor. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_914] [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: 11/14/2022] Open
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16
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Huang J, Milchenko M, Rao YJ, LaMontagne P, Abraham C, Robinson CG, Huang Y, Shimony JS, Rich KM, Benzinger T. A feasibility study to evaluate early treatment response of brain metastases one week after stereotactic radiosurgery using perfusion weighted imaging. PLoS One 2020; 15:e0241835. [PMID: 33141861 PMCID: PMC7608872 DOI: 10.1371/journal.pone.0241835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 07/17/2020] [Accepted: 10/20/2020] [Indexed: 01/06/2023] Open
Abstract
Background To explore if early perfusion-weighted magnetic resonance imaging (PWI) may be a promising imaging biomarker to predict local recurrence (LR) of brain metastases after stereotactic radiosurgery (SRS). Methods This is a prospective pilot study of adult brain metastasis patients who were treated with SRS and imaged with PWI before and 1 week later. Relative cerebral blood volume (rCBV) parameter maps were calculated by normalizing to the mean value of the contralateral white matter on PWI. Cox regression was conducted to explore factors associated with time to LR, with Bonferroni adjusted p<0.0006 for multiple testing correction. LR rates were estimated with the Kaplan-Meier method and compared using the log-rank test. Results Twenty-three patients were enrolled from 2013 through 2016, with 22 evaluable lesions from 16 patients. After a median follow-up of 13.1 months (range: 3.0–53.7), 5 lesions (21%) developed LR after a median of 3.4 months (range: 2.3–5.7). On univariable analysis, larger tumor volume (HR 1.48, 95% CI 1.02–2.15, p = 0.04), lower SRS dose (HR 0.45, 95% CI 0.21–0.97, p = 0.04), and higher rCBV at week 1 (HR 1.07, 95% CI 1.003–1.14, p = 0.04) had borderline association with shorter time to LR. Tumors >2.0cm3 had significantly higher LR than if ≤2.0cm3: 54% vs 0% at 1 year, respectively, p = 0.008. A future study to confirm the association of early PWI and LR of the high-risk cohort of lesions >2.0cm3 is estimated to require 258 patients. Conclusions PWI at week 1 after SRS may have borderline association with LR. Tumors <2.0cm3 have low risk of LR after SRS and may be low-yield for predictive biomarker studies. Information regarding sample size and potential challenges for future imaging biomarker studies may be gleaned from this pilot study.
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Affiliation(s)
- Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Mikhail Milchenko
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Yuan J Rao
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Pamela LaMontagne
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Christopher Abraham
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Yi Huang
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Joshua S Shimony
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Tammie Benzinger
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
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17
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Shah AS, Sylvester PT, Yahanda AT, Vellimana AK, Dunn GP, Evans J, Rich KM, Dowling JL, Leuthardt EC, Dacey RG, Kim AH, Grubb RL, Zipfel GJ, Oswood M, Jensen RL, Sutherland GR, Cahill DP, Abram SR, Honeycutt J, Shah M, Tao Y, Chicoine MR. Intraoperative MRI for newly diagnosed supratentorial glioblastoma: a multicenter-registry comparative study to conventional surgery. J Neurosurg 2020:1-10. [PMID: 33035996 DOI: 10.3171/2020.6.jns19287] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 02/01/2019] [Accepted: 06/04/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative MRI (iMRI) is used in the surgical treatment of glioblastoma, with uncertain effects on outcomes. The authors evaluated the impact of iMRI on extent of resection (EOR) and overall survival (OS) while controlling for other known and suspected predictors. METHODS A multicenter retrospective cohort of 640 adult patients with newly diagnosed supratentorial glioblastoma who underwent resection was evaluated. iMRI was performed in 332/640 cases (51.9%). Reviews of MRI features and tumor volumetric analysis were performed on a subsample of cases (n = 286; 110 non-iMRI, 176 iMRI) from a single institution. RESULTS The median age was 60.0 years (mean 58.5 years, range 20.5-86.3 years). The median OS was 17.0 months (95% CI 15.6-18.4 months). Gross-total resection (GTR) was achieved in 403/640 cases (63.0%). Kaplan-Meier analysis of 286 cases with volumetric analysis for EOR (grouped into 100%, 95%-99%, 80%-94%, and 50%-79%) showed longer OS for 100% EOR compared to all other groups (p < 0.01). Additional resection after iMRI was performed in 104/122 cases (85.2%) with initial subtotal resection (STR), leading to a 6.3% mean increase in EOR and a 2.2-cm3 mean decrease in tumor volume. For iMRI cases with volumetric analysis, the GTR rate increased from 54/176 (30.7%) on iMRI to 126/176 (71.5%) postoperatively. The EOR was significantly higher in the iMRI group for intended GTR and STR groups (p = 0.02 and p < 0.01, respectively). Predictors of GTR on multivariate logistic regression included iMRI use and intended GTR. Predictors of shorter OS on multivariate Cox regression included older age, STR, isocitrate dehydrogenase 1 (IDH1) wild type, no O6-methylguanine DNA methyltransferase (MGMT) methylation, and no Stupp therapy. iMRI was a significant predictor of OS on univariate (HR 0.82, 95% CI 0.69-0.98; p = 0.03) but not multivariate analyses. Use of iMRI was not associated with an increased rate of new permanent neurological deficits. CONCLUSIONS GTR increased OS for patients with newly diagnosed glioblastoma after adjusting for other prognostic factors. iMRI increased EOR and GTR rate and was a significant predictor of GTR on multivariate analysis; however, iMRI was not an independent predictor of OS. Additional supporting evidence is needed to determine the clinical benefit of iMRI in the management of glioblastoma.
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Affiliation(s)
- Amar S Shah
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Peter T Sylvester
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander T Yahanda
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ananth K Vellimana
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gavin P Dunn
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - John Evans
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua L Dowling
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Eric C Leuthardt
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Robert L Grubb
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J Zipfel
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mark Oswood
- 2Department of Radiology, University of Minnesota, Minneapolis, Minnesota
- 3Allina Health, Minneapolis, Minnesota
| | - Randy L Jensen
- 4Department of Neurosurgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Garnette R Sutherland
- 5Department of Clinical Sciences and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Daniel P Cahill
- 6Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven R Abram
- 7Department of Neurosurgery, St. Thomas Hospital, Nashville, Tennessee
| | - John Honeycutt
- 8Department of Neurosurgery, Cook Children's Hospital, Fort Worth, Texas; and
| | - Mitesh Shah
- 9Department of Neurological Surgery, Goodman Campbell and Indiana University, Indianapolis, Indiana
| | - Yu Tao
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R Chicoine
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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18
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Ponisio MR, McConathy JE, Dahiya SM, Miller-Thomas MM, Rich KM, Salter A, Wang Q, LaMontagne PJ, Guzmán Pérez-Carrillo GJ, Benzinger TLS. Dynamic 18F-FDOPA-PET/MRI for the preoperative evaluation of gliomas: correlation with stereotactic histopathology. Neurooncol Pract 2020; 7:656-667. [PMID: 33312679 DOI: 10.1093/nop/npaa044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background MRI alone has limited accuracy for delineating tumor margins and poorly predicts the aggressiveness of gliomas, especially when tumors do not enhance. This study evaluated simultaneous 3,4-dihydroxy-6-[18F]fluoro-L-phenylalanine (FDOPA)-PET/MRI to define tumor volumes compared to MRI alone more accurately, assessed its role in patient management, and correlated PET findings with histopathology. Methods Ten patients with known or suspected gliomas underwent standard of care surgical resection and/or stereotactic biopsy. FDOPA-PET/MRI was performed prior to surgery, allowing for precise co-registration of PET, MR, and biopsies. The biopsy sites were modeled as 5-mm spheres, and the local FDOPA uptake at each site was determined. Correlations were performed between measures of tumor histopathology, and static and dynamic PET values: standardized uptake values (SUVs), tumor to brain ratios, metabolic tumor volumes, and tracer kinetics at volumes of interest (VOIs) and biopsy sites. Results Tumor FDOPA-PET uptake was visualized in 8 patients. In 2 patients, tracer uptake was similar to normal brain reference with no histological findings of malignancy. Eight biopsy sites confirmed for glioma had FDOPA uptake without T1 contrast enhancement. The PET parameters were highly correlated only with the cell proliferation marker, Ki-67 (SUVmax: r = 0.985, P = .002). In this study, no statistically significant difference between high-grade and low-grade tumors was demonstrated. The dynamic PET analysis of VOIs and biopsy sites showed decreasing time-activity curves patterns. FDOPA-PET imaging directly influenced patient management. Conclusions Simultaneous FDOPA-PET/MRI allowed for more accurate visualization and delineation of gliomas, enabling more appropriate patient management and simplified validation of PET findings with histopathology.
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Affiliation(s)
- Maria R Ponisio
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Jonathan E McConathy
- Department of Radiology, Division of Molecular Imaging and Therapeutics, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Sonika M Dahiya
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Michelle M Miller-Thomas
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri
| | - Amber Salter
- Department of Biostatistics, Washington University School of Medicine, St Louis, Missouri
| | - Qing Wang
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Pamela J LaMontagne
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | | | - Tammie L S Benzinger
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
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19
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Hwang JY, Aum DJ, Chicoine MR, Dacey RG, Osbun JW, Rich KM, Zipfel GJ, Klatt-Cromwell CN, McJunkin JL, Pipkorn P, Schneider JS, Silverstein JM, Kim AH. Axis-specific analysis and predictors of endocrine recovery and deficits for non-functioning pituitary adenomas undergoing endoscopic transsphenoidal surgery. Pituitary 2020; 23:389-399. [PMID: 32388803 DOI: 10.1007/s11102-020-01045-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE Endoscopic transsphenoidal surgery (ETSS) is a well-established treatment for patients with nonfunctioning pituitary adenomas (NFPAs). Data on the rates of pituitary dysfunction and recovery in a large cohort of NFPA patients undergoing ETSS and the predictors of endocrine function before and after ETSS are scarce. This study is purposed to analyze the comprehensive changes in hormonal function and identify factors that predict recovery or worsening of hormonal axes following ETSS for NFPA. METHODS A retrospective review of 601 consecutive patients who underwent ETSS between 2010 and 2018 at one institution was performed. Recovery or development of new hypopituitarism was analyzed in 209 NFPA patients who underwent ETSS. RESULTS Patients with preoperative endocrine deficits (59.8%) in one or more pituitary axes had larger tumor volumes (P = 0.001) than those without preoperative deficits. Recovery of preoperative pituitary deficit occurred in all four axes, with overall mean recovery of 29.7%. The cortisol axis showed the highest recovery whereas the thyroid axis showed the lowest, with 1-year cumulative recovery rates of 44.3% and 6.1%, respectively. Postoperative hypopituitarism occurred overall in 17.2%, most frequently in the thyroid axis (24.3%, 27/111) and least frequently in the cortisol axis (9.7%, 16/165). Axis-specific predictors of post-operative recovery and deficiency were identified. CONCLUSIONS Dynamic alterations in pituitary hormones were observed in a proportion of patients following ETSS in NFPA patients. Postoperative endocrine vulnerability, recovery, and factors that predicted recovery or loss of endocrine function depended on the hormonal system, necessitating an axis-specific surveillance strategy postoperatively.
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Affiliation(s)
- Jenie Y Hwang
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Diane J Aum
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Joshua W Osbun
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Cristine N Klatt-Cromwell
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jonathan L McJunkin
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - John S Schneider
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie M Silverstein
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Albert H Kim
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
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Akbari SHA, Sylvester PT, Kulwin C, Shah MV, Somasundaram A, Kamath AA, Beaumont TL, Rich KM, Chicoine MR. Initial Experience Using Intraoperative Magnetic Resonance Imaging During a Trans-Sulcal Tubular Retractor Approach for the Resection of Deep-Seated Brain Tumors: A Case Series. Oper Neurosurg (Hagerstown) 2020; 16:292-301. [PMID: 29850853 DOI: 10.1093/ons/opy108] [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: 12/11/2017] [Accepted: 04/12/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Treatment of deep-seated subcortical intrinsic brain tumors remains challenging and may be improved with trans-sulcal tubular brain retraction techniques coupled with intraoperative magnetic resonance imaging (iMRI). OBJECTIVE To conduct a preliminary assessment of feasibility and efficacy of iMRI in tubular retractor-guided resections of intrinsic brain tumors. METHODS Assessment of this technique and impact upon outcomes were assessed in a preliminary series of brain tumor patients from 2 centers. RESULTS Ten patients underwent resection with a tubular retractor system and iMRI. Mean age was 53.2 ± 9.0 yr (range: 37-61 yr, 80% male). Lesions included 6 gliomas (3 glioblastomas, 1 recurrent anaplastic astrocytoma, and 2 low-grade gliomas) and 4 brain metastases (1 renal cell, 1 breast, 1 lung, and 1 melanoma). Mean maximal tumor diameter was 2.9 ± 0.95 cm (range 1.2-4.3 cm). The iMRI demonstrated subtotal resection (STR) in 6 of 10 cases (60%); additional resection was performed in 5 of 6 cases (83%), reducing STR rate to 2 of 10 cases (20%), with both having tumor encroaching on eloquent structures. Seven patients (70%) were stable or improved neurologically immediately postoperatively. Three patients (30%) had new postoperative neurological deficits, 2 of which were transient. Average hospital length of stay was 3.4 ± 2.0 d (range: 1-7 d). CONCLUSION Combining iMRI with tubular brain retraction techniques is feasible and may improve the extent of resection of deep-seated intrinsic brain tumors that are incompletely visualized with the smaller surgical exposure of tubular retractors.
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Affiliation(s)
- S Hassan A Akbari
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Peter T Sylvester
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Charles Kulwin
- Department of Neurological Surgery, Indiana University-Purdue University, Indianapolis, Indiana
| | - Mitesh V Shah
- Department of Neurological Surgery, Indiana University-Purdue University, Indianapolis, Indiana
| | - Aravind Somasundaram
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ashwin A Kamath
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas L Beaumont
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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21
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Yahanda AT, Patel B, Shah AS, Cahill DP, Sutherland G, Honeycutt J, Jensen RL, Rich KM, Dowling JL, Limbrick DD, Dacey RG, Kim AH, Leuthardt EC, Dunn GP, Zipfel GJ, Leonard JR, Smyth MD, Shah MV, Abram SR, Evans J, Chicoine MR. Impact of Intraoperative Magnetic Resonance Imaging and Other Factors on Surgical Outcomes for Newly Diagnosed Grade II Astrocytomas and Oligodendrogliomas: A Multicenter Study. Neurosurgery 2020; 88:63-73. [DOI: 10.1093/neuros/nyaa320] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/24/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Few studies use large, multi-institutional patient cohorts to examine the role of intraoperative magnetic resonance imaging (iMRI) in the resection of grade II gliomas.
OBJECTIVE
To assess the impact of iMRI and other factors on overall survival (OS) and progression-free survival (PFS) for newly diagnosed grade II astrocytomas and oligodendrogliomas.
METHODS
Retrospective analyses of a multicenter database assessed the impact of patient-, treatment-, and tumor-related factors on OS and PFS.
RESULTS
A total of 232 resections (112 astrocytomas and 120 oligodendrogliomas) were analyzed. Oligodendrogliomas had longer OS (P < .001) and PFS (P = .01) than astrocytomas. Multivariate analyses demonstrated improved OS for gross total resection (GTR) vs subtotal resection (STR; P = .006, hazard ratio [HR]: .23) and near total resection (NTR; P = .02, HR: .64). GTR vs STR (P = .02, HR: .54), GTR vs NTR (P = .04, HR: .49), and iMRI use (P = .02, HR: .54) were associated with longer PFS. Frontal (P = .048, HR: 2.11) and occipital/parietal (P = .003, HR: 3.59) locations were associated with shorter PFS (vs temporal). Kaplan-Meier analyses showed longer OS with increasing extent of surgical resection (EOR) (P = .03) and 1p/19q gene deletions (P = .02). PFS improved with increasing EOR (P = .01), GTR vs NTR (P = .02), and resections above STR (P = .04). Factors influencing adjuvant treatment (35.3% of patients) included age (P = .002, odds ratio [OR]: 1.04) and EOR (P = .003, OR: .39) but not glioma subtype or location. Additional tumor resection after iMRI was performed in 105/159 (66%) iMRI cases, yielding GTR in 54.5% of these instances.
CONCLUSION
EOR is a major determinant of OS and PFS for patients with grade II astrocytomas and oligodendrogliomas. Intraoperative MRI may improve EOR and was associated with increased PFS.
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Affiliation(s)
- Alexander T Yahanda
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Bhuvic Patel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Amar S Shah
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel P Cahill
- Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Garnette Sutherland
- Department of Neurological Surgery, University of Calgary School of Medicine, Calgary, Canada
| | - John Honeycutt
- Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas
| | - Randy L Jensen
- Department of Neurological Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Joshua L Dowling
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - David D Limbrick
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gavin P Dunn
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Jeffrey R Leonard
- Department of Neurological Surgery, Ohio State University College of Medicine, Columbus, Ohio
| | - Matthew D Smyth
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Mitesh V Shah
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Steven R Abram
- Department of Neurological Surgery, St. Thomas Hospital, Nashville, Tennessee
| | - John Evans
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Xu L, Khaddour K, Chen J, Rich KM, Perrin RJ, Campian JL. Pituitary carcinoma: Two case reports and review of literature. World J Clin Oncol 2020; 11:91-102. [PMID: 32133278 PMCID: PMC7046923 DOI: 10.5306/wjco.v11.i2.91] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/11/2019] [Accepted: 12/15/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pituitary carcinoma is a rare type of malignancy that can be very difficult to diagnose and treat. Many cases were diagnosed at autopsy. Delays in diagnosis often adversely impact patients' outcomes. Even with prompt diagnosis, treatment decisions remain challenging in the absence of randomized controlled trials.
CASE SUMMARY We report two cases of pituitary carcinoma in men with a history of pituitary adenoma. In the first case, a 55-year-old man was initially diagnosed with pituitary macroadenoma. He underwent subtotal debulking of the tumor followed by adjuvant radiotherapy. Subsequently, he developed relapsed disease and multifocal intracranial metastases and a diagnosis of pituitary carcinoma was rendered. He passed away despite several lines of systemic therapies including temozolomide, lomustine and bevacizumab. Another 52-year-old man was diagnosed with atypical pituitary adenoma with presentation of sudden onset of vision loss in the right eye. He had recurrent pituitary carcinoma with spinal metastases, treated with surgery, radiation and temozolomide.
CONCLUSION Pituitary carcinoma is a rare neoplasm with poor prognosis that is difficult to diagnose and treat. The small number of cases restricts our ability to design randomized clinical trials. Management is largely driven by retrospective studies and case series. Establishing molecular biomarkers and comprehensive genomic profiling could help in decisions about diagnosis and management of pituitary carcinoma.
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Affiliation(s)
- Lai Xu
- Divisions of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Karam Khaddour
- Divisions of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Jie Chen
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Richard J Perrin
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Jian Li Campian
- Divisions of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, United States
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Desai R, Rich KM. Therapeutic Role of Gamma Knife Stereotactic Radiosurgery in Neuro-Oncology. Mo Med 2020; 117:33-38. [PMID: 32158047 PMCID: PMC7023953] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The Gamma Knife Center of St. Louis has established itself as a key facility offering stereotactic radiosurgery (SRS) for a variety of neuro-oncologic disorders. Since the Gamma Knife unit was first brought to Washington University in 1997, we have treated 5,696 patients. In this review, we discuss the effective role of Gamma Knife SRS in the treatment strategies for patients with neuro-oncologic disorders including brain metastases, meningiomas, pituitary adenomas, and acoustic neuromas. While there is active ongoing research evaluating the most effective treatment for patients with these disorders, it is clear that best management practices may be tailored for individual patients utilizing SRS either alone or in conjunction alternative treatment strategies including open neurosurgical procedures, laser thermos-ablative surgery, and even new medical oncological treatment strategies.
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Affiliation(s)
- Rupen Desai
- Keith M. Rich, MD, MSMA member since 1986, is Professor of Neurosurgery, and Rupen Desai, MD, is Neurosurgery Resident PGY4, Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- Keith M. Rich, MD, MSMA member since 1986, is Professor of Neurosurgery, and Rupen Desai, MD, is Neurosurgery Resident PGY4, Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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24
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Wang Q, Pérez-Carrillo GJG, Ponisio MR, LaMontagne P, Dahiya S, Marcus DS, Milchenko M, Shimony J, Liu J, Chen G, Salter A, Massoumzadeh P, Miller-Thomas MM, Rich KM, McConathy J, Benzinger TLS, Wang Y. Heterogeneity Diffusion Imaging of gliomas: Initial experience and validation. PLoS One 2019; 14:e0225093. [PMID: 31725772 PMCID: PMC6855653 DOI: 10.1371/journal.pone.0225093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 10/29/2019] [Indexed: 12/05/2022] Open
Abstract
Objectives Primary brain tumors are composed of tumor cells, neural/glial tissues, edema, and vasculature tissue. Conventional MRI has a limited ability to evaluate heterogeneous tumor pathologies. We developed a novel diffusion MRI-based method—Heterogeneity Diffusion Imaging (HDI)—to simultaneously detect and characterize multiple tumor pathologies and capillary blood perfusion using a single diffusion MRI scan. Methods Seven adult patients with primary brain tumors underwent standard-of-care MRI protocols and HDI protocol before planned surgical resection and/or stereotactic biopsy. Twelve tumor sampling sites were identified using a neuronavigational system and recorded for imaging data quantification. Metrics from both protocols were compared between World Health Organization (WHO) II and III tumor groups. Cerebral blood volume (CBV) derived from dynamic susceptibility contrast (DSC) perfusion imaging was also compared with the HDI-derived perfusion fraction. Results The conventional apparent diffusion coefficient did not identify differences between WHO II and III tumor groups. HDI-derived slow hindered diffusion fraction was significantly elevated in the WHO III group as compared with the WHO II group. There was a non-significantly increasing trend of HDI-derived tumor cellularity fraction in the WHO III group, and both HDI-derived perfusion fraction and DSC-derived CBV were found to be significantly higher in the WHO III group. Both HDI-derived perfusion fraction and slow hindered diffusion fraction strongly correlated with DSC-derived CBV. Neither HDI-derived cellularity fraction nor HDI-derived fast hindered diffusion fraction correlated with DSC-derived CBV. Conclusions Conventional apparent diffusion coefficient, which measures averaged pathology properties of brain tumors, has compromised accuracy and specificity. HDI holds great promise to accurately separate and quantify the tumor cell fraction, the tumor cell packing density, edema, and capillary blood perfusion, thereby leading to an improved microenvironment characterization of primary brain tumors. Larger studies will further establish HDI’s clinical value and use for facilitating biopsy planning, treatment evaluation, and noninvasive tumor grading.
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Affiliation(s)
- Qing Wang
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | | | - Maria Rosana Ponisio
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Pamela LaMontagne
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Sonika Dahiya
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Daniel S. Marcus
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Mikhail Milchenko
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Joshua Shimony
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Jingxia Liu
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Gengsheng Chen
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Amber Salter
- Department of Biostatistics, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Parinaz Massoumzadeh
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Michelle M. Miller-Thomas
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Keith M. Rich
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Jonathan McConathy
- Department of Radiology, Division of Molecular Imaging and Therapeutics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Tammie L. S. Benzinger
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Yong Wang
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States of America
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri, United States of America
- * E-mail:
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25
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Knutson NC, Hawkins BJ, Bollinger D, Goddu SM, Kavanaugh JA, Santanam L, Mitchell TJ, Zoberi JE, Tsien C, Huang J, Robinson CG, Perkins SM, Dowling JL, Chicoine MR, Rich KM, Dunn GP, Mutic S. Characterization and validation of an intra-fraction motion management system for masked-based radiosurgery. J Appl Clin Med Phys 2019; 20:21-26. [PMID: 31055877 PMCID: PMC6522989 DOI: 10.1002/acm2.12573] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 07/12/2018] [Revised: 01/28/2019] [Accepted: 03/07/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose Characterize the intra‐fraction motion management (IFMM) system found on the Gamma Knife Icon (GKI), including spatial accuracy, latency, temporal performance, and overall effect on delivered dose. Methods A phantom was constructed, consisting of a three‐axis translation mount, a remote motorized flipper, and a thermoplastic sphere surrounding a radiation detector. An infrared marker was placed on the translation mount secured to the flipper. The spatial accuracy of the IFMM was measured via the translation mount in all Cartesian planes. The detector was centered at the radiation focal point. A remote signal was used to move the marker out of the IFMM tolerance and pause the beam. A two‐channel electrometer was used to record the signals from the detector and the flipper when motion was signaled. These signals determined the latency and temporal performance of the GKI. Results The spatial accuracy of the IFMM was found to be <0.1 mm. The measured latency was <200 ms. The dose difference with five interruptions was <0.5%. Conclusion This work provides a quantitative characterization of the GKI IFMM system as required by the Nuclear Regulatory Commission. This provides a methodology for GKI users to satisfy these requirements using common laboratory equipment in lieu of a commercial solution.
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Affiliation(s)
- Nels C Knutson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Douglas Bollinger
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - S Murty Goddu
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - James A Kavanaugh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Lakshmi Santanam
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Timothy J Mitchell
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Christina Tsien
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Stephanie M Perkins
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Joshua L Dowling
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Gavin P Dunn
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
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Sterl K, Thompson B, Goss CW, Dacey RG, Rich KM, Zipfel GJ, Chicoine MR, Kim AH, Silverstein JM. Withholding Perioperative Steroids in Patients Undergoing Transsphenoidal Resection for Pituitary Disease: Randomized Prospective Clinical Trial to Assess Safety. Neurosurgery 2018; 85:E226-E232. [DOI: 10.1093/neuros/nyy479] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/18/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Perioperative steroid protocols for patients undergoing transsphenoidal surgery (TSS) for pituitary pathology vary by institution.
OBJECTIVE
To assess the safety of withholding glucocorticoids in patients undergoing TSS.
METHODS
Patients with an intact hypothalamic-pituitary-adrenal (HPA) axis undergoing TSS for a pituitary tumor at the same academic institution between 2012 and 2015 were randomized to either receive 100 mg of intravenous hydrocortisone followed by 0.5 mg of intravenous dexamethasone every 6 h for 4 doses (STER, n = 23) or to undergo surgery without steroids (NOSTER, n = 20). Postoperative cortisol levels were then used to determine the need for glucocorticoids after surgery. Data regarding postoperative cortisol levels, hospital stay length, and complications were collected.
RESULTS
Mean postoperative 8 am cortisol levels were higher in the NOSTER group compared to the STER group (745 ± 359 nmol/L and 386 ± 193 nmol/L, respectively, P = .001) and more patients were discharged on glucocorticoids in the STER group (42% vs 12%, P = .07). There was no difference in the incidence of postoperative complications, including hyperglycemia, diabetes insipidus, or permanent adrenal insufficiency. Permanent adrenal insufficiency occurred in 8% of patients.
CONCLUSION
Perioperative steroids can be safely withheld in patients with an intact HPA axis undergoing TSS. Although administration of perioperative glucocorticoids does not appear to increase the risk of complications, it may interfere with assessment of the HPA axis after surgery.
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Affiliation(s)
- Karin Sterl
- Divsion of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| | - Bithika Thompson
- Division of Endocrinology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Julie M Silverstein
- Divsion of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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27
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Milchenko M, Snyder AZ, Campbell MC, Dowling JL, Rich KM, Brier LM, Perlmutter JS, Norris SA. ESM-CT: a precise method for localization of DBS electrodes in CT images. J Neurosci Methods 2018; 308:366-376. [PMID: 30201271 DOI: 10.1016/j.jneumeth.2018.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus produces variable effects in Parkinson disease. Variation may result from different electrode positions relative to target. Thus, precise electrode localization is crucial when investigating DBS effects. NEW METHOD We developed a semi-automated method, Electrode Shaft Modeling in CT images (ESM-CT) to reconstruct DBS lead trajectories and contact locations. We evaluated methodological sensitivity to operator-dependent steps, robustness to image resampling, and test-retest replicability. ESM-CT was applied in 56 patients to study electrode position change (and relation to time between scans, postoperative subdural air volume, and head tilt during acquisition) between images acquired immediately post-implantation (DBS-CT) and months later (DEL-CT). RESULTS Electrode tip localization was robust to image resampling and replicable to within ∼ 0.2 mm on test-retest comparisons. Systematic electrode displacement occurred rostral-ventral-lateral between DBS-CT and DEL-CT scans. Head angle was a major explanatory factor (p < 0.001,Pearson's r = 0.46, both sides) and volume of subdural air weakly predicted electrode displacement (p = 0.02,r = 0.29:p = 0.1,r = 0.25 for left:right). Modeled shaft curvature was slightly greater in DEL-CT. Magnitude of displacement and degree of curvature were independent of elapsed time between scans. COMPARISON WITH EXISTING METHODS Comparison of ESM-CT against two existing methods revealed systematic differences in one coordinate (1 ± 0.3 mm,p < 0.001) for one method and in three coordinates for another method (x:0.1 ± 0.1 mm, y:0.4 ± 0.2 mm, z:0.4 ± 0.2 mm, p < 10-10). Within-method coordinate variability across participants is similar. CONCLUSION We describe a robust and precise method for CT DBS contact localization. Application revealed that acquisition head angle significantly impacts electrode position. DBS localization schemes should account for head angle.
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Affiliation(s)
- Mikhail Milchenko
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Abraham Z Snyder
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Meghan C Campbell
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Joshua L Dowling
- Department of Neurosurgical Surgery, Washington University School of Medicine, (CB 8057), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Keith M Rich
- Department of Neurosurgical Surgery, Washington University School of Medicine, (CB 8057), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Lindsey M Brier
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Joel S Perlmutter
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurosurgical Surgery, Washington University School of Medicine, (CB 8057), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neuroscience, Washington University School of Medicine, (CB 8108), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Occupational Therapy, CB 8505, 4444 Forest Park Ave, St. Louis, MO 63108, USA; Department of Physical Therapy, CB 8502, 4444 Forest Park Ave, St. Louis, MO, 63108, USA
| | - Scott A Norris
- Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA.
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Shah AS, Sylvester P, Vellimana AK, Dunn GP, Evans J, Jensen RL, Honeycutt JH, Sutherland GR, Cahill DP, Shah MV, Abram SR, Oswood MC, Kim AH, Leuthardt EC, Dowling JL, Rich KM, Dacey RG, Zipfel GJ, Tao Y, Chicoine MR. 215 The Impact of Intraoperative MRI and Other Factors on Survival for Patients With Newly Diagnosed Glioblastoma. A Multicenter Assessment of Over 800 Patients. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.215] [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: 11/13/2022] Open
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Ibarra R, Rich KM, Adasme M, Kamp A, Singer RS, Atlagich M, Estrada C, Jacob R, Zimin-Veselkoff N, Escobar-Dodero J, Mardones FO. Animal production, animal health and food safety: Gaps and challenges in the chilean industry. Food Microbiol 2018; 75:114-118. [PMID: 30056955 DOI: 10.1016/j.fm.2017.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 10/04/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
This paper summarizes the gaps and challenges related to animal production, health, and food safety as discussed by a panel at the 1st International Symposium of Food Safety (ISFS) in Santiago, Chile, in December 2016. Participating representatives of academia, industry, and government and statements from the audience confirmed that food safety is essential for increasing food security. First, panelists identified the need for a science-based regulatory framework to implement effective regulations. Second, they highlighted the importance of a risk analysis framework to quantify the risk of the potential for antimicrobial resistance associated with the use of antimicrobials, and the need of studies to evaluate foodborne prevention/control strategies. Third, the challenges of filling the gaps between industry and academia were addressed, including examples of successful collaboration, opportunities, and weakness identified by industry. Finally, challenges in animal food production included issues related to changing consumer preferences, animal welfare, the use of antimicrobials, and sustainable animal production. The symposium provided a regional platform to share experiences from the implementation of methods and approaches for food safety. The roundtable successfully explored the future science and technology challenges that are of strategic importance for Chile and the region in animal health and food safety.
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Affiliation(s)
- R Ibarra
- Instituto Tecnológico del Salmón (INTESAL de SalmonChile), Av. Juan Soler Manfredini 41, Of. 1802, Puerto Montt, Chile
| | - K M Rich
- International Livestock Research Institute, East and Southeast Asia Regional Office, Hanoi, Viet Nam
| | - M Adasme
- Asociación Gremial de Productores de Cerdos de Chile (ASPROCER), Av. Isidora Goyenechea 2939, Of. 101, Las Condes, Santiago, Chile
| | - A Kamp
- SOPRAVAL, Panamericana Norte 500, La Calera, Valparaíso, Chile
| | - R S Singer
- Department of Veterinary and Biomedical Sciences, University of Minnesota, 1971 Commonwealth Ave., St. Paul, MN 55108, USA; Instituto de Medicina Preventiva Veterinaria, Facultad de Ciencias, Veterinarias, Universidad Austral de Chile, Valdivia, Chile
| | - M Atlagich
- AGROSUPER, Camino La Estrella 401, Of. 7, Sector Punta de Cortés, Rancagua, Chile
| | - C Estrada
- United States Department of Agriculture, Animal and Plant Health Inspection Service, International Affairs (USDA-APHIS-IS), US Embassy, SES Quadra 801, Brasilia 70403-900, Brazil
| | - R Jacob
- Agencia Chilena para la Inocuidad y Calidad Alimentaria (ACHIPIA), Calle Nueva York 17, 4to piso, Santiago, Chile
| | - N Zimin-Veselkoff
- Escuela de Medicina Veterinaria, Facultad de Ecología y Recursos Naturales, Universidad Andres Bello (UNAB), Republica 440, Santiago, Chile
| | - J Escobar-Dodero
- Escuela de Medicina Veterinaria, Facultad de Ecología y Recursos Naturales, Universidad Andres Bello (UNAB), Republica 440, Santiago, Chile
| | - F O Mardones
- Escuela de Medicina Veterinaria, Facultad de Ecología y Recursos Naturales, Universidad Andres Bello (UNAB), Republica 440, Santiago, Chile.
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Lin AJ, Hui C, Dahiya S, Lu HC, Kim AH, Campian JL, Tsien C, Zipfel GJ, Rich KM, Chicoine M, Huang J. Radiologic Response and Disease Control of Recurrent Intracranial Meningiomas Treated With Reirradiation. Int J Radiat Oncol Biol Phys 2018; 102:194-203. [PMID: 29970312 DOI: 10.1016/j.ijrobp.2018.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/14/2018] [Accepted: 05/02/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the clinical outcomes of reirradiation of recurrent meningiomas and factors related to patient selection and treatment modality. METHODS AND MATERIALS Recurrent meningioma patients who failed prior stereotactic radiosurgery (SRS) or fractionated external beam radiation therapy (EBRT) received reirradiation using either SRS or EBRT. Complete response (CR), partial response (PR), and progression after reirradiation were evaluated using the MacDonald criteria. Local control (LC), progression-free survival (PFS), and overall survival (OS) after reirradiation were analyzed using the Kaplan-Meier method. Logistic and Cox regression analyses were performed to identify factors associated with reirradiation modality and PFS, respectively. RESULTS Forty-three patients (14 grade 1/unknown, 29 grade 2/3) were reirradiated with SRS (67%) or EBRT (33%). Median time from initial SRS/EBRT to reirradiation was 60 months (range, 7.5-202); median tumor volume at the time of reirradiation was 4.8 cm3 (range, 0.14-64). After a median radiologic follow-up of 19.4 months, the response rate (CR + PR) was 8% for grade 1 and 20% for grade 2/3 meningiomas. After 2 years, LC was 78%, PFS was 63%, and OS was 80%. Larger tumor volume and prior SRS were associated with reirradiation using EBRT. Reirradiated grade 2/3 meningiomas had significantly worse PFS than grade 1 (2-year PFS: 50% vs 92%, respectively; P = .02) but not LC (P = .11) or OS (P = .39). On multivariable analysis, worse PFS was significantly associated with grade 2/3 histology (hazard ratio, 3.92; 95% confidence interval, 1.33-11.6) as well as worse Karnofsky Performance Scale score but not reirradiation dose, volume, and modality. Grades 3 to 4 radiation necrosis developed in 4 patients (10%). CONCLUSIONS Reirradiation of recurrent meningiomas appears to be feasible with promising clinical outcomes and an acceptable toxicity profile.
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Affiliation(s)
- Alexander J Lin
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Caressa Hui
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Sonika Dahiya
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Hsiang-Chih Lu
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri
| | - Jian L Campian
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Christina Tsien
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri
| | - Michael Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri.
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Gabani P, Fischer-Valuck BW, Johanns TM, Hernandez-Aya LF, Keller JW, Rich KM, Kim AH, Dunn GP, Robinson CG, Chicoine MR, Huang J, Abraham CD. Stereotactic radiosurgery and immunotherapy in melanoma brain metastases: Patterns of care and treatment outcomes. Radiother Oncol 2018; 128:266-273. [PMID: 29960685 DOI: 10.1016/j.radonc.2018.06.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [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: 04/27/2018] [Revised: 06/08/2018] [Accepted: 06/11/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Preclinical studies have suggested that radiation therapy (RT) enhances antitumor immune response and can act synergistically when administered with immunotherapy. However, this effect in melanoma brain metastasis is not well studied. We aim to explore the clinical effect of combining RT and immunotherapy in patients with melanoma brain metastasis (MBM). MATERIALS AND METHODS Patients with MBM between 2011 and 2013 were obtained from the National Cancer Database. Patients who did not have identifiable sites of metastasis and who did not receive RT for the treatment of their MBM were excluded. Patients were separated into cohorts that received immunotherapy versus patients who did not. Univariable and multivariable analyses were performed using Cox model to determine predictors of OS. Kaplan-Meier method was used to compare OS. Univariable and multivariable analyses using logistic regression model were used to determine the factors predictive for the use of immunotherapy. Propensity score analysis was used to account for differences in baseline patient characteristics between the RT and RT + immunotherapy groups. Significance was defined as a P value ≤ 0.05. RESULTS A total of 1104 patients were identified: 912 received RT alone and 192 received RT plus immunotherapy. The median follow-up time was 6.4 (0.1-56.8) months. Patients with extracranial disease (OR 1.603, 95% CI 1.146-2.243, P = 0.006), and patients receiving SRS (OR 1.955, 95% CI 1.410-2.711, P < 0.001) as compared to WBRT, had a higher likelihood of being treated with immunotherapy. The utilization of immunotherapy had nearly doubled between 2011 and 2013 (12.9-22.8%). On multivariable analysis, factors associated with superior OS were younger age, lower medical comorbidities, lack of extracranial disease, and treatment with immunotherapy and SRS. The median OS was 11.1 (8.9-13.4) months in RT plus immunotherapy vs. 6.2 (5.6-6.8) months in RT alone (P < 0.001), which remained significant after propensity score matching. CONCLUSIONS An increase in trend for the use of immunotherapy was noted, however, an overwhelming majority of the patients with this disease are still treated without immunotherapy. Addition of immunotherapy to RT is associated with improved OS in MBM. Given the selection biases that are inherent in this analysis, prospective trials investigating the combination of RT, especially SRS and immunotherapy are warranted.
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Affiliation(s)
- Prashant Gabani
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Benjamin W Fischer-Valuck
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Tanner M Johanns
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, United States
| | - Leonel F Hernandez-Aya
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, United States
| | - Jesse W Keller
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, United States
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, United States
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, United States
| | - Gavin P Dunn
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, United States
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, United States
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Christopher D Abraham
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States.
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Yang R, Duan C, Yuan L, Engelbach JA, Tsien CI, Beeman SC, Perez-Torres CJ, Ge X, Rich KM, Ackerman JJH, Garbow JR. Inhibitors of HIF-1α and CXCR4 Mitigate the Development of Radiation Necrosis in Mouse Brain. Int J Radiat Oncol Biol Phys 2017; 100:1016-1025. [PMID: 29485043 DOI: 10.1016/j.ijrobp.2017.12.257] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/30/2017] [Accepted: 12/11/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE There is mounting evidence that, in addition to angiogenesis, hypoxia-induced inflammation via the hypoxia-inducible factor 1α (HIF-1α)-CXC chemokine receptor 4 (CXCR4) pathway may contribute to the pathogenesis of late-onset, irradiation-induced necrosis. This study investigates the mitigative efficacy of an HIF-1α inhibitor, topotecan, and a CXCR4 antagonist, AMD3100, on the development of radiation necrosis (RN) in an intracranial mouse model. METHODS AND MATERIALS Mice received a single-fraction, 50-Gy dose of hemispheric irradiation from the Leksell Gamma Knife Perfexion and were then treated with either topotecan, an HIF-1α inhibitor, from 1 to 12 weeks after irradiation, or AMD3100, a CXCR4 antagonist, from 4 to 12 weeks after irradiation. The onset and progression of RN were monitored longitudinally via noninvasive, in vivo magnetic resonance imaging (MRI) from 4 to 12 weeks after irradiation. Conventional hematoxylin-eosin staining and immunohistochemistry staining were performed to evaluate the treatment response. RESULTS The progression of brain RN was significantly mitigated for mice treated with either topotecan or AMD3100 compared with control animals. MRI-derived lesion volumes were significantly smaller for both of the treated groups, and histologic findings correlated well with the MRI data. By hematoxylin-eosin staining, both treated groups demonstrated reduced irradiation-induced tissue damage compared with controls. Furthermore, immunohistochemistry results revealed that expression levels of vascular endothelial growth factor, CXC chemokine ligand 12, CD68, CD3, and tumor necrosis factor α in the lesion area were significantly lower in treated (topotecan or AMD3100) brains versus control brains, while ionized calcium-binding adapter molecule 1 (Iba1) and HIF-1α expression was similar, though somewhat reduced. CXCR4 expression was reduced only in topotecan-treated mice, while interleukin 6 expression was unaffected by either topotecan or AMD3100. CONCLUSIONS By reducing inflammation, both topotecan and AMD3100 can, independently, mitigate the development of RN in the mouse brain. When combined with first-line, antiangiogenic treatment, anti-inflammation therapy may provide an adjuvant therapeutic strategy for clinical, postirradiation management of tumors, with additional benefits in the mitigation of RN development.
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Affiliation(s)
- Ruimeng Yang
- Department of Radiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China; Department of Radiology, Washington University, St Louis, Missouri
| | - Chong Duan
- Department of Chemistry, Washington University, St Louis, Missouri
| | - Liya Yuan
- Department of Neurosurgery, Washington University, St Louis, Missouri
| | - John A Engelbach
- Department of Radiology, Washington University, St Louis, Missouri
| | - Christina I Tsien
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Scott C Beeman
- Department of Radiology, Washington University, St Louis, Missouri
| | | | - Xia Ge
- Department of Radiology, Washington University, St Louis, Missouri
| | - Keith M Rich
- Department of Neurosurgery, Washington University, St Louis, Missouri; Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Joseph J H Ackerman
- Department of Radiology, Washington University, St Louis, Missouri; Department of Chemistry, Washington University, St Louis, Missouri; Department of Medicine, Washington University, St Louis, Missouri; Alvin J. Siteman Cancer Center, Washington University, St Louis, Missouri
| | - Joel R Garbow
- Department of Radiology, Washington University, St Louis, Missouri; Alvin J. Siteman Cancer Center, Washington University, St Louis, Missouri.
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Abraham C, Garsa A, Badiyan SN, Drzymala R, Yang D, DeWees T, Tsien C, Dowling JL, Rich KM, Chicoine MR, Kim AH, Leuthardt EC, Robinson C. Internal dose escalation is associated with increased local control for non-small cell lung cancer (NSCLC) brain metastases treated with stereotactic radiosurgery (SRS). Adv Radiat Oncol 2017; 3:146-153. [PMID: 29904739 PMCID: PMC6000027 DOI: 10.1016/j.adro.2017.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 09/19/2017] [Revised: 11/12/2017] [Accepted: 11/16/2017] [Indexed: 11/24/2022] Open
Abstract
Objective To identify potentially actionable dosimetric predictors of local control (LC) for non-small cell lung cancer (NSCLC) brain metastases treated with single-fraction stereotactic radiosurgery (SRS). Methods and materials Patients with NSCLC brain metastases treated with single-fraction SRS were identified. Eligible patients had at least 1 follow-up magnetic resonance imaging scan and were without prior metastasectomy or SRS to the same lesion. LC and overall survival (OS) were estimated using the Kaplan-Meier method. The Cox proportional hazards model was used for univariate (UVA) and multivariate analysis (MVA). Receiver operating characteristic (ROC) analysis was used to identify optimal cut points for dose-volume histogram metrics relative to LC. Results A total of 612 NSCLC brain metastasis were identified in 299 patients with single-fraction SRS between 1999 and 2014. Median follow-up was 10 months. Median OS from time of SRS was 11 months. Overall LC was 75% and 66% at 1 and 2 years, respectively. On UVA, increasing dose by any measure was associated with improved LC. On MVA, volume receiving at least 32 Gy (V32; hazard ratio [HR], 0.069; P < .000), along with higher prescription isodose (HR, 0.953; P = .031) and lower volume (HR, 1.359; P < .000), were independent predictors of improved LC. ROC analysis demonstrated a V32 of 24% to be most predictive for LC. For the entire cohort, 1-year LC for V32 ≥24% was 89% versus 67% for V32 <24% (P = .000). Stratifying by volume, lesions ≤2 cm (n = 323) had a 1-year LC of 95% versus 82% (P = .005) for V32 above and below 24%, respectively. For lesions 2.1 to 3 cm (n = 211), 1-year LC was 79% versus 59% (P = .003) for V32 above and below 24%, respectively. Total tumor volume alone was predictive for OS. Conclusions Volume, prescription isodose line, and V32 are independent predictors of LC. V32 represents an actionable SRS treatment planning parameter for NSCLC brain metastases.
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Affiliation(s)
- Christopher Abraham
- Department of Radiation Oncology, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
| | - Adam Garsa
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Shahed N Badiyan
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Robert Drzymala
- Department of Radiation Oncology, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
| | - Deshan Yang
- Department of Radiation Oncology, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
| | - Todd DeWees
- Department of Radiation Oncology, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
| | - Christina Tsien
- Department of Radiation Oncology, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
| | - Joshua L Dowling
- Department of Neurosurgery, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- Department of Neurosurgery, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neurosurgery, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
| | - Cliff Robinson
- Department of Radiation Oncology, Barnes-Jewish Hospital, and Washington University School of Medicine, St. Louis, Missouri
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Sun SQ, Cai C, Murphy RKJ, DeWees T, Dacey RG, Grubb RL, Rich KM, Zipfel GJ, Dowling JL, Leuthardt EC, Simpson JR, Robinson CG, Chicoine MR, Perrin RJ, Huang J, Kim AH. Radiation Therapy for Residual or Recurrent Atypical Meningioma: The Effects of Modality, Timing, and Tumor Pathology on Long-Term Outcomes. Neurosurgery 2017; 79:23-32. [PMID: 26645969 DOI: 10.1227/neu.0000000000001160] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [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
BACKGROUND Optimal use of stereotactic radiosurgery (SRS) vs external beam radiation therapy (EBRT) for treatment of residual/recurrent atypical meningioma is unclear. OBJECTIVE To analyze features associated with progression after radiation therapy. METHODS Fifty radiation-naive patients who received SRS or EBRT for residual and/or recurrent atypical meningioma were examined for predictors of progression using Cox regression and Kaplan-Meier analyses. RESULTS Thirty-two patients (64%) received adjuvant radiation after subtotal resection, 12 patients (24%) received salvage radiation after progression following subtotal resection, and 6 patients (12%) received salvage radiation after recurrence following gross total resection. Twenty-one patients (42%) received SRS (median 18 Gy), and 7 (33%) had tumor progression. Twenty-nine patients (58%) received EBRT (median 54 Gy), and 13 (45%) had tumor progression. Whereas tumor volume (P = .53), SRS vs EBRT (P = .45), and adjuvant vs salvage (P = .34) were not associated with progression after radiation therapy, spontaneous necrosis (hazard ratio [HR] = 82.3, P < .001), embolization necrosis (HR = 15.6, P = .03), and brain invasion (HR = 3.8, P = .008) predicted progression in univariate and multivariate analyses. Tumors treated with SRS/EBRT had 2- and 5-year actuarial locoregional control rates of 91%/88% and 71%/69%, respectively. Tumors with spontaneous necrosis, embolization necrosis, and no necrosis had 2- and 5-year locoregional control rates of 76%, 92%, and 100% and 36%, 73%, and 100%, respectively (P < .001). CONCLUSION This study suggests that necrosis may be a negative predictor of radiation response regardless of radiation timing or modality. ABBREVIATIONS AM, atypical meningiomaEBRT, external beam radiation therapyGTR, gross total resectionLC, locoregional controlOS, overall survivalPOE, preoperative embolizationRT, radiation therapySRS, stereotactic radiosurgerySTR, subtotal resection.
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Affiliation(s)
- Sam Q Sun
- ‡Washington University School of Medicine, St. Louis, Missouri; §Department of Pathology and Immunology, Washington University, St. Louis, Missouri; ¶Department of Neurosurgery, Washington University, St. Louis, Missouri; ‖Department of Radiation Oncology, Washington University, St. Louis, Missouri
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Abstract
Animal disease outbreaks generate a range of economic and non-economic impacts. While a significant number of research studies have estimated the effects of various diseases in a variety of contexts, examining the differential impacts and implications associated with the introduction of a novel disease into a developing country, as opposed to a developed one, is a rich area for further research. In this paper, the authors highlight some of the key dimensions and implications associated with the impacts of new diseases, how they differ in different contexts, and their implications for public policy.
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Duan C, Perez-Torres CJ, Yuan L, Engelbach JA, Beeman SC, Tsien CI, Rich KM, Schmidt RE, Ackerman JJH, Garbow JR. Can anti-vascular endothelial growth factor antibody reverse radiation necrosis? A preclinical investigation. J Neurooncol 2017; 133:9-16. [PMID: 28425047 DOI: 10.1007/s11060-017-2410-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 04/03/2017] [Indexed: 01/16/2023]
Abstract
Anti-vascular endothelial growth factor (anti-VEGF) antibodies are a promising new treatment for late time-to-onset radiation-induced necrosis (RN). We sought to evaluate and validate the response to anti-VEGF antibody in a mouse model of RN. Mice were irradiated with the Leksell Gamma Knife Perfexion™ and then treated with anti-VEGF antibody, beginning at post-irradiation (PIR) week 8. RN progression was monitored via anatomic and diffusion MRI from weeks 4-12 PIR. Standard histology, using haematoxylin and eosin (H&E), and immunohistochemistry staining were used to validate the response to treatment. After treatment, both post-contrast T1-weighted and T2-weighted image-derived lesion volumes decreased (P < 0.001), while the lesion volumes for the control group increased. The abnormally high apparent diffusion coefficient (ADC) for RN also returned to the ADC range for normal brain following treatment (P < 0.001). However, typical RN pathology was still present histologically. Large areas of focal calcification were observed in ~50% of treated mouse brains. Additionally, VEGF and hypoxia-inducible factor 1-alpha (HIF-1α) were continually upregulated in both the anti-VEGF and control groups. Despite improvements observed radiographically following anti-VEGF treatment, lesions were not completely resolved histologically. The subsequent calcification and the continued upregulation of VEGF and HIF-1α merit further preclinical/clinical investigation.
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Affiliation(s)
- Chong Duan
- Department of Chemistry, Washington University, Saint Louis, MO, USA
| | - Carlos J Perez-Torres
- Department of Radiology, Washington University, Saint Louis, MO, USA.,School of Health Sciences, Purdue University, West Lafayette, IN, 47907, USA
| | - Liya Yuan
- Department of Neurosurgery, Washington University, Saint Louis, MO, USA
| | - John A Engelbach
- Department of Radiology, Washington University, Saint Louis, MO, USA
| | - Scott C Beeman
- Department of Radiology, Washington University, Saint Louis, MO, USA
| | - Christina I Tsien
- Department of Radiation Oncology, Washington University, Saint Louis, MO, USA
| | - Keith M Rich
- Department of Neurosurgery, Washington University, Saint Louis, MO, USA.,Department of Radiation Oncology, Washington University, Saint Louis, MO, USA
| | - Robert E Schmidt
- Department of Pathology and Immunology, Washington University, Saint Louis, MO, USA
| | - Joseph J H Ackerman
- Department of Chemistry, Washington University, Saint Louis, MO, USA.,Department of Radiology, Washington University, Saint Louis, MO, USA.,Department of Medicine, Washington University, Saint Louis, MO, USA.,Alvin J Siteman Cancer Center, Washington University, Saint Louis, MO, USA
| | - Joel R Garbow
- Department of Radiology, Washington University, Saint Louis, MO, USA. .,Alvin J Siteman Cancer Center, Washington University, Saint Louis, MO, USA.
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Lin AL, White M, Miller-Thomas MM, Fulton RS, Tsien CI, Rich KM, Schmidt RE, Tran DD, Dahiya S. Molecular and histologic characteristics of pseudoprogression in diffuse gliomas. J Neurooncol 2016; 130:529-533. [PMID: 27704386 DOI: 10.1007/s11060-016-2247-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 05/11/2016] [Accepted: 08/21/2016] [Indexed: 10/20/2022]
Abstract
During the 6 month period following chemoradiotherapy, gliomas frequently develop new areas of contrast enhancement, which are due to treatment effect rather than tumor progression. We sought to characterize this phenomenon in oligodendrogliomas (OG) and mixed oligoastrocytomas (MOA). We reviewed the imaging findings from 143 patients with a WHO grade II or III OG or MOA for evidence of pseudoprogression (PsP) or early tumor progression. We characterized these cases for 1p/19q codeletions by FISH, IDH1 R132H mutation by immunohistochemistry, and TP53, ATRX, and EGFR mutations by next generation sequencing. We then reviewed the pathologic specimens of the patient cases in which a re-resection was performed. We found that OG and MOA that are 1p/19q intact developed PsP at a higher rate than tumors that are 1p/19q codeleted (27 vs. 8 %). Moreover, IDH1 wild-type (WT) tumors developed PsP at a higher rate than IDH1 R132H cases (27 vs. 11 %). Patients with ATRX or TP53 mutations developed PsP at an intermediate rate of 21 %. Ten patients in our cohort underwent a re-resection for early contrast enhancement; these tumors were predominantly 1p/19q intact (90 %) and had a low rate of IDH1 R132H mutation (50 %). 8 of 10 tumors demonstrated primarily treatment effects, while the remaining 2 of 10 demonstrated recurrent/residual tumor of the same grade. Early contrast enhancement that develops during the first 6 months after chemoradiotherapy is typically due to PsP and occurs primarily in OG and MOA that are 1p/19q intact and IDH WT.
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Affiliation(s)
- Andrew L Lin
- Department of Neurology, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, St. Louis, MO, 63110, USA.,Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Michael White
- Department of Neurology, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, St. Louis, MO, 63110, USA
| | - Michelle M Miller-Thomas
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, St. Louis, MO, 63110, USA
| | - Robert S Fulton
- McDonnell Genome Institute, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, St. Louis, MO, 63110, USA
| | - Christina I Tsien
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, St. Louis, MO, 63110, USA
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, St. Louis, MO, 63110, USA
| | - Robert E Schmidt
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, St. Louis, MO, 63110, USA
| | - David D Tran
- Neuro-Oncology Program, Department of Internal Medicine, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, St. Louis, MO, 63110, USA. .,Division of Neuro-Oncology, Department of Neurosurgery, University of Florida, 1149 S Newell Drive, Suite L2-100, Gainesville, FL, 32611, USA.
| | - Sonika Dahiya
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, St. Louis, MO, 63110, USA.
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Greenberg JK, Guniganti R, Arias EJ, Desai K, Washington CW, Yan Y, Weng H, Xiong C, Fondahn E, Cross DT, Moran CJ, Rich KM, Chicoine MR, Dhar R, Dacey RG, Derdeyn CP, Zipfel GJ. Predictors of 30-day readmission after aneurysmal subarachnoid hemorrhage: a case-control study. J Neurosurg 2016; 126:1847-1854. [PMID: 27494820 DOI: 10.3171/2016.5.jns152644] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite persisting questions regarding its appropriateness, 30-day readmission is an increasingly common quality metric used to influence hospital compensation in the United States. However, there is currently insufficient evidence to identify which patients are at highest risk for readmission after aneurysmal subarachnoid hemorrhage (SAH). The objective of this study was to identify predictors of 30-day readmission after SAH, to focus preventative efforts, and to provide guidance to funding agencies seeking to risk-adjust comparisons among hospitals. METHODS The authors performed a case-control study of 30-day readmission among aneurysmal SAH patients treated at a single center between 2003 and 2013. To control for geographic distance from the hospital and year of treatment, the authors randomly matched each case (30-day readmission) with approximately 2 SAH controls (no readmission) based on home ZIP code and treatment year. They evaluated variables related to patient demographics, socioeconomic characteristics, comorbidities, presentation severity (e.g., Hunt and Hess grade), and clinical course (e.g., need for gastrostomy or tracheostomy, length of stay). Conditional logistic regression was used to identify significant predictors, accounting for the matched design of the study. RESULTS Among 82 SAH patients with unplanned 30-day readmission, the authors matched 78 patients with 153 nonreadmitted controls. Age, demographics, and socioeconomic factors were not associated with readmission. In univariate analysis, multiple variables were significantly associated with readmission, including Hunt and Hess grade (OR 3.0 for Grade IV/V vs I/II), need for gastrostomy placement (OR 2.0), length of hospital stay (OR 1.03 per day), discharge disposition (OR 3.2 for skilled nursing vs other disposition), and Charlson Comorbidity Index (OR 2.3 for score ≥ 2 vs 0). However, the only significant predictor in the multivariate analysis was discharge to a skilled nursing facility (OR 3.2), and the final model was sensitive to criteria used to enter and retain variables. Furthermore, despite the significant association between discharge disposition and readmission, less than 25% of readmitted patients were discharged to a skilled nursing facility. CONCLUSIONS Although discharge disposition remained significant in multivariate analysis, most routinely collected variables appeared to be weak independent predictors of 30-day readmission after SAH. Consequently, hospitals interested in decreasing readmission rates may consider multifaceted, cost-efficient interventions that can be broadly applied to most if not all SAH patients.
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Affiliation(s)
| | | | | | | | | | | | - Hua Weng
- Division of Biostatistics, Washington University School of Medicine in St. Louis, Missouri; and
| | - Chengjie Xiong
- Division of Biostatistics, Washington University School of Medicine in St. Louis, Missouri; and
| | | | - DeWitte T Cross
- Departments of 1 Neurological Surgery.,Mallinckrodt Institute of Radiology, and
| | - Christopher J Moran
- Departments of 1 Neurological Surgery.,Mallinckrodt Institute of Radiology, and
| | | | | | | | | | - Colin P Derdeyn
- Departments of 1 Neurological Surgery.,Neurology.,Mallinckrodt Institute of Radiology, and.,Departments of Radiology, Neurology, and Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Holekamp TF, Mollman ME, Murphy RKJ, Kolar GR, Kramer NM, Derdeyn CP, Moran CJ, Perrin RJ, Rich KM, Lanzino G, Zipfel GJ. Dural arteriovenous fistula-induced thalamic dementia: report of 4 cases. J Neurosurg 2016; 124:1752-65. [DOI: 10.3171/2015.5.jns15473] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nonhemorrhagic neurological deficits are underrecognized symptoms of intracranial dural arteriovenous fistulas (dAVFs) having cortical venous drainage. These symptoms are the consequence of cortical venous hypertension and portend a clinical course with increased risk of neurological morbidity and mortality. One rarely documented and easily misinterpreted type of nonhemorrhagic neurological deficit is progressive dementia, which can result from venous hypertension in the cortex or in bilateral thalami. The latter, which is due to dAVF drainage into the deep venous system, is the less common of these 2 dementia syndromes. Herein, the authors report 4 cases of dAVF with venous drainage into the vein of Galen causing bithalamic edema and rapidly progressive dementia. Two patients were treated successfully with endovascular embolization, and the other 2 patients were treated successfully with endovascular embolization followed by surgery. The radiographic abnormalities and presenting symptoms rapidly resolved after dAVF obliteration in all 4 cases. Detailed descriptions of these 4 cases are presented along with a critical review of 15 previously reported cases. In our analysis of these 19 published cases, the following were emphasized: 1) the clinical and radiographic differences between dAVF-induced thalamic versus cortical dementia syndromes; 2) the differential diagnosis and necessary radiographic workup for patients presenting with a rapidly progressive thalamic dementia syndrome; 3) the frequency at which delays in diagnosis occurred and potentially dangerous and avoidable diagnostic procedures were used; and 4) the rapidity and completeness of symptom resolution following dAVF treatment.
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Affiliation(s)
| | | | | | | | | | - Colin P. Derdeyn
- Departments of 1Neurological Surgery,
- 4Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, Missouri; and
- 5Neurology, and
| | - Christopher J. Moran
- Departments of 1Neurological Surgery,
- 4Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, Missouri; and
| | | | - Keith M. Rich
- Departments of 1Neurological Surgery,
- 4Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, Missouri; and
| | - Giuseppe Lanzino
- 3Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
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Abstract
In this paper, the authors review the impacts of diseases facing salmon aquaculture, drawing lessons from terrestrial animal diseases. They discuss the implementation of current control strategies, taking into account transmission patterns (vertical versus horizontal), disease reservoirs, and interactions with wild fish. In addition, the decision-making context of aquatic disease control and the institutional organisation of control strategies are considered, with particular emphasis on the roles and responsibilities of regulatory authorities and the private sector. Case studies on the emergence and control of infectious salmon anaemia worldwide and pancreas disease in Norway are used to examine some of the controversies that may influence decision making and provide lessons for the future.
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Abstract
OBJECTIVE Colloid cysts are rare, histologically benign lesions that may result in obstructive hydrocephalus and death. Understanding the natural history of colloid cysts has been challenging given their low incidence and the small number of cases in most reported series. This has complicated efforts to establish reliable prognostic factors and surgical indications, particularly for asymptomatic patients with incidental lesions. Risk factors for obstructive hydrocephalus in the setting of colloid cysts remain poorly defined, and there are no grading scales on which to develop standard management strategies. METHODS The authors performed a single-center retrospective review of all cases of colloid cysts of the third ventricle treated over nearly 2 decades at Washington University. Univariate analysis was used to identify clinical, imaging, and anatomical factors associated with 2 outcome variables: symptomatic clinical status and presentation with obstructive hydrocephalus. A risk-prediction model was defined using bootstrapped logistic regression. Predictive factors were then combined into a simple 5-point clinical scale referred to as the Colloid Cyst Risk Score (CCRS), and this was evaluated with receiver-operator characteristics. RESULTS The study included 163 colloid cysts, more than half of which were discovered incidentally. More than half of the incidental cysts (58%) were followed with surveillance neuroimaging (mean follow-up 5.1 years). Five patients with incidental cysts (8.8%) progressed and underwent resection. No patient with an incidental, asymptomatic colloid cyst experienced acute obstructive hydrocephalus or sudden neurological deterioration in the absence of antecedent trauma. Nearly half (46.2%) of symptomatic patients presented with hydrocephalus. Eight patients (12.3%) presented acutely, and there were 2 deaths due to obstructive hydrocephalus and herniation. The authors identified several factors that were strongly correlated with the 2 outcome variables and defined third ventricle risk zones where colloid cysts can cause obstructive hydrocephalus. No patient with a lesion outside these risk zones presented with obstructive hydrocephalus. The CCRS had significant predictive capacity for symptomatic clinical status (area under the curve [AUC] 0.917) and obstructive hydrocephalus (AUC 0.845). A CCRS ≥ 4 was significantly associated with obstructive hydrocephalus (p < 0.0001, RR 19.4). CONCLUSIONS Patients with incidentally discovered colloid cysts can experience both lesion enlargement and symptom progression or less commonly, contraction and symptom regression. Incidental lesions rarely cause acute obstructive hydrocephalus or sudden neurological deterioration in the absence of antecedent trauma. Nearly one-half of patients with symptomatic colloid cysts present with obstructive hydrocephalus, which has an associated 3.1% risk of death. The CCRS is a simple 5-point clinical tool that can be used to identify symptomatic lesions and stratify the risk of obstructive hydrocephalus. External validation of the CCRS will be necessary before objective surgical indications can be established. Surgical intervention should be considered for all patients with CCRS ≥ 4, as they represent the high-risk subgroup.
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Affiliation(s)
| | | | | | - Franz J Wippold
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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42
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Schwetye KE, Joseph NM, Al-Kateb H, Rich KM, Schmidt RE, Perry A, Gutmann DH, Dahiya S. Gliosarcomas lackBRAFV600Emutation, but a subset exhibit β-catenin nuclear localization. Neuropathology 2016; 36:448-455. [DOI: 10.1111/neup.12293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Katherine E. Schwetye
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis MO USA
| | - Nancy M. Joseph
- Department of Pathology; University of California-San Francisco; San Francisco CA USA
| | - Hussam Al-Kateb
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis MO USA
| | - Keith M. Rich
- Department of Neurosurgery; Washington University School of Medicine; St. Louis MO USA
| | - Robert E. Schmidt
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis MO USA
| | - Arie Perry
- Department of Pathology; University of California-San Francisco; San Francisco CA USA
| | - David H. Gutmann
- Department of Neurology; Washington University School of Medicine; St. Louis MO USA
| | - Sonika Dahiya
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis MO USA
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Sylvester PT, Moran CJ, Derdeyn CP, Cross DT, Dacey RG, Zipfel GJ, Kim AH, Uppaluri R, Haughey BH, Tempelhoff R, Rich KM, Schneider J, Chole RA, Chicoine MR. Endovascular management of internal carotid artery injuries secondary to endonasal surgery: case series and review of the literature. J Neurosurg 2016; 125:1256-1276. [PMID: 26771847 DOI: 10.3171/2015.6.jns142483] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Internal carotid artery (ICA) injury is a rare but severe complication of endonasal surgery. The authors describe their endovascular experience managing ICA injuries after transsphenoidal surgery; they review and summarize the current literature regarding endovascular techniques; and they propose a treatment algorithm based on the available evidence. METHODS A retrospective review of 576 transsphenoidal pituitary adenoma resections was performed. Cases of ICA injury occurring at our institution and transfers from other hospitals were evaluated. Endovascular treatments for ICA injury reported in the literature were also reviewed and summarized. RESULTS Seven cases were identified from the institutional cohort (mean age 46.3 years, mean follow-up 43.4 months [1-107 months]) that received endovascular treatment for ICA injury. Five injuries occurred at our institution (5 [0.9%] of 576), and 2 injuries occurred at outside hospitals. Three patients underwent ICA sacrifice by coil placement, 2 underwent lesion embolization (coil or stent-assisted coil placement), and 2 underwent endoluminal reconstruction (both with flow diversion devices). Review of the literature identified 98 cases of ICA injury treated with endovascular methods. Of the 105 total cases, 46 patients underwent ICA sacrifice, 28 underwent lesion embolization, and 31 underwent endoluminal reconstruction. Sacrifice of the ICA proved a durable solution in all cases; however, the rate of persistent neurological complications was relatively high (10 [21.7%] of 46). Lesion embolization was primarily performed by coil embolization without stenting (16 cases) and stent-assisted coiling (9 cases). Both techniques had a relatively high rate of at least some technical complication (6 [37.5%] of 16 and 5 [55.6%] of 9, respectively) and major technical complications (i.e., injury, new neurological deficit, or ICA sacrifice) (5 [31.3%] of 16 and 2 [22.2%] of 9, respectively). Endoluminal reconstruction was performed by covered stent (24 cases) and flow diverter (5 cases) placement. Covered stents showed a reasonably high rate of technical complications (10 [41.7%] of 24); however, 8 of these problems were resolved, leaving a small percentage with major technical complications (2 [8.3%] of 24). Flow diverter placement was also well tolerated, with only 1 minor technical complication. CONCLUSIONS Endovascular treatments including vessel sacrifice, coil embolization (with or without stent assistance), and endoluminal reconstruction offer a tailored approach to ICA injury management after endonasal surgery. Vessel sacrifice remains the definitive treatment for acute, uncontrolled bleeding; however, vessel preservation techniques should be considered carefully in select patients. Multiple factors including vascular anatomy, injury characteristics, and risk of dual antiplatelet therapy should guide best treatment, but more study is needed (particularly with flow diverters) to refine this decision-making process. Ideally, all endovascular treatment options should be available at institutions performing endonasal surgery.
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Affiliation(s)
| | - Christopher J Moran
- Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
| | - Colin P Derdeyn
- Departments of 1 Neurosurgery.,Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
| | - DeWitte T Cross
- Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
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Jiang X, Yuan L, Engelbach JA, Cates J, Perez-Torres CJ, Gao F, Thotala D, Drzymala RE, Schmidt RE, Rich KM, Hallahan DE, Ackerman JJH, Garbow JR. A Gamma-Knife-Enabled Mouse Model of Cerebral Single-Hemisphere Delayed Radiation Necrosis. PLoS One 2015; 10:e0139596. [PMID: 26440791 PMCID: PMC4595209 DOI: 10.1371/journal.pone.0139596] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 09/14/2015] [Indexed: 11/26/2022] Open
Abstract
Purpose To develop a Gamma Knife-based mouse model of late time-to-onset, cerebral radiation necrosis (RN) with serial evaluation by magnetic resonance imaging (MRI) and histology. Methods and Materials Mice were irradiated with the Leksell Gamma Knife® (GK) PerfexionTM (Elekta AB; Stockholm, Sweden) with total single-hemispheric radiation doses (TRD) of 45- to 60-Gy, delivered in one to three fractions. RN was measured using T2-weighted MR images, while confirmation of tissue damage was assessed histologically by hematoxylin & eosin, trichrome, and PTAH staining. Results MRI measurements demonstrate that TRD is a more important determinant of both time-to-onset and progression of RN than fractionation. The development of RN is significantly slower in mice irradiated with 45-Gy than 50- or 60-Gy, where RN development is similar. Irradiated mouse brains demonstrate all of the pathologic features observed clinically in patients with confirmed RN. A semi-quantitative (0 to 3) histologic grading system, capturing both the extent and severity of injury, is described and illustrated. Tissue damage, as assessed by a histologic score, correlates well with total necrotic volume measured by MRI (correlation coefficient = 0.948, with p<0.0001), and with post-irradiation time (correlation coefficient = 0.508, with p<0.0001). Conclusions Following GK irradiation, mice develop late time-to-onset cerebral RN histology mirroring clinical observations. MR imaging provides reliable quantification of the necrotic volume that correlates well with histologic score. This mouse model of RN will provide a platform for mechanism of action studies, the identification of imaging biomarkers of RN, and the development of clinical studies for improved mitigation and neuroprotection.
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Affiliation(s)
- Xiaoyu Jiang
- Department of Chemistry, Washington University, St. Louis, Missouri, United States of America
| | - Liya Yuan
- Department of Neurosurgery, Washington University, St. Louis, Missouri, United States of America
| | - John A. Engelbach
- Department of Radiology, Washington University, St. Louis, Missouri, United States of America
| | - Jeremy Cates
- Department of Radiation Oncology, Washington University, St. Louis, Missouri, United States of America
| | - Carlos J. Perez-Torres
- Department of Radiology, Washington University, St. Louis, Missouri, United States of America
| | - Feng Gao
- Division of Biostatistics, Washington University, St. Louis, Missouri, United States of America
- Alvin J. Siteman Cancer Center, Washington University, St. Louis, Missouri, United States of America
| | - Dinesh Thotala
- Department of Radiation Oncology, Washington University, St. Louis, Missouri, United States of America
- Alvin J. Siteman Cancer Center, Washington University, St. Louis, Missouri, United States of America
| | - Robert E. Drzymala
- Department of Neurosurgery, Washington University, St. Louis, Missouri, United States of America
- Department of Radiation Oncology, Washington University, St. Louis, Missouri, United States of America
| | - Robert E. Schmidt
- Department of Neuropathology, Washington University, St. Louis, Missouri, United States of America
| | - Keith M. Rich
- Department of Neurosurgery, Washington University, St. Louis, Missouri, United States of America
- Department of Radiation Oncology, Washington University, St. Louis, Missouri, United States of America
| | - Dennis E. Hallahan
- Department of Radiation Oncology, Washington University, St. Louis, Missouri, United States of America
- Alvin J. Siteman Cancer Center, Washington University, St. Louis, Missouri, United States of America
| | - Joseph J. H. Ackerman
- Department of Chemistry, Washington University, St. Louis, Missouri, United States of America
- Department of Radiology, Washington University, St. Louis, Missouri, United States of America
- Alvin J. Siteman Cancer Center, Washington University, St. Louis, Missouri, United States of America
- Department of Internal Medicine, Washington University, St. Louis, Missouri, United States of America
| | - Joel R. Garbow
- Department of Radiology, Washington University, St. Louis, Missouri, United States of America
- Alvin J. Siteman Cancer Center, Washington University, St. Louis, Missouri, United States of America
- * E-mail:
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45
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Arias EJ, Vajapey S, Reynolds MR, Chicoine MR, Rich KM, Dacey RG, Dorward IG, Derdeyn CP, Moran CJ, Cross DT, Zipfel GJ, Dhar R. Utility of Screening for Cerebral Vasospasm Using Digital Subtraction Angiography. Stroke 2015; 46:3137-41. [PMID: 26405204 DOI: 10.1161/strokeaha.115.010081] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 05/15/2015] [Accepted: 08/06/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral arterial vasospasm (CVS) is a common complication of aneurysmal subarachnoid hemorrhage strongly associated with neurological deterioration and delayed cerebral ischemia (DCI). The utility of screening for CVS as a surrogate for early detection of DCI, especially in patients without clinical signs of DCI, remains uncertain. METHODS We performed a retrospective analysis of 116 aneurysmal subarachnoid hemorrhage patients who underwent screening digital subtraction angiography to determine the association of significant CVS and subsequent development of DCI. Patients were stratified into 3 groups: (1) no symptoms of DCI before screening, (2) ≥1 episodes of suspected DCI symptoms before screening, and (3) unable to detect symptoms because of poor examination. RESULTS Patients asymptomatic before screening had significantly lower rates of CVS (18%) compared with those with transient symptoms of DCI (60%; P<0.0001). None of the 79 asymptomatic patients developed DCI after screening, regardless of digital subtraction angiography findings, compared with 56% of those with symptoms (P<0.0001). Presence of CVS was significantly associated with DCI in those with transient symptoms and in those whose examinations did not permit clear assessment (odds ratio 16.0, 95% confidence interval 2.2-118.3, P=0.003). CONCLUSIONS Patients asymptomatic before screening have low rates of CVS and seem to be at negligible risk of developing DCI. Routine screening of asymptomatic patients seems to have little utility. Screening may still be considered in patients with possible symptoms of DCI or those with examinations too poor to clinically detect symptoms because finding CVS may be useful for risk stratification and guiding management.
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Affiliation(s)
- Eric J Arias
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO.
| | - Sravya Vajapey
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Matthew R Reynolds
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Michael R Chicoine
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Keith M Rich
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Ralph G Dacey
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Ian G Dorward
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Colin P Derdeyn
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Christopher J Moran
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - DeWitte T Cross
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Gregory J Zipfel
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Rajat Dhar
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
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Washington CW, Derdeyn CP, Dhar R, Arias EJ, Chicoine MR, Cross DT, Dacey RG, Han BH, Moran CJ, Rich KM, Vellimana AK, Zipfel GJ. A Phase I proof-of-concept and safety trial of sildenafil to treat cerebral vasospasm following subarachnoid hemorrhage. J Neurosurg 2015; 124:318-27. [PMID: 26314998 DOI: 10.3171/2015.2.jns142752] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Studies show that phosphodiesterase-V (PDE-V) inhibition reduces cerebral vasospasm (CVS) and improves outcomes after experimental subarachnoid hemorrhage (SAH). This study was performed to investigate the safety and effect of sildenafil (an FDA-approved PDE-V inhibitor) on angiographic CVS in SAH patients. METHODS A2-phase, prospective, nonrandomized, human trial was implemented. Subarachnoid hemorrhage patients underwent angiography on Day 7 to assess for CVS. Those with CVS were given 10 mg of intravenous sildenafil in the first phase of the study and 30 mg in the second phase. In both, angiography was repeated 30 minutes after infusion. Safety was assessed by monitoring neurological examination findings and vital signs and for the development of adverse reactions. For angiographic assessment, in a blinded fashion, pre- and post-sildenafil images were graded as "improvement" or "no improvement" in CVS. Unblinded measurements were made between pre- and post-sildenafil angiograms. RESULTS Twelve patients received sildenafil; 5 patients received 10 mg and 7 received 30 mg. There were no adverse reactions. There was no adverse effect on heart rate or intracranial pressure. Sildenafil resulted in a transient decline in mean arterial pressure, an average of 17% with a return to baseline in an average of 18 minutes. Eight patients (67%) were found to have a positive angiographic response to sildenafil, 3 (60%) in the low-dose group and 5 (71%) in the high-dose group. The largest degree of vessel dilation was an average of 0.8 mm (range 0-2.1 mm). This corresponded to an average percentage increase in vessel diameter of 62% (range 0%-200%). CONCLUSIONS The results from this Phase I safety and proof-of-concept trial assessing the use of intravenous sildenafil in patients with CVS show that sildenafil is safe and well tolerated in the setting of SAH. Furthermore, the angiographic data suggest that sildenafil has a positive impact on human CVS.
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Affiliation(s)
- Chad W Washington
- Departments of 1 Neurological Surgery.,Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Colin P Derdeyn
- Departments of 1 Neurological Surgery.,Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | | | | | | | - DeWitte T Cross
- Departments of 1 Neurological Surgery.,Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | | | | | - Christopher J Moran
- Departments of 1 Neurological Surgery.,Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Keith M Rich
- Departments of 1 Neurological Surgery.,Radiology, Washington University School of Medicine, Saint Louis, Missouri
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47
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Sun SQ, Kim AH, Cai C, Murphy RKJ, DeWees T, Sylvester P, Dacey RG, Grubb RL, Rich KM, Zipfel GJ, Dowling JL, Leuthardt EC, Leonard JR, Evans J, Simpson JR, Robinson CG, Perrin RJ, Huang J, Chicoine MR. Management of atypical cranial meningiomas, part 1: predictors of recurrence and the role of adjuvant radiation after gross total resection. Neurosurgery 2015; 75:347-54; discussion 354-5; quiz 355. [PMID: 24932707 DOI: 10.1227/neu.0000000000000461] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [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
BACKGROUND Indications for external beam radiation therapy (EBRT) for atypical meningiomas (AMs) remain unclear. OBJECTIVE To analyze features associated with recurrence in AM patients after gross total resection (GTR) and to assess the relative benefit of EBRT in a retrospective cohort study. METHODS One hundred fifty-one primary AMs after GTR (88 female patients; median follow-up, 45.0 months) were examined for possible predictors of recurrence (age, sex, location, volume, bone involvement, brain invasion). The Fisher exact and Wilcoxon rank-sum tests were used to analyze the association between these predictors and use of EBRT. The impact on recurrence for these predictors and EBRT was analyzed with Kaplan-Meier and Cox regression. RESULTS Of 151 patients, 13 (8.6%) experienced recurrence after GTR (median, 47.0 months). Multivariate analysis identified elevated mitotic index (P = .007) and brain invasion (P = .002) as predictors of recurrence. Larger volume (P = .96) was not associated with recurrence but was more likely to prompt EBRT (P = .001). Recurrences occurred in 11 of 112 with GTR (9.8%; median, 44 months) and 2 of 39 with GTR/EBRT (5.1%; median, 133 months). The 2-, 5-, and 10-year progression-free survival rates after GTR vs GTR/EBRT were 97%, 86%, and 68% vs 100%, 100%, and 78%. Kaplan-Meier analysis demonstrated no difference in progression-free survival or overall survival after GTR vs GTR/EBRT (P = .8, P > .99). CONCLUSION Brain invasion and high mitotic rates may predict recurrence. After GTR of AMs, EBRT appears not to affect progression-free survival and overall survival, suggesting that observation rather than EBRT may be indicated after GTR.
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Affiliation(s)
- Sam Q Sun
- ‡Washington University School of Medicine, St. Louis, Missouri; and §Department of Neurosurgery, ¶Pathology and Immunology, and ‖Radiation Oncology, Washington University, St. Louis, Missouri
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48
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Mao DD, Gujar AD, Mahlokozera T, Chen I, Pan Y, Luo J, Brost T, Thompson EA, Turski A, Leuthardt EC, Dunn GP, Chicoine MR, Rich KM, Dowling JL, Zipfel GJ, Dacey RG, Achilefu S, Tran DD, Yano H, Kim AH. A CDC20-APC/SOX2 Signaling Axis Regulates Human Glioblastoma Stem-like Cells. Cell Rep 2015; 11:1809-21. [PMID: 26074073 DOI: 10.1016/j.celrep.2015.05.027] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 02/28/2015] [Accepted: 05/12/2015] [Indexed: 11/29/2022] Open
Abstract
Glioblastoma harbors a dynamic subpopulation of glioblastoma stem-like cells (GSCs) that can propagate tumors in vivo and is resistant to standard chemoradiation. Identification of the cell-intrinsic mechanisms governing this clinically important cell state may lead to the discovery of therapeutic strategies for this challenging malignancy. Here, we demonstrate that the mitotic E3 ubiquitin ligase CDC20-anaphase-promoting complex (CDC20-APC) drives invasiveness and self-renewal in patient tumor-derived GSCs. Moreover, CDC20 knockdown inhibited and CDC20 overexpression increased the ability of human GSCs to generate brain tumors in an orthotopic xenograft model in vivo. CDC20-APC control of GSC invasion and self-renewal operates through pluripotency-related transcription factor SOX2. Our results identify a CDC20-APC/SOX2 signaling axis that controls key biological properties of GSCs, with implications for CDC20-APC-targeted strategies in the treatment of glioblastoma.
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Affiliation(s)
- Diane D Mao
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Amit D Gujar
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Tatenda Mahlokozera
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Program in Neuroscience, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ishita Chen
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Yanchun Pan
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jingqin Luo
- Division of Biostatistics, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Taylor Brost
- Program in Molecular Cell Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Elizabeth A Thompson
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Alice Turski
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Eric C Leuthardt
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Gavin P Dunn
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO 63110, USA; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Joshua L Dowling
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Samuel Achilefu
- Molecular Imaging Center, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - David D Tran
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA; Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Hiroko Yano
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA; Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA; Department of Genetics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Albert H Kim
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA; Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA; Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Bouhlel A, Zhou D, Li A, Yuan L, Rich KM, McConathy J. Synthesis, Radiolabeling, and Biological Evaluation of (R)- and (S)-2-Amino-5-[(18)F]fluoro-2-methylpentanoic Acid ((R)-, (S)-[(18)F]FAMPe) as Potential Positron Emission Tomography Tracers for Brain Tumors. J Med Chem 2015; 58:3817-29. [PMID: 25843369 DOI: 10.1021/jm502023y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A novel (18)F-labeled α,α-disubstituted amino acid-based tracer, 2-amino-5-[(18)F]fluoro-2-methylpentanoic acid ([(18)F]FAMPe), has been developed for brain tumor imaging with a longer alkyl side chain than previously reported compounds to increase brain availability via system L amino acid transport. Both enantiomers of [(18)F]FAMPe were obtained in good radiochemical yield (24-52% n = 8) and high radiochemical purity (>99%). In vitro uptake assays in mouse DBT gliomas cells revealed that (S)-[(18)F]FAMPe enters cells partly via sodium-independent system L transporters and also via other nonsystem A transport systems including transporters that recognize glutamine. Biodistribution and small animal PET/CT studies in the mouse DBT model of glioblastoma showed that both (R)- and (S)-[(18)F]FAMPe have good tumor imaging properties with the (S)-enantiomer providing higher tumor uptake and tumor to brain ratios. Comparison of the SUVs showed that (S)-[(18)F]FAMPe had higher tumor to brain ratios compared to (S)-[(18)F]FET, a well-established system L substrate.
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Affiliation(s)
- Ahlem Bouhlel
- †Department of Radiology, and ‡Department of Neurosurgery, Washington University in Saint Louis, School of Medicine, St. Louis, Missouri 63110, United States
| | - Dong Zhou
- †Department of Radiology, and ‡Department of Neurosurgery, Washington University in Saint Louis, School of Medicine, St. Louis, Missouri 63110, United States
| | - Aixiao Li
- †Department of Radiology, and ‡Department of Neurosurgery, Washington University in Saint Louis, School of Medicine, St. Louis, Missouri 63110, United States
| | - Liya Yuan
- †Department of Radiology, and ‡Department of Neurosurgery, Washington University in Saint Louis, School of Medicine, St. Louis, Missouri 63110, United States
| | - Keith M Rich
- †Department of Radiology, and ‡Department of Neurosurgery, Washington University in Saint Louis, School of Medicine, St. Louis, Missouri 63110, United States
| | - Jonathan McConathy
- †Department of Radiology, and ‡Department of Neurosurgery, Washington University in Saint Louis, School of Medicine, St. Louis, Missouri 63110, United States
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50
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Speirs CK, Simpson JR, Robinson CG, DeWees TA, Tran DD, Linette G, Chicoine MR, Dacey RG, Rich KM, Dowling JL, Leuthardt EC, Zipfel GJ, Kim AH, Huang J. Impact of 1p/19q Codeletion and Histology on Outcomes of Anaplastic Gliomas Treated With Radiation Therapy and Temozolomide. Int J Radiat Oncol Biol Phys 2015; 91:268-76. [DOI: 10.1016/j.ijrobp.2014.10.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 09/03/2014] [Accepted: 10/14/2014] [Indexed: 12/25/2022]
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