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Huang PW, Peng SJ, Pan DHC, Yang HC, Tsai JT, Shiau CY, Su IC, Chen CJ, Wu HM, Lin CJ, Chung WY, Guo WY, Lo WL, Lai SW, Lee CC. Vascular compactness of unruptured brain arteriovenous malformation predicts risk of hemorrhage after stereotactic radiosurgery. Sci Rep 2024; 14:4011. [PMID: 38369533 PMCID: PMC10874940 DOI: 10.1038/s41598-024-54369-2] [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: 11/13/2023] [Accepted: 02/12/2024] [Indexed: 02/20/2024] Open
Abstract
The aim of the study was to investigate whether morphology (i.e. compact/diffuse) of brain arteriovenous malformations (bAVMs) correlates with the incidence of hemorrhagic events in patients receiving Stereotactic Radiosurgery (SRS) for unruptured bAVMs. This retrospective study included 262 adult patients with unruptured bAVMs who underwent upfront SRS. Hemorrhagic events were defined as evidence of blood on CT or MRI. The morphology of bAVMs was evaluated using automated segmentation which calculated the proportion of vessel, brain tissue, and cerebrospinal fluid in bAVMs on T2-weighted MRI. Compactness index, defined as the ratio of vessel to brain tissue, categorized bAVMs into compact and diffuse types based on the optimal cutoff. Cox proportional hazard model was used to identify the independent factors for post-SRS hemorrhage. The median clinical follow-ups was 62.1 months. Post-SRS hemorrhage occurred in 13 (5.0%) patients and one of them had two bleeds, resulting in an annual bleeding rate of 0.8%. Multivariable analysis revealed bAVM morphology (compact versus diffuse), bAVM volume, and prescribed margin dose were significant predictors. The post-SRS hemorrhage rate increased with larger bAVM volume only among the diffuse nidi (1.7 versus 14.9 versus 30.6 hemorrhage per 1000 person-years in bAVM volume < 20 cm3 versus 20-40 cm3 versus > 40 cm3; p = 0.022). The significantly higher post-SRS hemorrhage rate of Spetzler-Martin grade IV-V compared with grade I-III bAVMs (20.0 versus 3.3 hemorrhages per 1000 person-years; p = 0.001) mainly originated from the diffuse bAVMs rather than the compact subgroup (30.9 versus 4.8 hemorrhages per 1000 person-years; p = 0.035). Compact and smaller bAVMs, with higher prescribed margin dose harbor lower risks of post-SRS hemorrhage. The post-SRS hemorrhage rate exceeded 2.2% annually within the diffuse and large (> 40 cm3) bAVMs and the diffuse Spetzler-Martin IV-V bAVMs. These findings may help guide patient selection of SRS for the unruptured bAVMs.
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Affiliation(s)
- Po-Wei Huang
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Syu-Jyun Peng
- Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jo-Ting Tsai
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - I-Chang Su
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Texas Health Science Center, Houston, TX, USA
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Lun Lo
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Shao-Wen Lai
- Product and Engineering, Zippin, San Carlos, CA, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Tseng HS, Lin CF, Yang HC, Chen CJ, Lin SC, Wu HM, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Hung-Chi Pan D, Lee CC. Natural History and Histopathology of Expanding Cysts and Hematomas After Stereotactic Radiosurgery for Arteriovenous Malformations of the Brain: A Case Series. World Neurosurg 2024; 182:e854-e865. [PMID: 38104931 DOI: 10.1016/j.wneu.2023.12.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND We reviewed the clinical course and histopathologic findings for cases involving the formation of expanding cysts and/or hematomas after gamma knife surgery (GKS) for arteriovenous malformations (AVMs). METHODS We report a single-center retrospective review of 18 patients who presented with cyst and/or hematoma expansion after GKS for AVMs between 1993 and 2023. Expanding cysts and hematomas were defined as well-demarcated cavities filled with fluid or well-marginated heterogenous hematomas presenting with expansion proximal to or in the location of the original AVM, respectively. Patient demographics, AVM characteristics, history of interventions and surgeries, and imaging and histopathologic features of expanding cysts and hematomas were collected for analysis. RESULTS Among 1072 AVM patients treated using GKS, 18 presented with expanding cysts or hematomas during a total follow-up period of 16,757 patient-years (0.11 case/100 persons/patient-year). The time to cyst or hematoma identification was 4-13 years after initial GKS, with a mean duration of 8.6 years. Among the patients examined, 7 (38.9%) presented mainly with hematoma, 10 (55.6%) presented mainly with cysts, and 1 presented with approximately equal components of both. Among the 18 patients, 13 (72.2%) underwent craniotomy to treat cyst or hematoma expansion. All the specimens had similar histopathologic characteristics, including organizing hematoma with fresh and old hemorrhage, fibrinoid necrosis of the vessels, gliosis of normal brain tissue, infiltration of hemosiderin-laden histiocytes, and extravascular protein leakage. CONCLUSIONS Our findings suggest that the formation of these 2 complications can be attributed to a common mechanism involving radiation-induced vascular damage in brain tissue adjacent to the AVM and subsequent chronic inflammation and capillary dilatation.
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Affiliation(s)
- Han-Song Tseng
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Fu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Shih-Chieh Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Pathology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Huang CY, Peng SJ, Yang HC, Wu HM, Chen CJ, Wang MC, Hu YS, Lin CJ, Shiau CY, Guo WY, Chung WY, Pan DHC, Lee CC. Association Between Pseudoprogression of Vestibular Schwannoma After Radiosurgery and Radiological Features of Solid and Cystic Components. Neurosurgery 2023; 93:1383-1392. [PMID: 37432016 DOI: 10.1227/neu.0000000000002599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/16/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The pathophysiology of vestibular schwannoma (VS) pseudoprogression after Gamma Knife radiosurgery (GKRS) remains unclear. Radiological features in pretreatment magnetic resonance images may help predict VS pseudoprogression. This study used VS radiological features quantified using an automated segmentation algorithm to predict pseudoprogression after GKRS treatment. METHODS This is a retrospective study comprising 330 patients with VS who received GKRS. After image preprocessing and T2W/contrast-enhanced T1-weighted image (CET1W) image generation, with fuzzy C-means clustering, VSs were segmented into solid and cystic components and classified as solid and cystic. Relevant radiological features were then extracted. The response to GKRS was classified into "nonpseudoprogression" and "pseudoprogression/fluctuation". The Z test for two proportions was used to compare solid and cystic VS for the likelihood of pseudoprogression/fluctuation. Logistic regression was used to assess the correlation between clinical variables and radiological features and response to GKRS. RESULTS The likelihood of pseudoprogression/fluctuation after GKRS was significantly higher for solid VS compared with cystic VS (55% vs 31%, P < .001). For the entire VS cohort, multivariable logistic regression revealed that a lower mean tumor signal intensity (SI) in T2W/CET1W images was associated with pseudoprogression/fluctuation after GKRS ( P = .001). For the solid VS subgroup, a lower mean tumor SI in T2W/CET1W images ( P = .035) was associated with pseudoprogression/fluctuation after GKRS. For the cystic VS subgroup, a lower mean SI of the cystic component in T2W/CET1W images ( P = .040) was associated with pseudoprogression/fluctuation after GKRS. CONCLUSION Pseudoprogression is more likely to occur in solid VS compared with cystic VS. Quantitative radiological features in pretreatment magnetic resonance images were associated with pseudoprogression after GKRS. In T2W/CET1W images, solid VS with a lower mean tumor SI and cystic VS with a lower mean SI of cystic component were more likely to have pseudoprogression after GKRS. These radiological features can help predict the likelihood of pseudoprogression after GKRS.
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Affiliation(s)
- Chih-Ying Huang
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Syu-Jyun Peng
- Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei , Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston , Texas , USA
| | - Mao-Che Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Cheng-Ying Shiau
- Cancer Center, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei , Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei , Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
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Karlsson B, Johansson AV, Jokura H, Petridis A, Yang HC, Yamamoto M, Martinez R, Kawagishi J, Guo WY, Chung WY, Söderman M, Nga V. Risk for Brain Arteriovenous Malformation Rupture During Pregnancy and Puerperium. Neurosurgery 2023; 93:918-923. [PMID: 37074063 DOI: 10.1227/neu.0000000000002496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/22/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND The hemorrhage risk of unruptured and untreated cerebral arteriovenous malformations (AVMs) has been shown to be higher for female patients than male patients in their child bearing ages. Although it has been neurosurgical practice to advise female patients in their childbearing ages to postpone pregnancy until proven AVM obliteration, there is no literature consensus regarding this potential hemorrhage risk increase. OBJECTIVE To accurately quantify the risk increase for AVM hemorrhage during pregnancy. METHODS This study is based on data from previous publications, consisting of known age at the first AVM hemorrhage in 3425 patients. The risk increase during pregnancy could be calculated from the difference in age distribution for the first AVM hemorrhage between male patients and female patients, taking the average pregnancy time per female into account. A comparison was also made with data for all hospital discharges (13 751) in Germany 2008 to 2018 with the diagnosis brain AVM. RESULTS The average pregnancy and puerperium time was 1.54 years per female in the patient population, which was used to determine the annual AVM hemorrhage risk during pregnancy to be around 9%. The increased risk during pregnancy was further evidenced by analysis of a subgroup of 105 female patients, for which pregnancy status at the time of hemorrhage was known. CONCLUSION The quantified annual risk for AVM hemorrhage during pregnancy is about 3 times higher than that of male patients at corresponding age. This provides an important basis for advising female patients with patent AVMs about the increased risk for hemorrhage that a pregnancy would entail.
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Affiliation(s)
- Bengt Karlsson
- Department of Surgery, Division of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Arne V Johansson
- Department of Engineering Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Hidefumi Jokura
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | - Athanasios Petridis
- Medical School, Heinrich Heine University, Düsseldorf, Germany
- St. Lukes Hospital, Panorama, Thessaloniki, Greece
| | - Huai-Che Yang
- Department of Neurosurgery, Veterans General Hospital, Taipei, Taiwan
- Yang-Ming Chiao Tung University, Taipei, Taiwan
| | | | | | - Jun Kawagishi
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | - Wan-Yuo Guo
- Department of Radiology, Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Veterans General Hospital, Taipei, Taiwan
| | - Michael Söderman
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Vincent Nga
- Department of Surgery, Division of Neurosurgery, National University Hospital, Singapore, Singapore
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Kuan AS, Chiang CL, Wu HM, Yang HC, Chen CJ, Lin CJ, Guo WY, Pan DHC, Chung WY, Lee CC. Improved survival and intracranial tumor control of EGFR-mutated NSCLC patients with newly developed brain metastases following stereotactic radiosurgery and EGFR-TKI: a large retrospective cohort study and meta-analyses. J Neurooncol 2023; 164:729-739. [PMID: 37721662 DOI: 10.1007/s11060-023-04452-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 09/12/2023] [Indexed: 09/19/2023]
Abstract
PURPOSE To examine the differential effects of SRS and TKI on EGFR-mutated NSCLC patients with brain metastases (BMs) and outcomes following continuation of the same TKI agent in case of new BMs. METHODS This study included 608 NSCLC patients (2,274 BMs) while meta-analyses included 1,651 NSCLC patients (> 3,944 BMs). Overall survival (OS) and intracranial progression free survival (iPFS) were estimated using Kaplan-Meier methods. Hazard ratios (95% CI) of prognostic factors were estimated using Cox regression models. RESULTS The median OS/iPFS (95% CI) (months) for patients with wildtype EGFR/ALK, EGFR mutations, and ALK rearrangements were 17.7 (12.9-23.6)/12.1 (9.8-15.6), 28.9 (23.8-33.3)/17.7 (14.8-21.2), and 118.0 (not reached)/71.7 (15.1-not reached), respectively. In EGFR-mutated patients, meta-analyses combining our data showed significantly improved OS and iPFS of patients who received SRS and TKI (OS:35.1 months, iPFS:20.0 months) when compared to those who have SRS alone (OS:20.8 months, iPFS:11.8 months) or TKI alone (OS:24.3 months, iPFS:13.8 months). Having SRS for newly diagnosed BMs while keeping the existing TKI agent yielded OS (30.0 vs. 32.1 months, p = 0.200) non-inferior to patients who started combined SRS and TKI therapy for their newly diagnosed NSCLC with BMs. Multivariable analyses showed that good performance score and TKI therapy were associated with improved outcomes. CONCLUSIONS Combined SRS and TKI resulted in favorable outcomes in EGFR-mutated NSCLC patients with newly diagnosed BMs. Continuation of the same TKI agent plus SRS in case of new brain metastases yielded good clinical outcomes and may be considered a standard-of-care treatment.
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Affiliation(s)
- Ai Seon Kuan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Lu Chiang
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA
| | - Chung-Jung Lin
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Hung JSE, Su YH, Chen CJ, Chiang CL, Shen CI, Yang HC, Shiau CY, Luo YH, Wu HM, Hu YS, Lin CJ, Liu KD, Chung WY, Guo WY, Lee CC. Is it advisable to perform radiosurgery for EGFR-TKI-controlled brain metastases? A retrospective study of the role of radiosurgery in lung cancer treatment. J Neurooncol 2023; 164:413-422. [PMID: 37656378 DOI: 10.1007/s11060-023-04425-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Given the availability of TKIs with high central nervous system efficacy, the question arises as to whether upfront SRS provides additional clinical benefits. The goal of this study was to characterize the clinical outcomes of SRS as salvage therapy for TKI-uncontrolled BMs. METHODS This retrospective study included EGFR-mutant NSCLC patients presenting BMs at the time of primary tumor diagnosis. BMs were categorized into three subgroups, referred to as "Nature of TKI-treated BMs", "TKI-controlled brain metastases ± SRS", and "SRS salvage therapy". The first subgroup analysis characterized the effects of TKIs on tumor behavior. In the second subgroup, we compared outcomes of TKI-controlled BMs treated with TKI alone versus those treated with combined TKI-SRS therapy. The third subgroup characterized the outcomes of TKI-uncontrolled BMs treated with SRS as salvage therapy Clinical outcomes include local and distant tumor control. RESULTS This study included 106 patients with a total of 683 BMs. TKI treatment achieved control in 63% of local tumors at 24 months. Among the TKI-controlled BMs, local tumor control was significantly higher in the combined TKI-SRS group (93%) than in the TKI-alone group (65%) at 24 months (p < 0.001). No differences were observed between the two groups in terms of distant tumor control (p = 0.832). In dealing with TKI-uncontrolled BMs, salvage SRS achieved local tumor control in 58% of BMs at 24 months. CONCLUSIONS While upfront TKI alone proved highly effective in BM control, this study also demonstrated the outcomes of SRS when implemented concurrently with TKI or as salvage therapy for TKI-uncontrolled BMs. This study also presents a strategy of the precise timing and targeting of SRS to lesions in progression.
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Affiliation(s)
- Joseph Shang-En Hung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yan-Hua Su
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Chi-Lu Chiang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-I Shen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yung-Hung Luo
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kang-Du Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Lee WK, Hong JS, Lin YH, Lu YF, Hsu YY, Lee CC, Yang HC, Wu CC, Lu CF, Sun MH, Pan HC, Wu HM, Chung WY, Guo WY, You WC, Wu YT. Federated Learning: A Cross-Institutional Feasibility Study of Deep Learning Based Intracranial Tumor Delineation Framework for Stereotactic Radiosurgery. J Magn Reson Imaging 2023. [PMID: 37572087 DOI: 10.1002/jmri.28950] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND Deep learning-based segmentation algorithms usually required large or multi-institute data sets to improve the performance and ability of generalization. However, protecting patient privacy is a key concern in the multi-institutional studies when conventional centralized learning (CL) is used. PURPOSE To explores the feasibility of a proposed lesion delineation for stereotactic radiosurgery (SRS) scheme for federated learning (FL), which can solve decentralization and privacy protection concerns. STUDY TYPE Retrospective. SUBJECTS 506 and 118 vestibular schwannoma patients aged 15-88 and 22-85 from two institutes, respectively; 1069 and 256 meningioma patients aged 12-91 and 23-85, respectively; 574 and 705 brain metastasis patients aged 26-92 and 28-89, respectively. FIELD STRENGTH/SEQUENCE 1.5T, spin-echo, and gradient-echo [Correction added after first online publication on 21 August 2023. Field Strength has been changed to "1.5T" from "5T" in this sentence.]. ASSESSMENT The proposed lesion delineation method was integrated into an FL framework, and CL models were established as the baseline. The effect of image standardization strategies was also explored. The dice coefficient was used to evaluate the segmentation between the predicted delineation and the ground truth, which was manual delineated by neurosurgeons and a neuroradiologist. STATISTICAL TESTS The paired t-test was applied to compare the mean for the evaluated dice scores (p < 0.05). RESULTS FL performed the comparable mean dice coefficient to CL for the testing set of Taipei Veterans General Hospital regardless of standardization and parameter; for the Taichung Veterans General Hospital data, CL significantly (p < 0.05) outperformed FL while using bi-parameter, but comparable results while using single-parameter. For the non-SRS data, FL achieved the comparable applicability to CL with mean dice 0.78 versus 0.78 (without standardization), and outperformed to the baseline models of two institutes. DATA CONCLUSION The proposed lesion delineation successfully implemented into an FL framework. The FL models were applicable on SRS data of each participating institute, and the FL exhibited comparable mean dice coefficient to CL on non-SRS dataset. Standardization strategies would be recommended when FL is used. LEVEL OF EVIDENCE 4 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Wei-Kai Lee
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Jia-Sheng Hong
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Yi-Hui Lin
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yung-Fa Lu
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ying-Yi Hsu
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei City, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei City, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Chih-Chun Wu
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Chia-Feng Lu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Ming-His Sun
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hung-Chuan Pan
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei City, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Shuang Ho Hospital, New Taipei City, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Weir-Chiang You
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Te Wu
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- College Medical Device Innovation and Translation Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
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Chen YC, Tsai CC, Chen SJ, Wu HM, Yang HC, Chen CJ, Hu YS, Lin CJ, Guo WY, Pan DHC, Chung WY, Lee CC. Stereotactic radiosurgery for orbital cavernous hemangiomas. J Neurosurg 2023; 138:1622-1629. [PMID: 37856889 DOI: 10.3171/2022.8.jns221222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to assess the safety and efficacy of single-session Gamma Knife radiosurgery (GKRS) for orbital cavernous hemangiomas (OCHs). METHODS Patients who presented with an OCH between September 1999 and May 2022 and were treated with single-session GKRS were included in this single-center cohort study. RESULTS There were 23 patients (7 males and 16 females) in this study. The median margin dose was 12 Gy (range 11-13 Gy). The median clinical and radiological follow-ups were 45 months (range 5-190 months) and 45 months (range 6-190 months), respectively. Nine (69.2%) of 13 patients with visual acuity impairment had improvement in best corrected visual acuity. Of the 8 patients with visual field defects, 5 patients (62.5%) had complete resolution. Tumor regression was observed in 22 patients (95.7%). The mean relative reduction in tumor volume was 82.6% ± 23.7%. The relative reductions in tumor volume were 33%, 49%, 72%, 84%, and 89% at 6, 12, 24, 36, and 48 months, respectively. Adverse effects of radiation were not observed. CONCLUSIONS GKRS appears to be safe and efficacious for treating OCHs over long-term follow-up. The treatment is associated with a high rate of regression in OCHs and remarkable improvement in both visual acuity and visual field deficits.
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Affiliation(s)
- You-Cong Chen
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chieh-Chih Tsai
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Departments of3Ophthalmology and
| | - Shih-Jen Chen
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Departments of3Ophthalmology and
| | - Hsiu-Mei Wu
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- 4Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Jen Chen
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Yong-Sin Hu
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- 4Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- 4Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- 4Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 7Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Yuh Chung
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Chia Lee
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- 5Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Lee WK, Yang HC, Lee CC, Lu CF, Wu CC, Chung WY, Wu HM, Guo WY, Wu YT. Lesion delineation framework for vestibular schwannoma, meningioma and brain metastasis for gamma knife radiosurgery using stereotactic magnetic resonance images. Comput Methods Programs Biomed 2023; 229:107311. [PMID: 36577161 DOI: 10.1016/j.cmpb.2022.107311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND OBJECTIVE GKRS is an effective treatment for smaller intracranial tumors with a high control rate and low risk of complications. Target delineation in medical MR images is essential in the planning of GKRS and follow-up. A deep learning-based algorithm can effectively segment the targets from medical images and has been widely explored. However, state-of-the-art deep learning-based target delineation uses fixed sizes, and the isotropic voxel size may not be suitable for stereotactic MR images which use different anisotropic voxel sizes and numbers of slices according to the lesion size and location for clinical GKRS planning. This study developed an automatic deep learning-based segmentation scheme for stereotactic MR images. METHODS We retrospectively collected stereotactic MR images from 506 patients with VS, 1,069 patients with meningioma and 574 patients with BM who had been treated using GKRS; the lesion contours and individual T1W+C and T2W MR images were extracted from the GammaPlan system. The three-dimensional patching-based training strategy and dual-pathway architecture were used to manage inconsistent FOVs and anisotropic voxel size. Furthermore, we used two-parametric MR image as training input to segment the regions with different image characteristics (e.g., cystic lesions) effectively. RESULTS Our results for VS and BM demonstrated that the model trained using two-parametric MR images significantly outperformed the model trained using single-parametric images with median Dice coefficients (0.91, 0.05 versus 0.90, 0.06, and 0.82, 0.23 versus 0.78, 0.34, respectively), whereas predicted delineations in meningiomas using the dual-pathway model were dominated by single-parametric images (median Dice coefficients 0.83, 0.17 versus 0.84, 0.22). Finally, we combined three data sets to train the models, achieving the comparable or even higher testing median Dice (VS: 0.91, 0.07; meningioma: 0.83, 0.22; BM: 0.84, 0.23) in three diseases while using two-parametric as input. CONCLUSIONS Our proposed deep learning-based tumor segmentation scheme was successfully applied to multiple types of intracranial tumor (VS, meningioma and BM) undergoing GKRS and for segmenting the tumor effectively from stereotactic MR image volumes for use in GKRS planning.
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Affiliation(s)
- Wei-Kai Lee
- Institute of Biophotonics, National Yang Ming Chiao Tung University, 155, Sec. 2, Li-Nong St. Beitou Dist., Taipei 112304, Taiwan
| | - Huai-Che Yang
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Feng Lu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Chun Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Te Wu
- Institute of Biophotonics, National Yang Ming Chiao Tung University, 155, Sec. 2, Li-Nong St. Beitou Dist., Taipei 112304, Taiwan; Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Huang YH, Yang HC, Chiang CL, Wu HM, Luo YH, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Lee CC. Gamma Knife Radiosurgery Irradiation of Surgical Cavity of Brain Metastases: Factor Analysis and Gene Mutations. Life (Basel) 2023; 13:life13010236. [PMID: 36676186 PMCID: PMC9864800 DOI: 10.3390/life13010236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/07/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
(1) Background: Surgical resection for the removal of brain metastases often fails to prevent tumor recurrence within the surgical cavity; hence, researchers are divided as to the benefits of radiation treatment following surgical resection. This retrospective study assessed the effects of post-operative stereotactic radiosurgery (SRS) on local tumor control and overall survival. (2) Methods: This study examined the demographics, original tumor characteristics, and surgical outcomes of 97 patients who underwent Gamma Knife Radiosurgery (GKRS) treatment (103 brain metastases). Kaplan-Meier plots and Cox regression were used to correlate clinical features to tumor control and overall survival. (3) Results: The overall tumor control rate was 75.0% and overall 12-month survival was 89.6%. Tumor control rates in the radiation group versus the non-radiation group were as follows: 12 months (83.1% vs. 57.7%) and 24 months (66.1% vs. 50.5%). During the 2-year follow-up period after SRS, the intracranial response rate was higher in the post-craniotomy radiation group than in the non-radiation group (p = 0.027). Cox regression multivariate analysis determined that post-craniotomy irradiation of the surgical cavity is predictive of tumor control (p = 0.035). However, EGFR mutation was not predictive of overall survival or tumor control. (4) Conclusions: Irradiating the surgical cavity after surgery can enhance local tumor control; however, it does not have a significant effect on overall survival.
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Affiliation(s)
- Yi-Han Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chi-Lu Chiang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Yung-Hung Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Yong-Sin Hu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Cancer Center, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Correspondence: ; Tel.: +886-2-28712121
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11
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Huang PW, Peng SJ, Pan DHC, Yang HC, Tsai JT, Shiau CY, Su IC, Chen CJ, Wu HM, Lin CJ, Chung WY, Guo WY, Lo WL, Lai SW, Lee CC. Compactness index: a radiosurgery outcome predictor for patients with unruptured brain arteriovenous malformations. J Neurosurg 2023; 138:241-250. [PMID: 35594883 DOI: 10.3171/2022.4.jns212369] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 04/07/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The goal of the study was to define and quantify brain arteriovenous malformation (bAVM) compactness and to assess its effect on outcomes after Gamma Knife radiosurgery (GKRS) for unruptured bAVMs. METHODS Unsupervised machine learning with fuzzy c-means clustering was used to differentiate the tissue constituents of bAVMs on T2-weighted MR images. The percentages of vessel, brain, and CSF were quantified. The proposed compactness index, defined as the ratio of vasculature tissue to brain tissue, categorized bAVM morphology into compact, intermediate, and diffuse types according to the tertiles of this index. The outcomes of interest were complete obliteration and radiation-induced changes (RICs). RESULTS A total of 209 unruptured bAVMs treated with GKRS were retrospectively included. The median imaging and clinical follow-up periods were 49.2 and 72.3 months, respectively. One hundred seventy-three bAVMs (82.8%) achieved complete obliteration after a median latency period of 43.3 months. The rates of RIC and permanent RIC were 76.1% and 3.8%, respectively. Post-GKRS hemorrhage occurred in 14 patients (6.7%), resulting in an annual bleeding risk of 1.0%. Compact bAVM, smaller bAVM volume, and exclusively superficial venous drainage were independent predictors of complete obliteration. Diffuse bAVM morphology, larger bAVM volume, and higher margin dose were independently associated with RICs. CONCLUSIONS The compactness index quantitatively describes the compactness of unruptured bAVMs. Moreover, compact bAVMs may have a higher obliteration rate and a smaller risk of RICs than diffuse bAVMs. This finding could help guide decision-making regarding GKRS treatment for patients with unruptured bAVMs.
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Affiliation(s)
- Po-Wei Huang
- 1Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City
| | - Syu-Jyun Peng
- 2Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei
| | - David Hung-Chi Pan
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,4Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,14Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; and
| | - Huai-Che Yang
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Jo-Ting Tsai
- 1Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,11Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,13Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Cheng-Ying Shiau
- 8Cancer Center, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - I-Chang Su
- 4Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,12Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,14Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; and
| | - Ching-Jen Chen
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hsiu-Mei Wu
- 7Department of Radiology, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chung-Jung Lin
- 7Department of Radiology, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wen-Yuh Chung
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,5Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wan-Yuo Guo
- 7Department of Radiology, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wei-Lun Lo
- 4Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,12Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,14Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; and
| | - Shao-Wen Lai
- 15Product and Engineering, Zippin, San Carlos, California
| | - Cheng-Chia Lee
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei.,10Brain Research Center, National Yang Ming Chiao Tung University, Taipei
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12
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Hu YS, Lee CC, Wu CA, Lin CJ, Yang HC, Guo WY, Liu KD, Chung WY, Shiau CY, Wu HM. Magnetic resonance imaging signal characteristics associated with prognosis of skull base chordoma after gamma knife radiosurgery. J Neurooncol 2023; 161:45-56. [PMID: 36565364 DOI: 10.1007/s11060-022-04199-x] [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: 10/14/2022] [Accepted: 11/14/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To investigate the association between the magnetic resonance imaging (MRI) signal characteristics of skull base chordoma and radiosurgical outcomes. METHODS Twenty-four patients with skull base chordomas treated with Gamma Knife radiosurgery (GKRS) after previous surgical resection were retrospectively (2001-2021) examined. Pre-GKRS MRIs were analyzed for RT2 (tumor-to-brainstem signal intensity ratio on T2-weighted imaging), RCE (tumor-to-brainstem signal intensity ratio on contrast-enhanced T1-weighted imaging), and mean apparent diffusion coefficient (ADC). Correlations of the parameters with patient survival and local tumor progression were made by using Cox regression and Kaplan-Meier analyses. RESULTS During a median follow-up of 46 months after GKRS, 9 patients died with significantly more local tumor progression events (median number: 2 vs 0, P = .012) than did 15 alive patients. On multivariable analysis, higher mean ADC was associated with longer patient survival (P = .016) after GKRS. The actuarial 5-year overall survival rates were 88.9% versus 54.7% for chordomas with an ADC of ≥ 1270 × 10-6 mm2/s versus < 1270 × 10-6 mm2/s. RT2 < 1.5 (P = .038) and RCE > 1.57 (P = .022) were associated with a lower probability of local tumor control. CONCLUSION Lower mean ADC values are associated with shorter patient survival in skull base chordomas after GKRS. Diffusion-weighted imaging may help in GKRS planning and outcome prediction for these patients.
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Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Taipei Hospital, Ministry of Health and Welfare, New Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, No. 201, Shipai Rd., Sec. 2, Beitou District, Taipei, 112, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-An Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, No. 201, Shipai Rd., Sec. 2, Beitou District, Taipei, 112, Taiwan.,Department of Radiology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, No. 201, Shipai Rd., Sec. 2, Beitou District, Taipei, 112, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, No. 201, Shipai Rd., Sec. 2, Beitou District, Taipei, 112, Taiwan
| | - Kang-Du Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Department of Radiology, Taipei Veterans General Hospital, No. 201, Shipai Rd., Sec. 2, Beitou District, Taipei, 112, Taiwan.
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13
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Liu CW, Yang HC, Chiang CL, Shen CI, Wu HM, Luo YH, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Pan DHC, Lee CC. Leukoencephalopathy in patients with brain metastases who received radiosurgery with or without whole brain radiotherapy. J Neurooncol 2023; 161:85-95. [PMID: 36544061 DOI: 10.1007/s11060-022-04210-5] [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: 08/21/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Whole brain radiation therapy (WBRT) for brain metastases (BMs) is a common cause of radiation-induced leukoencephalopathy; however the safety of alternative stereotactic radiosurgery (SRS) remains unclear. This study examined the incidence of leukoencephalopathy in patients treated with SRS alone versus WBRT plus SRS for BMs with a focus on the relationship between prognostic factors and leukoencephalopathy. METHODS Analysis was performed between 2002 and 2021. The total enrollment was 993 patients with the distribution: WBRT plus SRS (n = 291) and SRS only (n = 702). Leukoencephalopathy was graded from 0 to 3 for changes in white matter indicated by the MRI after WBRT or SRS. Patient characteristics and SRS dosimetric parameters were reviewed to identify factors that contributed to the incidence of leukoencephalopathy or overall survival. RESULTS The incidence of leukoencephalopathy was consistently higher in WBRT plus SRS group than in SRS alone group (p < 0.001). Leukoencephalopathy was also associated with a larger total tumor volume (≧28cm3; p = 0.028) and age (> 77 years; p = 0.025). Nonetheless, the SRS integral dose to skull in the subgroup of WBRT plus SRS treatment was not demonstrated significance in development of leukoencephalopathy (p = 0.986 for integral dose 1-2 J, p = 0.776 for integral dose > 2 J). CONCLUSIONS This study revealed that SRS is safe for oligo-BMs in terms of leukoencephalopathy development. Patient age and total tumor volume were identified as important factors in assessing the development of leukoencephalopathy. The additional of SRS (even at an integral dose > 2 J) did not increase the incidence of leukoencephalopathy.
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Affiliation(s)
- Chan-Wei Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Lu Chiang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-I Shen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yung-Hung Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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14
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Chiang CL, Yang HC, Luo YH, Chen CJ, Wu HM, Chen YM, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Chou TY, Pan DHC, Lee CC. Leptomeningeal metastasis in patients with non-small cell lung cancer after stereotactic radiosurgery for brain metastasis. J Neurosurg 2022:1-8. [PMID: 36681978 DOI: 10.3171/2022.11.jns221888] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/02/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is an effective treatment for brain metastases (BMs) in patients with non-small cell lung cancer (NSCLC). However, factors associated with the development of post-SRS leptomeningeal metastasis (LM) remain unclear. The authors analyzed the incidence and risk factors of LM development in patients with NSCLC and BMs after SRS and examined the survival outcomes and prognostic factors after LM development. METHODS This retrospective study included patients with NSCLC treated with SRS for MRI-diagnosed BM from 2002 to 2021. The authors recorded various clinical and demographic data, including age, sex, tumor histology, molecular profile of tumors, extracranial disease status, previous craniotomy, Karnofsky Performance Status, systemic treatments, tumor volume, and number of BMs. The management and survival outcomes after LM diagnosis were also recorded. RESULTS LM developed in 13.7% of patients with NSCLC and BMs after SRS treatment. Large initial tumor volume and more than 5 BM lesions, but not EGFR mutation status and post-SRS treatment, were associated with LM development after SRS. Multivariate analysis revealed that chemotherapy and targeted therapy after LM were associated with better survival in patients with LM after SRS. CONCLUSIONS This study is the first to evaluate the risk factors for LM in a relatively large cohort of patients with NSCLC after SRS. In patients with BMs harboring risk factors for subsequent LM, such as initial tumor volume and number of metastatic lesions, aggressive therapies with high CNS penetrating ability should be considered.
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Affiliation(s)
- Chi-Lu Chiang
- 1Departments of Chest Medicine
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 3Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Huai-Che Yang
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yung-Hung Luo
- 1Departments of Chest Medicine
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Ching-Jen Chen
- 5Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas
| | - Hsiu-Mei Wu
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 6Radiology, and
| | - Yuh-Min Chen
- 1Departments of Chest Medicine
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Yong-Sin Hu
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 6Radiology, and
| | - Chung-Jung Lin
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 6Radiology, and
| | - Wen-Yuh Chung
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 7Kaohsiung Veterans General Hospital, Kaohsiung City
| | | | | | - Teh-Ying Chou
- 3Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei
- 10Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei
| | - David Hung-Chi Pan
- 11Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- 2School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 9Brain Research Center, National Yang Ming Chiao Tung University, Taipei; and
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15
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Karlsson B, Jokura H, Yang HC, Yamamoto M, Martinez-Alvarez R, Kawagishi J, Guo WY, Chung WY, Söderman M, Yeo TT, Lax I. Risk for Hemorrhage the First 2 Years After Gamma Knife Surgery for Arteriovenous Malformations: An Update. Neurosurgery 2022; 91:920-927. [PMID: 36219806 PMCID: PMC9632947 DOI: 10.1227/neu.0000000000002130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/28/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Knowledge about the natural course of brain arteriovenous malformations (AVMs) have increased during the past 20 years, as has the number of AVMs treated, especially larger ones. It is thus timely to again analyze the risk for hemorrhage after Gamma Knife Surgery (GKS). OBJECTIVE To confirm or contradict conclusions drawn 20 years ago regarding factors that affect the risk for post-GKS hemorrhage. METHODS The outcome after GKS was studied in 5037 AVM patients followed for up to 2 years. The relation between post-treatment hemorrhage rate and a number of patient, AVM, and treatment parameters was analyzed. The results were also compared with the results from our earlier study. RESULTS The annual post-treatment hemorrhage rate was 2.4% the first 2 years after GKS. Large size, low treatment dose, and old age were independent risk factors for AVM hemorrhage. After having compensated for the factors above, peripheral AVM location and female sex, at least during their child bearing ages, were factors associated with a lower post-GKS hemorrhage rate. CONCLUSION Large AVMs (>5 cm 3 ) treated with low doses (≤16 Gy) had higher and small AVMs treated with high doses a lower risk for hemorrhage as compared with untreated AVMs. This was detectable within the first 6 months after GKS. No difference in hemorrhage rate could be detected for the other AVMs. Based on our findings, it is advisable to prescribe >16 Gy to larger AVMs, assuming that the risk for radiation-induced complications can be kept at an acceptable level.
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Affiliation(s)
- Bengt Karlsson
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore, Singapore
| | - Hidefumi Jokura
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | - Huai-Che Yang
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan;,National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | | | - Jun Kawagishi
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Michael Söderman
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore, Singapore
| | - Ingmar Lax
- Department of Hospitals Physics, Karolinska University Hospital, Stockholm, Sweden
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16
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Hu YS, Lin CJ, Wu CA, Wu HM, Yang HC, Lee CC, Luo CB, Liu KD, Chung WY, Guo WY. Outflow Patency Correlates with Radiosurgical Outcomes of Lateral Sinus Dural Arteriovenous Fistula. World Neurosurg 2022; 167:e397-e405. [PMID: 35964903 DOI: 10.1016/j.wneu.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To explore the impact of outflow patency on radiosurgical outcomes of lateral sinus dural arteriovenous fistulas (DAVFs). METHODS We retrospectively examined 83 lateral sinus DAVFs treated with Gamma Knife radiosurgery (GKRS) between 1995 and 2020. Two neuroradiologists blinded to the therapeutic outcomes served as imaging evaluators on pre-GKRS digital subtraction angiography and magnetic resonance images. The sinovenous outflow of lateral sinus DAVF was scored using combined conduit score (CCS), ranging from 0 (total occlusion) to 8 (full patency). The patients' follow-up magnetic resonance and digital subtraction angiography images were used to validate the radiosurgical outcomes (obliteration or non-obliteration) of lateral sinus DAVF. Cox regression and Kaplan-Meier analyses were performed to determine the correlations between the variables and outcomes. RESULTS Among the 83 cases, 60 (72%) lateral sinus DAVFs achieved obliteration after a GKRS at a median latency period of 24.5 months. After adjustment for aggressive presentation, cortical venous reflux, straight sinus reflux, and optic nerve sheath enlargement, a CCS of >6 was independently associated with lateral sinus DAVF obliteration (hazard ratio: 2.335, P = 0.007). The estimated 36-month probabilities of obliteration were 80% versus 53.6% for lateral sinus DAVFs with a CCS of >6 versus ≤6. CONCLUSIONS Lateral sinus DAVFs with a CCS of >6, indicating a nearly patent sinovenous outflow, were more likely to be obliterated after GKRS. Sinovenous outflow patency is a factor associated with therapeutic outcomes in radiosurgery for lateral sinus DAVFs.
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Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Taipei Hospital, Ministry of Health and Welfare, New Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-An Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Radiology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chao-Bao Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kang-Du Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.
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17
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Hu YS, Yang HC, Lin CJ, Lee CC, Guo WY, Luo CB, Liu KD, Chung WY, Wu HM. Imaging Markers Associated With Radiation-Induced Changes in Brain Arteriovenous Malformations After Radiosurgery. Neurosurgery 2022; 90:464-474. [PMID: 35080514 DOI: 10.1227/neu.0000000000001864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Radiation-induced changes (RICs) in brain tissue, seen as increased perinidal T2-weighted hyperintensity on MRI, are commonly observed in patients with brain arteriovenous malformations (BAVMs) within 2 years after Gamma Knife (Elekta) radiosurgery (GKRS). OBJECTIVE To explore the imaging markers associated with RICs in patients with BAVMs. METHODS We retrospectively included 106 treatment-naïve patients with BAVMs who received GKRS alone between 2011 and 2018 and had ≥24 months of clinical and MRI follow-up. Pre-GKRS angiography and MRIs were analyzed for morphological characteristics and quantitative digital subtraction angiography parameters. RIC severity was categorized as mild (grade I), moderate (grade II), or severe (grade III). Firth logistic regression analysis was conducted to determine the associations between the parameters and RICs. RESULTS Among the 106 patients, 83 (78.3%) developed RICs, with 16 categorized as grade I, 62 as grade II, and 5 as grade III. RICs were symptomatic in 19 patients (17.9%). In multivariable models, BAVMs with a volume of >5 cm3 (odds ratio [OR]: 4.322, P = .024) and neoangiogenesis on angiography before treatment (OR: 3.846, P = .029), and thrombus within nidus or drainage vein on follow-up MRI (OR: 3.679, P = .001) were independently associated with grade II or III RICs. Symptomatic RICs were more likely to develop in basal ganglia or brainstem. CONCLUSION Large BAVMs and neoangiogenesis were associated with moderate to severe RICs in treatment-naïve patients with BAVMs. Our findings may assist with the complication risk assessment for these patients.
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Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Taoyuan Branch, Taipei Veterans General Hospital, Taoyuan, Taiwan
- Department of Radiology, Taipei Hospital, Ministry of Health and Welfare, New Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chao-Bao Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kang-Du Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
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18
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Chiou GY, Chiang CL, Yang HC, Shen CI, Wu HM, Chen YW, Chen CJ, Luo YH, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Pan DHC, Lee CC. Combined stereotactic radiosurgery and tyrosine kinase inhibitor therapy versus tyrosine kinase inhibitor therapy alone for the treatment of non-small cell lung cancer patients with brain metastases. J Neurosurg 2021; 137:1-8. [PMID: 34920439 DOI: 10.3171/2021.9.jns211373] [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: 06/01/2021] [Accepted: 09/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Whether combined radiation and tyrosine kinase inhibitor (TKI) therapy in non-small cell lung cancer (NSCLC) patients with brain metastases (BMs) and epidermal growth factor receptor (EGFR) mutations confers additional benefits over TKI therapy alone remains a matter of debate. The goal of this study was to compare outcomes between combined TKI therapy with stereotactic radiosurgery (SRS) versus TKI therapy alone in NSCLC patients with BMs and EGFR mutations. METHODS Consecutive cases of NSCLC patients with EGFR mutations and BMs treated with TKIs were selected for inclusion in this study. Patients were categorized into two groups based on SRS: TKI therapy alone (group I) and combined SRS and TKI therapy (group II). Patients who had SRS or TKI as salvage therapy and those with prior radiation treatment for BMs were excluded. Tumor control (< 10% increase in tumor volume) and overall survival (OS) rates were compared using Kaplan-Meier analyses. Independent predictors of tumor control and OS were identified using multivariable Cox regression analyses. RESULTS The study cohort comprised 280 patients (n = 90 in group I and n = 190 in group II). Cumulative tumor control rates were higher in group II than in group I (79.8% vs 31.2% at 36 months, p < 0.0001). Cumulative OS rates were comparable between groups I and II (43.8% vs 59.4% at 36 months, p = 0.3203). Independent predictors of tumor control were older age (p < 0.01, HR 1.03), fewer BMs (p < 0.01, HR 1.09), lack of extracranial metastasis (p < 0.02, HR 0.70), and combined SRS and TKI therapy (p < 0.01, HR 0.25). Independent predictors of OS were fewer BMs (p < 0.01, HR 1.04) and a higher Karnofsky Performance Status score (p < 0.01, HR 0.97). CONCLUSIONS Although the OS rate did not differ between TKI therapy with and without SRS, the addition of SRS to TKI therapy resulted in improvement of intracranial tumor control. The lack of effect on survival rate with the addition of SRS may be attributable to extracranial disease progression. The addition of SRS to TKI therapy is recommended for intracranial disease control in NSCLC patients with BMs and EGFR mutations. Potential benefits may include prevention of neurological deficits and seizures. Future prospective studies may help clarify the clinical outcome benefits of SRS in these patients.
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Affiliation(s)
- Guan-Ying Chiou
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
| | - Chi-Lu Chiang
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- 8Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; and
| | - Huai-Che Yang
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chia-I Shen
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- 8Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; and
| | - Hsiu-Mei Wu
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Yu-Wei Chen
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
| | - Ching-Jen Chen
- 9Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Yung-Hung Luo
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- 8Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; and
| | - Yong-Sin Hu
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chung-Jung Lin
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wen-Yuh Chung
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Cheng-Ying Shiau
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Cancer Center, Taipei Veterans General Hospital, Taipei
| | - Wan-Yuo Guo
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - David Hung-Chi Pan
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 7Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei
| | - Cheng-Chia Lee
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 6Brain Research Center, National Yang Ming Chiao Tung University, Taipei
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19
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Li CC, Wu MY, Sun YC, Chen HH, Wu HM, Fang ST, Chung WY, Guo WY, Lu HHS. Ensemble classification and segmentation for intracranial metastatic tumors on MRI images based on 2D U-nets. Sci Rep 2021; 11:20634. [PMID: 34667233 PMCID: PMC8526612 DOI: 10.1038/s41598-021-99984-5] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/01/2021] [Indexed: 12/21/2022] Open
Abstract
The extraction of brain tumor tissues in 3D Brain Magnetic Resonance Imaging (MRI) plays an important role in diagnosis before the gamma knife radiosurgery (GKRS). In this article, the post-contrast T1 whole-brain MRI images had been collected by Taipei Veterans General Hospital (TVGH) and stored in DICOM format (dated from 1999 to 2018). The proposed method starts with the active contour model to get the region of interest (ROI) automatically and enhance the image contrast. The segmentation models are trained by MRI images with tumors to avoid imbalanced data problem under model construction. In order to achieve this objective, a two-step ensemble approach is used to establish such diagnosis, first, classify whether there is any tumor in the image, and second, segment the intracranial metastatic tumors by ensemble neural networks based on 2D U-Net architecture. The ensemble for classification and segmentation simultaneously also improves segmentation accuracy. The result of classification achieves a F1-measure of [Formula: see text], while the result of segmentation achieves an IoU of [Formula: see text] and a DICE score of [Formula: see text]. Significantly reduce the time for manual labeling from 30 min to 18 s per patient.
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Affiliation(s)
- Cheng-Chung Li
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Meng-Yun Wu
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Ying-Chou Sun
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hung-Hsun Chen
- Center of Teaching and Learning Development, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ssu-Ting Fang
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Henry Horng-Shing Lu
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.
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20
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Deemer J, Melinis N, Brown S, Chung WY. Delays in diagnostic tests used to identify transthyretin amyloid cardiomyopathy (ATTR-CM) in the EU4 + UK. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an underdiagnosed, progressive disease characterised by amyloid protein deposits building in the left ventricle. The symptoms of ATTR-CM are like those associated with heart failure, and specialised tests are needed to identify ATTR-CM.
Purpose
This paper examines the tests used to identify ATTR-CM in France, Germany, Italy, Spain and United Kingdom and the time between these tests.
Methods
Ipsos' ATTR-CM Therapy Monitor was fielded between November 2020 and December 2020, with 210 (FR: 46, DE: 40, IT: 43, ES: 42, UK: 39) treating doctors providing data on 320 (FR: 71, DE: 63, IT: 64, ES: 63, UK: 59) patients diagnosed with ATTR-CM. Ipsos analysed information provided on the diagnostic tests ordered for the 320 patients to understand how ATTR-CM is diagnosed across the five markets, and also tracked the order in which the tests were conducted, across four batteries, to understand the flow of the diagnostic procedures.
Results
Overall, the patients in our study went through 6 diagnostic tests on average before receiving a confirmed ATTR-CM diagnosis via Echocardiogram (ECHO) with strain imaging (83%), Cardiac Magnetic Resonance Imaging MRI (75%), Genetic tests (69%), Laboratory tests (59%), Scintigraphy tests (52%), and Biopsy tests (51%) as the top tests ordered. Overall, 15% of the reported patients had an unknown order of tests. Patients in Germany, France and Italy received the most tests on average (FR: 6, DE: 7, IT: 6, ES: 5 and UK: 5). Patients in Germany also experienced the shortest delays between batteries of tests (3.2 wks. between 1st and 2nd batteries; 3.9 wks. between 2nd and 3rd batteries) and were most likely to receive a Genetic test (84%) or Biopsy test (68%) to confirm diagnosis. In comparison, patients in Spain experienced the longest testing delays (7.3 wks. between 1st and 2nd batteries; 5.8 wks. between 2nd and 3rd batteries) and went through only 5 diagnostic tests before receiving a confirmed diagnosis.
Across the markets, 59% of doctors experienced a decline in ability to diagnose patients with ATTR-CM due to COVID-19, with the degree of impact differing drastically by region (FR: 43%, DE: 20%, IT: 79%, ES: 88% and UK: 64%). With doctors indicating that 16% of their patients were untreated due to late diagnosis with advanced disease (FR: 15%, DE: 10%, IT: 16%, ES: 20% and UK: 21%), identifying suspected ATTR-CM and running the necessary tests to diagnose ATTR-CM early are essential.
Conclusion
Overall, the patients reported on in this study received upwards of 6 diagnostic tests before confirmation of ATTR-CM, with 4.5 weeks between each battery of tests. In addition to regional nuances in regard to test choice, we see evidence that there are country level differences between how quickly patients receive diagnostic tests. Further research is needed to identify ways of increasing the speed of testing and subsequent diagnosis.
Funding Acknowledgement
Type of funding sources: None. Diagnostic Procedures by Region
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Affiliation(s)
- J Deemer
- Ipsos, New York City, United States of America
| | - N Melinis
- Ipsos, New York City, United States of America
| | - S Brown
- Ipsos, London, United Kingdom
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21
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Isherwood J, Karki BB, Chung WY, AlSaoudi T, Wolff J, Malde D, Bhardwaj N, Garcea G, Dennison A. 228 Outcomes of Gallstone Complications During the COVID Pandemic. Br J Surg 2021. [PMCID: PMC8524580 DOI: 10.1093/bjs/znab259.826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background The Intercollegiate General Surgery Guidance on COVID-19 recommended either non-surgical management or cholecystostomy drains for the management of acute biliary disease replacing gold standard practice of early laparoscopic cholecystectomy within 1 week of index admission with drainage reserved for high-risk patients where surgery is not appropriate. Method This is the retrospective study presenting the impact of gallstone disease in our unit during five months of the COVID- 19 pandemic (March 2020-August 2020) compared with the equivalent period in 2019. Results Patients presenting to the HPB unit with a coded diagnosis of gallstones were included and during the study period 1447 patients presented compared with 1413 in 2019. In 2020 compared with 2019 there was a significant decrease in patients presenting with cholecystitis (240 vs 313; p = 0.031) but no significant difference in patients presenting due to gallbladder perforation (44 vs 51). Interestingly the numbers of cholecystostomies were comparable, with 11 in 2020 and 15 in 2019 representing significantly less than the 7.2% figure published by Peckham-Cooper et al. Conclusions In our study there was a decrease in patients with cholecystitis and perforation and there was an increase in patients with gallstone pancreatitis, increase waiting lists with increase in the incidence of serious complications. In our trust we currently have 656 patients awaiting cholecystectomy compared to 280 in august 2019. With the recent elevation of the alert level to 4 and increased government restrictions, a consistent National approach is required to mitigate these risks.
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Affiliation(s)
- J Isherwood
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - B B Karki
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - W Y Chung
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - T AlSaoudi
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - J Wolff
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - D Malde
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - N Bhardwaj
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - G Garcea
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - A Dennison
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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22
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Sun YC, Hsieh AT, Fang ST, Wu HM, Kao LW, Chung WY, Chen HH, Liou KD, Lin YS, Guo WY, Lu HHS. Can 3D artificial intelligence models outshine 2D ones in the detection of intracranial metastatic tumors on magnetic resonance images? J Chin Med Assoc 2021; 84:956-962. [PMID: 34613943 DOI: 10.1097/jcma.0000000000000614] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study aimed to compare the prediction performance of two-dimensional (2D) and three-dimensional (3D) semantic segmentation models for intracranial metastatic tumors with a volume ≥ 0.3 mL. METHODS We used postcontrast T1 whole-brain magnetic resonance (MR), which was collected from Taipei Veterans General Hospital (TVGH). Also, the study was approved by the institutional review board (IRB) of TVGH. The 2D image segmentation model does not fully use the spatial information between neighboring slices, whereas the 3D segmentation model does. We treated the U-Net as the basic model for 2D and 3D architectures. RESULTS For the prediction of intracranial metastatic tumors, the area under the curve (AUC) of the 3D model was 87.6% and that of the 2D model was 81.5%. CONCLUSION Building a semantic segmentation model based on 3D deep convolutional neural networks might be crucial to achieve a high detection rate in clinical applications for intracranial metastatic tumors.
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Affiliation(s)
- Ying-Chou Sun
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ang-Ting Hsieh
- Institute of Data Science and Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Ssu-Ting Fang
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Liang-Wei Kao
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Wen-Yuh Chung
- Division of Functional Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Neurological, Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hung-Hsun Chen
- Center of Teaching and Learning Development, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Kang-Du Liou
- Division of Functional Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Neurological, Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu-Shiou Lin
- Institute of Data Science and Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Henry Horng-Shing Lu
- Institute of Data Science and Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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23
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Huang CY, Peng SJ, Wu HM, Yang HC, Chen CJ, Wang MC, Hu YS, Chen YW, Lin CJ, Guo WY, Pan DHC, Chung WY, Lee CC. Quantification of tumor response of cystic vestibular schwannoma to Gamma Knife radiosurgery by using artificial intelligence. J Neurosurg 2021:1-9. [PMID: 34598136 DOI: 10.3171/2021.4.jns203700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) is a common treatment modality for vestibular schwannoma (VS). The ability to predict treatment response is important in patient counseling and decision-making. The authors developed an algorithm that can automatically segment and differentiate cystic and solid tumor components of VS. They also investigated associations between the quantified radiological features of each component and tumor response after GKRS. METHODS This is a retrospective study comprising 323 patients with VS treated with GKRS. After preprocessing and generation of pretreatment T2-weighted (T2W)/T1-weighted with contrast (T1WC) images, the authors segmented VSs into cystic and solid components by using fuzzy C-means clustering. Quantitative radiological features of the entire tumor and its cystic and solid components were extracted. Linear regression models were implemented to correlate clinical variables and radiological features with the specific growth rate (SGR) of VS after GKRS. RESULTS A multivariable linear regression model of radiological features of the entire tumor demonstrated that a higher tumor mean signal intensity (SI) on T2W/T1WC images (p < 0.001) was associated with a lower SGR after GKRS. Similarly, a multivariable linear regression model using radiological features of cystic and solid tumor components demonstrated that a higher solid component mean SI (p = 0.039) and a higher cystic component mean SI (p = 0.004) on T2W/T1WC images were associated with a lower SGR after GKRS. A larger cystic component proportion (p = 0.085) was associated with a trend toward a lower SGR after GKRS. CONCLUSIONS Radiological features of VSs on pretreatment MRI that were quantified using fuzzy C-means were associated with tumor response after GKRS. Tumors with a higher tumor mean SI, a higher solid component mean SI, and a higher cystic component mean SI on T2W/T1WC images were more likely to regress in volume after GKRS. Those with a larger cystic component proportion also trended toward regression after GKRS. Further refinement of the algorithm may allow direct prediction of tumor response.
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Affiliation(s)
- Chih-Ying Huang
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
| | - Syu-Jyun Peng
- 2Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University
| | - Hsiu-Mei Wu
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Ching-Jen Chen
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mao-Che Wang
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 6Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital
| | - Yong-Sin Hu
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 7Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University; and
| | - Wen-Yuh Chung
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Cheng-Chia Lee
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 8Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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24
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Layton GR, Chung WY, Isherwood J, Fraser RE, Issa E, Robertson GS, Garcea G, Bhardwaj N, Dennison AR. Endoscopic retrograde cholangiopancreatography in the COVID era: considerations for hepatobiliary and pancreatic surgery units. Br J Surg 2021; 108:e290-e291. [PMID: 34000030 DOI: 10.1093/bjs/znab161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 04/14/2021] [Indexed: 01/28/2023]
Affiliation(s)
- G R Layton
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - W Y Chung
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - J Isherwood
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - R E Fraser
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - E Issa
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - G S Robertson
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - G Garcea
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - N Bhardwaj
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - A R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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25
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Chou CL, Chen HH, Yang HC, Chen YW, Chen CJ, Chen YW, Wu HM, Guo WY, Pan DHC, Chung WY, Wong TT, Lee CC. Effects of stereotactic radiosurgery versus conventional radiotherapy on body mass index in patients with craniopharyngioma. J Neurosurg Pediatr 2021:1-7. [PMID: 33990078 DOI: 10.3171/2020.12.peds20165] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 12/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hypothalamic obesity is common among patients with craniopharyngioma. This study examined whether precise stereotactic radiosurgery reduces the risk of hypothalamic obesity in cases of craniopharyngioma with expected long-term survival. METHODS This cohort study included 40 patients who had undergone Gamma Knife radiosurgery (GKRS; n = 22) or fractionated radiotherapy (FRT; n = 18) for residual or recurrent craniopharyngioma. Neurological presentations, tumor volume changes, and BMI values were meticulously reviewed. The median clinical follow-up durations were 9.7 years in the GKRS group and 10.8 years in the FRT group. RESULTS The median ages at the time of GKRS and FRT were 9.0 years and 10.0 years, respectively. The median margin dose of GKRS was 12.0 Gy (range 10.0-16.0 Gy), whereas the median dose of FRT was 50.40 Gy (range 44.1-56.3 Gy). Prior to GKRS or FRT, the median BMI values were 20.5 kg/m2 in the GKRS cohort and 20.0 kg/m2 in the FRT cohort. The median BMIs after radiation therapy at final follow-up were 21.0 kg/m2 and 24.0 kg/m2 for the GKRS and FRT cohorts, respectively. In the FRT cohort, BMI curves rapidly increased beyond the 85th percentile of the upper limit of the general population. BMI curves in the GKRS cohort increased more gradually, and many of the patients merged into the normal growth curve after adolescence. However, the observed difference was not statistically significant (p = 0.409). CONCLUSIONS The study compared the two adjuvant radiation modalities most commonly used for recurrent and residual craniopharyngioma. The authors' results revealed that precise radiosurgery dose planning can mediate the subsequent increase in BMI. There is every indication that meticulous GKRS treatment is an effective approach to treating craniopharyngioma while also reducing the risk of hypothalamic obesity.
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Affiliation(s)
| | - Hsin-Hung Chen
- 1Department of Neurosurgery, Neurological Institute.,3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Huai-Che Yang
- 1Department of Neurosurgery, Neurological Institute.,3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Yi-Wei Chen
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei.,5Cancer Center, Taipei Veterans General Hospital, Taipei
| | - Ching-Jen Chen
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Yu-Wei Chen
- 1Department of Neurosurgery, Neurological Institute
| | - Hsiu-Mei Wu
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei.,4Department of Radiology, and
| | - Wan-Yuo Guo
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei.,4Department of Radiology, and
| | - David Hung-Chi Pan
- 1Department of Neurosurgery, Neurological Institute.,3School of Medicine, National Yang Ming Chiao Tung University, Taipei.,7Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei
| | - Wen-Yuh Chung
- 1Department of Neurosurgery, Neurological Institute.,3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Tai-Tong Wong
- 1Department of Neurosurgery, Neurological Institute.,3School of Medicine, National Yang Ming Chiao Tung University, Taipei.,8Department of Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan; and
| | - Cheng-Chia Lee
- 1Department of Neurosurgery, Neurological Institute.,2Brain Research Center and.,3School of Medicine, National Yang Ming Chiao Tung University, Taipei
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26
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Alsaoudi T, Slavin D, Khasawneh F, Chung WY, Eltweri A, Sahloul M, Bhardwaj N, Malde D, Dennison AR, Garcea G. Selective impact of COVID-19 in patients presenting with non-specific abdominal pain. Br J Surg 2021; 108:e150-e151. [PMID: 33792638 PMCID: PMC8083566 DOI: 10.1093/bjs/znaa152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 11/20/2022]
Affiliation(s)
- T Alsaoudi
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - D Slavin
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - F Khasawneh
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - W Y Chung
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - A Eltweri
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - M Sahloul
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - N Bhardwaj
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - D Malde
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - A R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - G Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
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27
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Isheerwood J, Winyard J, Bekhyat Karki B, Chung WY, Layton G, Issa E, Garcea G, Dennison A. 88 Prevalence Of SARS-COVID-19 Serum Igg Antibodies Amongst Staff on An Acute Surgical Unit. Br J Surg 2021. [PMCID: PMC8135893 DOI: 10.1093/bjs/znab134.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background The United Kingdom now has one of the highest death rates from COVID 19, with over 40,000 deaths (1). It has been posited that the identification of care workers with immunity or increased resistance could be important in developing future strategies. Method This was a retrospectively conducted survey of general surgical staff at a tertiary surgical unit. Results We surveyed 215 staff that had undergone antibody testing. Of the 175/215 who reported contact with COVID-19 positive patients, 6/215 had a positive PCR result and 15/215 reported a positive antibody test. Only 3/6 that had a positive PCR test demonstrated antibodies. Conclusions Our “immunity” rate of 7% is extremely low and is concerning especially in respect of the anticipated “herd immunity” which would mitigate many of the issues presently being confronted and it is likely to be many months at least before this makes realistic contribution. Continued testing for the presence of COVID-19 antibodies will contribute to crucial seroprevalence data that can be used by public health bodies whose advice will necessarily evolve as increasing data sets become available.
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Affiliation(s)
- J Isheerwood
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - J Winyard
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - B Bekhyat Karki
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - W Y Chung
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - G Layton
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - E Issa
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - G Garcea
- Leicester General Hospital, Leicester, United Kingdom
| | - A Dennison
- Leicester General Hospital, Leicester, United Kingdom
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28
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Isherwood J, Karki B, Chung WY, AlSaoudi T, Wolff J, Malde D, Bhardwaj N, Garcea G, Dennison AR. Outcomes of gallstone complications during the COVID pandemic. Br J Surg 2021; 108:e29-e30. [PMID: 33640947 DOI: 10.1093/bjs/znaa068] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 12/31/2022]
Abstract
As data and metadata from the SARS-CoV-2 pandemic mature, the true impact on non-cancer, non-emergency surgical practice is becoming apparent. The authors present data on the impact of gallstone disease in their unit during 5 months of the COVID-19 pandemic (March 2020 to August 2020) compared with the equivalent period in 2019. Although the total number of patients presenting with gallstone disease was comparable, there was a decrease in patients with cholecystitis and perforation (although it is possibly too early for these to have presented), and there was a small but worrying increase in patients with gallstone pancreatitis. With the recent increase in alert level to 4 and increased government restrictions in an attempt to avoid a second national lockdown, a consistent national approach is required to mitigate these risks.
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Affiliation(s)
- J Isherwood
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - B Karki
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - W Y Chung
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - T AlSaoudi
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - J Wolff
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - D Malde
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - N Bhardwaj
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - G Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - A R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
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29
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Lee CC, Lee WK, Wu CC, Lu CF, Yang HC, Chen YW, Chung WY, Hu YS, Wu HM, Wu YT, Guo WY. Applying artificial intelligence to longitudinal imaging analysis of vestibular schwannoma following radiosurgery. Sci Rep 2021; 11:3106. [PMID: 33542422 PMCID: PMC7862268 DOI: 10.1038/s41598-021-82665-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 01/18/2021] [Indexed: 02/06/2023] Open
Abstract
Artificial intelligence (AI) has been applied with considerable success in the fields of radiology, pathology, and neurosurgery. It is expected that AI will soon be used to optimize strategies for the clinical management of patients based on intensive imaging follow-up. Our objective in this study was to establish an algorithm by which to automate the volumetric measurement of vestibular schwannoma (VS) using a series of parametric MR images following radiosurgery. Based on a sample of 861 consecutive patients who underwent Gamma Knife radiosurgery (GKRS) between 1993 and 2008, the proposed end-to-end deep-learning scheme with automated pre-processing pipeline was applied to a series of 1290 MR examinations (T1W+C, and T2W parametric MR images). All of which were performed under consistent imaging acquisition protocols. The relative volume difference (RVD) between AI-based volumetric measurements and clinical measurements performed by expert radiologists were + 1.74%, - 0.31%, - 0.44%, - 0.19%, - 0.01%, and + 0.26% at each follow-up time point, regardless of the state of the tumor (progressed, pseudo-progressed, or regressed). This study outlines an approach to the evaluation of treatment responses via novel volumetric measurement algorithm, and can be used longitudinally following GKRS for VS. The proposed deep learning AI scheme is applicable to longitudinal follow-up assessments following a variety of therapeutic interventions.
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Affiliation(s)
- Cheng-Chia Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Kai Lee
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Chun Wu
- Department of Radiology, Taipei Veteran General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Feng Lu
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veteran General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veteran General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Te Wu
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan.
- Institute of Biophotonics, National Yang-Ming University, Taipei, Taiwan.
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veteran General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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30
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Yang HC, Peng SJ, Lee CC, Wu HM, Chen YW, Lin CJ, Shiau CY, Guo WY, Pan DHC, Liu KD, Chung WY, Lin YY. Does the Diffuseness of the Nidus Affect the Outcome of Stereotactic Radiosurgery in Patients with Unruptured Cerebral Arteriovenous Malformations? Stereotact Funct Neurosurg 2020; 99:113-122. [PMID: 33264796 DOI: 10.1159/000510683] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/31/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND We proposed an algorithm to automate the components within the identification of components within the nidus of cerebral arteriovenous malformations (AVMs) which may be used to analyze the relationship between its diffuseness and treatment outcomes following stereotactic radiosurgery (SRS). OBJECTIVES to determine the impact of the diffuseness of the AVM nidus on SRS outcomes. METHODS This study conducted regular follow-ups of 209 patients with unruptured AVMs who underwent SRS. The diffuseness of the AVM nidus was estimated by quantifying the proportions of vascular nidal component, brain parenchyma, and cerebrospinal fluid in T2-weighted MRIs. We used Cox regression analysis to characterize the association between nidal diffuseness and treatment outcomes in terms of obliteration rate and radiation-induced change (RICs) rate following SRS. RESULTS The median AVM volume was 20.7 cm3. The median duration of imaging follow-up was 51 months after SRS. The overall AVM obliteration rate was 68.4%. RICs were identified in 156 of the 209 patients (74.6%). The median proportions of the nidus of AVM and brain parenchyma components within the prescription isodose range were 30.2 and 52.2%, respectively. Cox regression multivariate analysis revealed that the only factor associated with AVM obliteration rate after SRS was AVM volume. However, a larger AVM volume (>20 mL) and a larger proportion of brain parenchyma (>50%) within the prescription isodose range were both correlated with a higher RIC rate following SRS. CONCLUSIONS The diffuseness of the nidus indeed appears to affect the RIC rate following SRS in patients with unruptured AVMs.
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Affiliation(s)
- Huai-Che Yang
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Syu-Jyun Peng
- Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Kang-Du Liu
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yung-Yang Lin
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan, .,School of Medicine, National Yang-Ming University, Taipei, Taiwan, .,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, .,Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,
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31
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Yang HC, Wu CC, Lee CC, Huang HE, Lee WK, Chung WY, Wu HM, Guo WY, Wu YT, Lu CF. Prediction of pseudoprogression and long-term outcome of vestibular schwannoma after Gamma Knife radiosurgery based on preradiosurgical MR radiomics. Radiother Oncol 2020; 155:123-130. [PMID: 33161011 DOI: 10.1016/j.radonc.2020.10.041] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE Gamma Knife radiosurgery (GKRS) is a safe and effective treatment modality with a long-term tumor control rate over 90% for vestibular schwannoma (VS). However, numerous tumors may undergo a transient pseudoprogression during 6-18 months after GKRS followed by a long-term volume reduction. The aim of this study is to determine whether the radiomics analysis based on preradiosurgical MRI data could predict the pseudoprogression and long-term outcome of VS after GKRS. MATERIALS AND METHODS A longitudinal dataset of patients with VS treated by single GKRS were retrospectively collected. Overall 336 patients with no previous craniotomy for tumor removal and a median of 65-month follow-up period after radiosurgery were finally included in this study. In total 1763 radiomic features were extracted from the multiparameteric MRI data before GKRS followed by the machine-learning classification. RESULTS We constructed a two-level machine-learning model to predict the long-term outcome and the occurrence of transient pseudoprogression after GKRS separately. The prediction of long-term outcome achieved an accuracy of 88.4% based on five radiomic features describing the variation of T2-weighted intensity and inhomogeneity of contrast enhancement in tumor. The prediction of transient pseudoprogression achieved an accuracy of 85.0% based on another five radiomic features associated with the inhomogeneous hypointensity pattern of contrast enhancement and the variation of T2-weighted intensity. CONCLUSION The proposed machine-learning model based on the preradiosurgical MR radiomics provides a potential to predict the pseudoprogression and long-term outcome of VS after GKRS, which can benefit the treatment strategy in clinical practice.
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Affiliation(s)
- Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Chun Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Huai-En Huang
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan; Department of Medical Imaging, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Wei-Kai Lee
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Yu-Te Wu
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan; Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan; Institute of Biophotonics, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Feng Lu
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan; Institute of Biophotonics, National Yang-Ming University, Taipei, Taiwan.
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32
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Alsaoudi T, Chung WY, Isherwood J, Bhardwaj N, Malde D, Dennison AR, Garcea G. HPB surgery in the time of COVID. Br J Surg 2020; 107:e588-e589. [PMID: 32936449 DOI: 10.1002/bjs.12030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/12/2020] [Indexed: 06/11/2023]
Affiliation(s)
- T Alsaoudi
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - W Y Chung
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - J Isherwood
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - N Bhardwaj
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - D Malde
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - A R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - G Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
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33
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Isherwood J, Winyard J, Karki B, Chung WY, Layton G, Issa E, Garcea G, Dennison AR. Prevalence of SARS-COVID-19 serum IgG antibodies amongst staff on an acute surgical unit. Br J Surg 2020; 107:e576-e577. [PMID: 32909272 PMCID: PMC7929108 DOI: 10.1002/bjs.11976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/14/2020] [Indexed: 11/11/2022]
Affiliation(s)
- J Isherwood
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - J Winyard
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - B Karki
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - W Y Chung
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - G Layton
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - E Issa
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - G Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - A R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
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34
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Chung WY, Winyard J, Layton GR, Isherwood J, Issa E, Radjendrin A, Sangal S, Dennison AR, Garcea G. Impact of the COVID-19 pandemic on acute adult surgical admissions- a single centre experience. Br J Surg 2020; 107:e370-e371. [PMID: 32710553 PMCID: PMC7929173 DOI: 10.1002/bjs.11807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 12/24/2022]
Affiliation(s)
- W Y Chung
- Department of Hepatobiliary and Pancreatic Surgery, Leicester, UK
| | - J Winyard
- Department of Hepatobiliary and Pancreatic Surgery, Leicester, UK
| | - G R Layton
- Department of Hepatobiliary and Pancreatic Surgery, Leicester, UK
| | - J Isherwood
- Department of Hepatobiliary and Pancreatic Surgery, Leicester, UK
| | - E Issa
- Department of Hepatobiliary and Pancreatic Surgery, Leicester, UK
| | - A Radjendrin
- Department of Colorectal Surgery, Leicester General Hospital, Leicester, UK
| | - S Sangal
- Department of Colorectal Surgery, Leicester General Hospital, Leicester, UK
| | - A R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, Leicester, UK
| | - G Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester, UK
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35
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Karlsson B, Jokura H, Yang HC, Yamamoto M, Martinez R, Kawagishi J, Guo WY, Beute G, Chung WY, Söderman M, Yeo TT. Clinical outcome following cerebral AVM hemorrhage. Acta Neurochir (Wien) 2020; 162:1759-1766. [PMID: 32385636 DOI: 10.1007/s00701-020-04380-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/29/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND A significant difference exists between the published results reporting the clinical outcome following brain arteriovenous malformation (AVM) ruptures. Information about the outcome following hemorrhage in an AVM population treated with radiosurgery could provide additional information to assess the risk of mortality and morbidity following an AVM hemorrhage. METHODS Clinical outcome was studied in 383 patients, the largest patient population yet studied, who suffered from a symptomatic hemorrhage after Gamma Knife® surgery (GKS) but before confirmed AVM obliteration. The impact of different patient, AVM, and treatment parameters on the clinical outcome was analyzed. The aim was to generate outcome predictions by comparing our data to and combining them with earlier published results. RESULTS No relation was found between clinical outcome and treatment parameters, indicating that the results are applicable also on untreated AVMs. Twenty-one percent of the patients died, 45% developed or experienced worsening of neurological sequelae, and 35% recovered completely after the hemorrhage. Old age was a predictor of poor outcome. Sex, AVM location, AVM volume, and history of prior hemorrhage did not influence the outcome. The mortality rate was comparable to earlier published prospective data, but higher than that found in retrospective studies. CONCLUSIONS The mortality rates in earlier published retrospective series as well as in studies focusing on clinical outcome following AVM hemorrhage significantly underestimate the risk for a mortal outcome following an AVM hemorrhage. Based on our findings, an AVM rupture has around 20% likelihood to result in mortality, 45% likelihood to result in a minor or major deficit, and 35% likelihood of complete recovery. The findings are probably applicable also for AVM ruptures in general. The cumulative mortality and morbidity rates 25 years after diagnosis were estimated to be around 40% in a patient with a patent AVM.
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Affiliation(s)
- Bengt Karlsson
- Department of Surgery, Div. of Neurosurgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore.
| | - Hidefumi Jokura
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Furukawa, Osaki, Japan
| | - Huai-Che Yang
- Department of Neurosurgery, Veterans General Hospital, Taipei, Taiwan
- Yang-Ming University, Taipei, Taiwan
| | | | | | - Jun Kawagishi
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Furukawa, Osaki, Japan
| | - Wan-Yuo Guo
- Department of Radiology, Veterans General Hospital, Taipei, Taiwan
| | - Guus Beute
- St Elizabeth Ziekenhuis, Tilburg, the Netherlands
| | - Wen-Yuh Chung
- Department of Neurosurgery, Veterans General Hospital, Taipei, Taiwan
| | | | - Tseng Tsai Yeo
- Department of Surgery, Div. of Neurosurgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
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36
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Lee WK, Wu CC, Lee CC, Lu CF, Yang HC, Huang TH, Lin CY, Chung WY, Wang PS, Wu HM, Guo WY, Wu YT. Combining analysis of multi-parametric MR images into a convolutional neural network: Precise target delineation for vestibular schwannoma treatment planning. Artif Intell Med 2020; 107:101911. [PMID: 32828450 DOI: 10.1016/j.artmed.2020.101911] [Citation(s) in RCA: 8] [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: 12/05/2019] [Revised: 04/22/2020] [Accepted: 06/09/2020] [Indexed: 11/30/2022]
Abstract
Manual delineation of vestibular schwannoma (VS) by magnetic resonance (MR) imaging is required for diagnosis, radiosurgery dose planning, and follow-up tumor volume measurement. A rapid and objective automatic segmentation method is required, but problems have been encountered due to the low through-plane resolution of standard VS MR scan protocols and because some patients have non-homogeneous cystic areas within their tumors. In this study, we retrospectively collected multi-parametric MR images from 516 patients with VS; these were extracted from the Gamma Knife radiosurgery planning system and consisted of T1-weighted (T1W), T2-weighted (T2W), and T1W with contrast (T1W + C) images. We developed an end-to-end deep-learning-based method via an automatic preprocessing pipeline. A two-pathway U-Net model involving two sizes of convolution kernel (i.e., 3 × 3 × 1 and 1 × 1 × 3) was used to extract the in-plane and through-plane features of the anisotropic MR images. A single-pathway model that adopted the same architecture as the two-pathway model, but used a kernel size of 3 × 3 × 3, was also developed for comparison purposes. In addition, we used multi-parametric MR images with different image contrasts as the model training input in order to effectively segment tumors with solid as well as cystic parts. The results of the automatic segmentation demonstrated that (1) the two-pathway model outperformed single-pathway model in terms of dice scores (0.90 ± 0.05 versus 0.87 ± 0.07); both of them having been trained using the T1W, T1W + C and T2W anisotropic MR images, (2) the optimal single-parametric two-pathway model (dice score: 0.88 ± 0.06) was then trained using the T1W + C images, and (3) the two-pathway models trained using bi-parametric (T1W + C and T2W) and tri-parametric (T1W, T2W, and T1W + C) images outperformed the model trained using the single-parametric (T1W + C) images (dice scores: 0.89 ± 0.05 and 0.90 ± 0.05, respectively, larger than 0.88 ± 0.06) because it showed improved segmentation of the non-homogeneous parts of the tumors. The proposed two-pathway U-Net model outperformed the single-pathway U-Net model when segmenting VS using anisotropic MR images. The multi-parametric models effectively improved on the defective segmentation obtained using the single-parametric models by separating the non-homogeneous tumors into their solid and cystic parts.
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Affiliation(s)
- Wei-Kai Lee
- National Yang-Ming University, Department of Biomedical Imaging and Radiological Sciences, Taipei, Taiwan
| | - Chih-Chun Wu
- Taipei Veteran General Hospital, Department of Radiology, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Taipei Veteran General Hospital, Department of Neurosurgery, Taiwan
| | - Chia-Feng Lu
- National Yang-Ming University, Department of Biomedical Imaging and Radiological Sciences, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Taipei Veteran General Hospital, Department of Neurosurgery, Taiwan
| | - Tzu-Hsuan Huang
- National Yang-Ming University, Institute of Biophotonics, Taipei, Taiwan
| | - Chun-Yi Lin
- National Yang-Ming University, Institute of Biophotonics, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Taipei Veteran General Hospital, Department of Neurosurgery, Taiwan
| | - Po-Shan Wang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; National Yang-Ming University, Institute of Biophotonics, Taipei, Taiwan; Municipal Gan-Dau Hospital, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Taipei Veteran General Hospital, Department of Radiology, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wan-Yuo Guo
- Taipei Veteran General Hospital, Department of Radiology, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Yu-Te Wu
- National Yang-Ming University, Department of Biomedical Imaging and Radiological Sciences, Taipei, Taiwan; National Yang-Ming University, Institute of Biophotonics, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
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37
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Lin YY, Wu HM, Yang HC, Chen CJ, Lin CJ, Chen YW, Chen HH, Wong TT, Hu YS, Chung WY, Shiau CY, Guo WY, Pan DHC, Lee CC. Repeated gamma knife radiosurgery enables longer tumor control in cases of highly-recurrent intracranial ependymoma. J Neurooncol 2020; 148:363-372. [PMID: 32405998 DOI: 10.1007/s11060-020-03531-7] [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: 02/26/2020] [Accepted: 05/05/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) is a potential re-irradiation treatment for recurrent intracranial ependymoma after prior radiation therapy. The purpose of this study was to examine the efficacy and safety of repeated SRS in the treatment of recurrent intracranial ependymomas. METHODS This is a retrospective study of consecutive patients with residual or recurrent intracranial ependymomas who were treated with SRS between 1993 and 2018. Tumor progression was defined as a ≥ 10% increase in tumor volume. Tumor regression was defined as a ≥ 10% reduction in tumor volume. A tumor that remained within 10% of its original volume was defined as stable. Tumor control comprised tumor regression and stability. Time-dependent analyses were performed using two treatment failure endpoint definitions: (1) evidence of local tumor progression or distant metastasis (single SRS analysis), and (2) lack of tumor response to SRS (repeated SRS analysis). These analyses were adjusted for the competing risk of death. RESULTS The study comprised 37 patients (65 intracranial ependymomas) who underwent multiple SRS sessions (range: 1-7). Median age was 10.2 years (range: 0.8-53.8 years), and median tumor volume was 1.5 mL (range: 0.01-22.5 mL). The median radiation dose was 13.3 Gy (range: 7.9-22.0 Gy) at a median isodose line of 57% (range: 50-90%). Overall tumor control rates in the single SRS analysis adjusting for the competing risk of death were 53.6%, 30.5%, and 23.6% at 1, 3, and 5 years, respectively. Overall tumor control rates in the repeated SRS analysis adjusting for the competing risk of death were 70.6%, 50.4%, and 43.1% at 1, 3, and 5 years, respectively. Prior gross total resection was the only independent predictor of overall tumor control after SRS (aHR = 25.62 (1.55-422.1), p = 0.02). CONCLUSIONS Repeated GKRS appeared to be an effective treatment strategy for recurrent or residual intracranial ependymomas, with acceptable complication rates.
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Affiliation(s)
- Yen-Yu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsin-Hung Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tai-Tong Wong
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
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38
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Hu YS, Lee CC, Guo WY, Lin CJ, Yang HC, Wu HM, Liu KD, Chung WY. Trigeminal Nerve Atrophy Predicts Pain Recurrence After Gamma Knife Stereotactic Radiosurgery for Classical Trigeminal Neuralgia. Neurosurgery 2020; 84:927-934. [PMID: 29660047 DOI: 10.1093/neuros/nyy122] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 03/13/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Trigeminal nerve atrophy and neurovascular compression (NVC) are frequently observed in classical trigeminal neuralgia (CTN). OBJECTIVE To determine whether nerve characteristics contribute to Gamma Knife (Elekta AB, Stockholm, Sweden) surgery (GKS) outcomes in unilateral CTN without previous surgery. METHODS From 2006 to 2012, 67 patients with unilateral CTN without previous surgery received GKS with a maximal dose of 90 Gy delivered to the trigeminal nerve juxta brainstem. Two evaluators, blinded to the side of pain, analyzed the magnetic resonance images before GKS to obtain the parameters, including nerve cross-sectional area (CSA), vessel type of NVC, and site of NVC along the nerve. Correlations of the parameters with pain relief (Barrow Neurological Institute [BNI] grades I-IIIb) and recurrence (BNI grades VI-V) were made by using Cox regression and Kaplan-Meier analyses. RESULTS The median CSA of the symptomatic nerves was significantly smaller than that of the asymptomatic nerves (4.95 vs 5.9 mm2, P < .001). After adjustment for age and sex, larger nerve CSA was associated with lower initial pain relief (hazard ratio 0.81, P = .03) and lower pain recurrence after initial response (hazard ratio 0.58, P = .02). Patients with nerve atrophy (CSA of ≤ 4.4 mm2 after receiver operating characteristic curve analysis) had a lower 5-yr probability of maintaining pain relief after initial response than those without nerve atrophy (65% vs 86%, P = .04). CONCLUSION Trigeminal nerve atrophy may predict pain recurrence in patients with initial post-GKS relief of CTN. Arterial and proximal NVC are not predictive of GKS outcomes. Future studies are required to determine optimal treatments for long-term pain relief in patients with CTN and trigeminal nerve atrophy.
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Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming University, Taipei, Taiwan.,Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming University, Taipei, Taiwan.,Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Kang-Du Liu
- School of Medicine, National Yang Ming University, Taipei, Taiwan.,Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming University, Taipei, Taiwan.,Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
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Hu YS, Guo WY, Lin CJ, Wu HM, Luo CB, Wu CA, Lee CC, Yang HC, Liu KD, Chung WY. Magnetic resonance imaging as a single diagnostic tool for verifying radiosurgery outcomes of cavernous sinus dural arteriovenous fistula. Eur J Radiol 2020; 125:108866. [PMID: 32065928 DOI: 10.1016/j.ejrad.2020.108866] [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] [Received: 10/27/2019] [Revised: 01/24/2020] [Accepted: 02/02/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE MRI and MR angiography (MRA) are noninvasive methods for examining cavernous sinus dural arteriovenous fistulas (CSDAVFs) after radiosurgery. In this study, we investigated the accuracy of unenhanced MRI/3-dimensional time-of-flight (3D TOF) MRA in evaluating CSDAVF obliteration as compared with digital subtraction angiography (DSA). METHODS From 1995-2012, 48 cases of CSDAVFs received Gamma Knife surgery (GKS) and had undergone both unenhanced MRI/3D TOF MRA and DSA for posttreatment evaluation. Two blinded observers independently interpreted the results of MRI/MRA. The results of MRI/MRA were compared with those of DSA. The sensitivity (the probability of MRI/MRA showing obliteration when DSA showed complete obliteration), specificity, positive predictive value, and negative predictive value for CSDAVF obliteration were reported. RESULTS The median interval between the final MRI/MRA and the subsequent DSA was 2 months. Follow-up DSA revealed that 38 of 48 (79.2 %) CSDAVFs were completely obliterated. The results of interobserver agreement assessment showed almost perfect agreement between the 2 observers. For unenhanced MRI/3D TOF MRA, the observed sensitivity was 84.2 %, specificity was 100 %, positive predictive value was 100 %, and negative predictive value was 62.5 %. CONCLUSIONS Unenhanced MRI/3D TOF MRA alone may be adequate to document the complete obliteration of CSDAVFs after GKS. Time-resolved MRA or DSA can be reserved for a suspected residual CSDAVF after a sufficient latency period after GKS.
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Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital Taoyuan Branch, Taoyuan, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan.
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chia-An Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming University, Taipei, Taiwan; Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming University, Taipei, Taiwan; Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kang-Du Liu
- School of Medicine, National Yang Ming University, Taipei, Taiwan; Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming University, Taipei, Taiwan; Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
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40
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Huang CY, Lee CC, Yang HC, Lin CJ, Wu HM, Chung WY, Shiau CY, Guo WY, Pan DHC, Peng SJ. Radiomics as prognostic factor in brain metastases treated with Gamma Knife radiosurgery. J Neurooncol 2020; 146:439-449. [PMID: 32020474 DOI: 10.1007/s11060-019-03343-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [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: 09/13/2019] [Accepted: 11/12/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Gamma Knife radiosurgery (GKRS) is a non-invasive procedure for the treatment of brain metastases. This study sought to determine whether radiomic features of brain metastases derived from pre-GKRS magnetic resonance imaging (MRI) could be used in conjunction with clinical variables to predict the effectiveness of GKRS in achieving local tumor control. METHODS We retrospectively analyzed 161 patients with non-small cell lung cancer (576 brain metastases) who underwent GKRS for brain metastases. The database included clinical data and pre-GKRS MRI. Brain metastases were demarcated by experienced neurosurgeons, and radiomic features of each brain metastasis were extracted. Consensus clustering was used for feature selection. Cox proportional hazards models and cause-specific proportional hazards models were used to correlate clinical variables and radiomic features with local control of brain metastases after GKRS. RESULTS Multivariate Cox proportional hazards model revealed that higher zone percentage (hazard ratio, HR 0.712; P = .022) was independently associated with superior local tumor control. Similarly, multivariate cause-specific proportional hazards model revealed that higher zone percentage (HR 0.699; P = .014) was independently associated with superior local tumor control. CONCLUSIONS The zone percentage of brain metastases, a radiomic feature derived from pre-GKRS contrast-enhanced T1-weighted MRIs, was found to be an independent prognostic factor of local tumor control following GKRS in patients with non-small cell lung cancer and brain metastases. Radiomic features indicate the biological basis and characteristics of tumors and could potentially be used as surrogate biomarkers for predicting tumor prognosis following GKRS.
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Affiliation(s)
- Chih-Ying Huang
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Syu-Jyun Peng
- Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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41
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Lee CC, Wang WH, Yang HC, Lin CJ, Wu HM, Lin YY, Hu YS, Chen CJ, Chen YW, Chou CC, Liu YT, Chung WY, Shiau CY, Guo WY, Hung-Chi Pan D, Hsu SPC. Gamma Knife radiosurgery for cerebral cavernous malformation. Sci Rep 2019; 9:19743. [PMID: 31874979 PMCID: PMC6930272 DOI: 10.1038/s41598-019-56119-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/02/2019] [Indexed: 11/28/2022] Open
Abstract
This is a retrospective study examining the efficacy and safety of Gamma Knife radiosurgery (GKS) in treating patients with cerebral cavernous malformations (CCMs). Between 1993 and 2018, 261 patients with 331 symptomatic CCMs were treated by GKS. The median age was 39.9 years and females were predominant (54%). The median volume of CCMs was 3.1 mL. The median margin dose was 11.9 Gy treat to a median isodose level of 59%. Median clinical and imaging follow-up times were 69 and 61 months, respectively. After the initial hemorrhage that led to CCM diagnosis, 136 hemorrhages occurred in the period prior to GKS (annual incidence = 23.6%). After GKS, 15 symptomatic hemorrhages occurred within the first 2 years of follow-up (annual incidence = 3.22%), and 37 symptomatic hemorrhages occurred after the first 2 years of follow-up (annual incidence = 3.16%). Symptomatic radiation-induced complication was encountered in 8 patients (3.1%). Mortality related to GKS occurred in 1 patient (0.4%). In conclusion, GKS decreased the risk of hemorrhage in CCM patients presenting with symptomatic hemorrhage. GKS is a viable alternative treatment option for patients with surgically-inaccessible CCMs or significant medical comorbidities.
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Affiliation(s)
- Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Hsin Wang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Yu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chien-Chen Chou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yo-Tsen Liu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Sanford P C Hsu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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42
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Hu YS, Lee CC, Wu HM, Yang HC, Lin TM, Luo CB, Guo WY, Chung WY, Lin CJ. Stagnant Venous Outflow Predicts Brain Arteriovenous Malformation Obliteration After Gamma Knife Radiosurgery Without Prior Intervention. Neurosurgery 2019; 87:338-347. [DOI: 10.1093/neuros/nyz507] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/10/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Gamma Knife radiosurgery (GKRS) obliterates 65% to 82% of brain arteriovenous malformations (BAVMs).
OBJECTIVE
To explore the impact of hemodynamics on GKRS outcomes.
METHODS
We retrospectively (2011-2017) included 98 patients with BAVMs who had received GKRS alone. Two evaluators, blinded to the outcomes, analyzed the pre-GKRS angiography and magnetic resonance images to obtain the morphological characteristics and quantitative digital subtraction angiography (QDSA) parameters. The venous stasis index was defined as the inflow gradient divided by the absolute value of the outflow gradient. Patients’ follow-up magnetic resonance or digital subtraction angiography images were evaluated for the presence of complete obliteration (CO). Cox regression and Kaplan–Meier analyses were conducted to determine the correlations between the parameters and outcomes.
RESULTS
Among the 98 patients, 63 (63.4%) achieved CO after GKRS at a median latency period of 31 mo. In multivariable analyses with adjustments for age and sex, increased BAVM volume (hazard ratio (HR) 0.949, P = .022) was an independent characteristic predictor, and venous stenosis (HR 2.595, P = .009), venous rerouting (HR 0.375, P = .022), and larger stasis index (HR 1.227, P = .025) were independent angiographic predictors of CO. BAVMs with a stasis index of >1.71 had a higher 36-mo probability of CO than those with a stasis index of ≤1.71 (61.1% vs 26.7%, P < .001).
CONCLUSION
BAVMs with a larger stasis index, indicating more stagnant venous outflow, may predict obliteration after GKRS. QDSA analysis may help in predicting BAVM treatment outcomes and making therapeutic decisions.
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Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Te-Ming Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Karlsson B, Johansson AV, Yang HC, Jokura H, Yamamoto M, Martínez-Álvarez R, Kawagishi J, Guo WY, Beute G, Pan DHC, Chung WY, Söderman M, Aiyama H, Yeo TT. A novel method to determine the natural course of unruptured brain arteriovenous malformations without the need for follow-up information. J Neurosurg 2019; 129:10-16. [PMID: 30544301 DOI: 10.3171/2018.7.gks181278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 05/07/2018] [Accepted: 07/11/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThere is a strong clinical need to accurately determine the average annual hemorrhage risk in unruptured brain arteriovenous malformations (AVMs). This need motivated the present initiative to use data from a uniquely large patient population and design a novel methodology to achieve a risk determination with unprecedented accuracy. The authors also aimed to determine the impact of sex, pregnancy, AVM volume, and location on the risk for AVM rupture.METHODSThe present study does not consider any specific management of the AVMs, but only uses the age distribution for the first hemorrhage, the shape of which becomes universal for a sufficiently large set of patients. For this purpose, the authors collected observations, including age at first hemorrhage and AVM size and location, in 3425 patients. The average annual risk for hemorrhage could then be determined from the simple relation that the number of patients with their first hemorrhage at a specific age equals the risk for hemorrhage times the number of patients at risk at that age. For a subset of the patients, the information regarding occurrence of AVM hemorrhage after treatment of the first hemorrhage was used for further analysis of the influence on risk from AVM location and pregnancy.RESULTSThe age distribution for the first AVM hemorrhage was used to determine the average annual risk for hemorrhage in unruptured AVMs at adult ages (25-60 years). It was concluded to be 3.1% ± 0.2% and unrelated to AVM volume but influenced by its location, with the highest risk for centrally located AVMs. The hemorrhage risk was found to be significantly higher for females in their fertile years.CONCLUSIONSThe present methodology allowed the authors to determine the average annual risk for the first AVM hemorrhage at 3.1% ± 0.2% without the need for individual patient follow-up. This methodology has potential also for other similar types of investigations. The conclusion that centrally located AVMs carry a higher risk was confirmed by follow-up information. Follow-up information was also used to conclude that pregnancy causes a substantially greater AVM hemorrhage risk. The age distribution for AVM hemorrhage is incompatible with AVMs present at birth having the same hemorrhage risk as AVMs in adults. Plausibly, they instead develop in the early years of life, possibly with a lower hemorrhage risk during that time period.
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Affiliation(s)
- Bengt Karlsson
- 1Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Arne V Johansson
- 2Department of Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | | | - Hidefumi Jokura
- 4Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | | | | | - Jun Kawagishi
- 4Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | - Wan-Yuo Guo
- 9Radiology, Veterans General Hospital, Taipei, Taiwan
| | - Guus Beute
- 7ETZ Elizabeth, Tilburg, The Netherlands; and
| | | | | | | | | | - Tseng Tsai Yeo
- 1Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
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44
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Lee CC, Hsu SPC, Lin CJ, Wu HM, Chen YW, Luo YH, Chiang CL, Hu YS, Chung WY, Shiau CY, Guo WY, Hung-Chi Pan D, Yang HC. Epidermal growth factor receptor mutations: association with favorable local tumor control following Gamma Knife radiosurgery in patients with non-small cell lung cancer and brain metastases. J Neurosurg 2019; 133:1-8. [PMID: 31226692 DOI: 10.3171/2019.4.jns19446] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 04/03/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The presence of epidermal growth factor receptor (EGFR) mutations in non-small cell lung cancer (NSCLC) has been associated with elevated radiosensitivity in vitro. However, results from clinical studies on radiosensitivity in cases of NSCLC with EGFR mutations are inconclusive. This paper presents a retrospective analysis of patients with NSCLC who underwent regular follow-up imaging after radiotherapy for brain metastases (BMs). The authors also investigated the influence of EGFR mutations on the efficacy of Gamma Knife radiosurgery (GKRS). METHODS This study included 264 patients (1069 BMs) who underwent GKRS treatment and for whom EGFR mutation status, demographics, performance status, and tumor characteristics were available. Radiological images were obtained at 3 months after GKRS and at 3-month intervals thereafter. Kaplan-Meier plots and Cox regression analysis were used to correlate EGFR mutation status and other clinical features with tumor control and overall survival. RESULTS The tumor control rates and overall 12-month survival rates were 87.8% and 65.5%, respectively. Tumor control rates in the EGFR mutant group versus the EGFR wild-type group were 90.5% versus 79.4% at 12 months and 75.0% versus 24.5% at 24 months. During the 2-year follow-up period after SRS, the intracranial response rate in the EGFR mutant group was approximately 3-fold higher than that in the wild-type group (p < 0.001). Cox regression multivariate analysis identified EGFR mutation status, extracranial metastasis, primary tumor control, and prescribed margin dose as predictors of tumor control (p = 0.004, p < 0.001, p = 0.004, and p = 0.026, respectively). Treatment with a combination of GKRS and tyrosine kinase inhibitors (TKIs) was the most important predictor of overall survival (p < 0.001). CONCLUSIONS The current study demonstrated that, among patients with NSCLC-BMs, EGFR mutations were independent prognostic factors of tumor control. It was also determined that a combination of GKRS and TKI had the most pronounced effect on prolonging survival after SRS. In select patient groups, treatment with SRS in conjunction with EGFR-TKIs provided effective tumor control for NSCLC-BMs.
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Affiliation(s)
- Cheng-Chia Lee
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei
- 6Brain Research Center, National Yang-Ming University, Taipei
| | - Sanford P C Hsu
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei
| | - Chung-Jung Lin
- 2Department of Radiology, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei
| | - Hsiu-Mei Wu
- 2Department of Radiology, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei
| | - Yu-Wei Chen
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 2Department of Radiology, Taipei Veterans General Hospital
| | - Yung-Hung Luo
- 3School of Medicine, National Yang-Ming University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital
- 8Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chi-Lu Chiang
- 3School of Medicine, National Yang-Ming University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital
- 8Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yong-Sin Hu
- 2Department of Radiology, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei
| | - Wen-Yuh Chung
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei
| | - Cheng-Ying Shiau
- 3School of Medicine, National Yang-Ming University, Taipei
- 4Cancer Center, Taipei Veterans General Hospital
| | - Wan-Yuo Guo
- 2Department of Radiology, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei
| | - David Hung-Chi Pan
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 7Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University; and
| | - Huai-Che Yang
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei
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45
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Yang HC, Lin CJ, Luo CB, Lee CC, Wu HM, Guo WY, Chung WY, Liu KD. Treatment Outcomes of Cavernous Sinus Dural Arteriovenous Fistulas: Comparison of Radiosurgery and Endovascular Embolisation. Clin Neuroradiol 2019; 30:321-330. [PMID: 31098665 DOI: 10.1007/s00062-019-00787-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 03/13/2019] [Accepted: 04/23/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular treatment (EVT) and stereotaxic gamma-knife radiosurgery (GKRS) can both effectively treat cavernous sinus dural arteriovenous fistulas (CSDAVF). This study compared the prognostic factors and treatment effectiveness of GKRS and EVT for different CSDAVF types. METHODS The charts of 200 patients undergoing GKRS and 105 patients undergoing EVT were reviewed for data on symptoms (e.g. orbital, cavernous, ocular, and cerebral). The CSDAVFs were classified into proliferative, restrictive, and late restrictive types. The prognostic factors for complete obliteration (CO) were evaluated in both the GKRS and EVT groups and the latent period to CO was measured. For statistical analysis χ2-tests were used to compare final CO rates for EVT and GKRS across the three CSDAVF types. RESULTS The EVT and cavernous symptoms were significant independent predictors of CO. The CO rate after EVT (97.9%) was significantly higher than that after GKRS (63.5%) for restrictive CSDAVFs (P < 0.001) but not for proliferative or late restrictive types. In the GKRS group, cavernous symptoms (hazard ratio, HR: 0.557) and target volume (HR: 0.853) predicted CO, but only target volume remained significant in multivariate analysis. In the EVT group, the latent period to CO was shortest for restrictive CSDAVFs (3.2 ± 1.6 months, P = 0.05). CONCLUSION Angioarchitecture did not affect treatment outcomes. Cavernous symptoms were strongly associated with lower complete obliteration rates in the GKRS but not the EVT group. The EVT method remains the treatment of choice, especially for restrictive CSDAVFs; however, compared to EVT, GKRS had lower complication rates and similar therapeutic effects for proliferative type fistulas.
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Affiliation(s)
- Huai-Che Yang
- Neurologic Institute, Department of Neurosurgery, Taipei Veterans General Hospital, 201 Shipai Rd, Sec 2, Beitou District, 112, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, 201 Shipai Rd, Sec 2, Beitou District, 112, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, 201 Shipai Rd, Sec 2, Beitou District, 112, Taipei, Taiwan, ROC.
- School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC.
- Department of Radiology, Tri-service General Hospital and National Defense Medical Center, Taipei, Taiwan, ROC.
| | - Cheng-Chia Lee
- Neurologic Institute, Department of Neurosurgery, Taipei Veterans General Hospital, 201 Shipai Rd, Sec 2, Beitou District, 112, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, 201 Shipai Rd, Sec 2, Beitou District, 112, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, 201 Shipai Rd, Sec 2, Beitou District, 112, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC
| | - Wen-Yuh Chung
- Neurologic Institute, Department of Neurosurgery, Taipei Veterans General Hospital, 201 Shipai Rd, Sec 2, Beitou District, 112, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC
| | - Kang-Du Liu
- Neurologic Institute, Department of Neurosurgery, Taipei Veterans General Hospital, 201 Shipai Rd, Sec 2, Beitou District, 112, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC
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Abstract
Intracranial dural arteriovenous fistulas (DAVFs) are abnormal arteriovenous connections within the dura, in which meningeal arteries shunt blood directly into the dural sinus or leptomeningeal veins. Among all the treatment options for the treatment of DAVFs, stereotactic radiosurgery (SRS) is a safe and effective modality. SRS provides a minimally invasive therapy for patients who harbor less aggressive DAVFs without cortical vein drainage (CVD), but who suffer from intolerable headache, bruit, or ocular symptoms. For more aggressive DAVFs with CVD associated with immediate risks of hemorrhage, initial treatment with endovascular embolization or surgery for the prompt elimination of the aggressive components of DAVFs is necessary. In such cases, radiosurgery may serve as a secondary treatment for further management of residual nidus after initial intervention. The latent period for the effects of radiation to occur and the longer time for cure compared to surgery and endovascular therapy remains a major drawback for radiosurgery. However, the gradual obliteration of a DAVF after radiosurgery can avoid the immediate risk of aggravated venous hypertension or infarction, which sometimes complicates endovascular embolization and surgery.
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Affiliation(s)
- Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan,
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David H C Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
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Hung YC, Lee CC, Guo WY, Shiau CY, Chang YC, Pan DHC, Sheehan JP, Chung WY. Gamma knife radiosurgery for the treatment of cavernous sinus meningiomas: post-treatment long-term clinical outcomes, complications, and volume changes. J Neurooncol 2019; 143:261-270. [PMID: 31020456 DOI: 10.1007/s11060-019-03090-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 01/03/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE To evaluate the outcomes of patients who underwent Gamma Knife radiosurgery (GKRS) for the treatment of cavernous sinus (CS) meningiomas. METHODS We retrospectively reviewed the clinical and radiological outcomes of 95 patients with CS meningiomas at Taipei Veterans General Hospital between 1993 and 2011. The study cohort comprised 27 men and 68 women with a median age of 50 years (range 29-79 years). The median pre-GKRS tumor volume was 6.6 ml (range 0.9-35.7 ml). The median margin dose was 12 Gy (range 11-21 Gy). The clinical factors related to favorable outcomes were assessed. RESULTS The median follow-up period was 59 (range 12-209) months. At the final follow-up, the tumor volume regressed in 70 patients (74%) and progressed in eight (8%). Kaplan-Meier analysis revealed that the progression-free survival rates at 5 and 10 years were 92.7% and 81.2%, respectively. Three patients (3.2%) experienced exacerbated cranial nerve dysfunction following radiosurgery. Confined tumors were found to be an independent prognostic factor for tumor control and shorter times to regression in the multivariable analyses. No risk factor for tumor progression was identified in either the univariate or multivariate analyses. CONCLUSIONS GKRS provides good long-term tumor control and is associated with low cranial nerve-related morbidity development rates in patients with small- to medium-sized CS meningiomas. Confined tumor could be an independent prognostic factor for tumor control and shorter times to regression in multivariate analysis. Life-long follow-up is mandatory in such settings, even for outpatients with shrunken or stabilized tumors.
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Affiliation(s)
- Yi-Chieh Hung
- Department of Neurosurgery, Chi-Mei Medical Center, Tainan, Taiwan, Republic of China.,Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan, Republic of China.,Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, 17 F., No. 210, Sec. 2, Shi-Pai Rd., Beitou, Taipei, 11217, Taiwan, Republic of China
| | - Wan-Yuo Guo
- School of Medicine, National Yang-Ming University, 17 F., No. 210, Sec. 2, Shi-Pai Rd., Beitou, Taipei, 11217, Taiwan, Republic of China.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Cheng-Ying Shiau
- School of Medicine, National Yang-Ming University, 17 F., No. 210, Sec. 2, Shi-Pai Rd., Beitou, Taipei, 11217, Taiwan, Republic of China.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Yue-Cune Chang
- Department of Mathematics, Tamkang University, Taipei, Taiwan, Republic of China
| | - David Hung-Chi Pan
- School of Medicine, National Yang-Ming University, 17 F., No. 210, Sec. 2, Shi-Pai Rd., Beitou, Taipei, 11217, Taiwan, Republic of China.,Department of Neurosurgery, Taipei Medical University- Shuang Ho Hospital, New Taipei City, Taiwan, Republic of China
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China. .,School of Medicine, National Yang-Ming University, 17 F., No. 210, Sec. 2, Shi-Pai Rd., Beitou, Taipei, 11217, Taiwan, Republic of China.
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Chong CCN, Chung WY, Cheung YS, Fung AKY, Fong AKW, Lok HT, Wong J, Lee KF, Chan SKC, Lai PBS. Enhanced recovery after surgery for liver resection. Hong Kong Med J 2019; 25:94-101. [PMID: 30919808 DOI: 10.12809/hkmj187656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) reduces postoperative length of hospital stay and patient stress response to liver surgery. The aim of the present study was to evaluate the efficacy and feasibility of an ERAS programme for liver resection. METHODS A multidisciplinary ERAS protocol was implemented for both open and laparoscopic liver resection in a tertiary hospital in Hong Kong. The clinical outcomes of patients who underwent liver resection and underwent the ERAS perioperative programme were compared with those who received a conventional perioperative programme between September 2015 and July 2016. Propensity score matching analysis was used to minimise background differences. RESULTS A total of 20 patients who underwent liver resection were recruited to the ERAS programme. Their clinical outcomes were compared with another 20 patients who received hepatectomy under a conventional perioperative programme after propensity score matching. The ERAS programme was associated with a significantly shorter length of hospital stay (P=0.033) without an increase in complication rates in patients who underwent open liver resection. There was no such significant association in patients who underwent laparoscopic liver resection. No patients required readmission in this cohort. CONCLUSIONS The ERAS perioperative programme for liver resection is safe and feasible. It significantly shortened the hospital stay after open liver resection but not after laparoscopic liver resection.
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Affiliation(s)
- C C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - W Y Chung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Y S Cheung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - A K Y Fung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - A K W Fong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - H T Lok
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - J Wong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - K F Lee
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - S K C Chan
- Department of Anaesthesia, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - P B S Lai
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Wu CA, Yang HC, Hu YS, Wu HM, Lin CJ, Luo CB, Guo WY, Lee CC, Liu KD, Chung WY. Venous outflow restriction as a predictor of cavernous sinus dural arteriovenous fistula obliteration after Gamma Knife surgery. J Neurosurg 2019; 132:1-8. [PMID: 30684940 DOI: 10.3171/2018.9.jns182040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife surgery (GKS) obliterates 65%-87% of cavernous sinus dural arteriovenous fistulas (CSDAVFs). However, the hemodynamic effect on GKS outcomes is relatively unknown. The authors thus used the classification scheme developed by Suh et al. to explore this effect. METHODS The authors retrospectively (1993-2016) included 123 patients with CSDAVFs who received GKS alone at the institute and classified them as proliferative type (PT; n = 23), restrictive type (RT; n = 61), or late restrictive type (LRT; n = 39) after analyzing their pre-GKS angiography images. Treatment parameters, the presence of numerous arterial feeders, and venous drainage numbers were compared across the CSDAVF types. Patients' follow-up MR images were evaluated for the presence of complete obliteration. A Kaplan-Meier analysis was conducted to determine the correlation between CSDAVF types and outcomes. RESULTS The 36-month probability of complete obliteration was 74.3% for all patients, with no significant differences across types (p = 0.56). PT had the largest radiation volume (6.5 cm3, p < 0.001), the most isocenters (5, p = 0.015) and venous drainage routes (3, p < 0.001), and the lowest peripheral dose (16.6 Gy, p = 0.011) and isodose level coverage (64.3%, p = 0.006). CSDAVFs presenting with ocular patterns were less likely to be completely obliterated (hazard ratio 0.531, p = 0.009). After adjustment for age, CSDAVFs with more venous drainage routes were less likely to be completely obliterated (hazard ratio 0.784, p = 0.039). CONCLUSIONS GKS is an equally effective treatment option for all 3 CSDAVF types. Furthermore, the number of venous drainage routes may help in predicting treatment outcomes and making therapeutic decisions.
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Affiliation(s)
- Chia-An Wu
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Huai-Che Yang
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Yong-Sin Hu
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Hsiu-Mei Wu
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Chung-Jung Lin
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Chao-Bao Luo
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Wan-Yuo Guo
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Cheng-Chia Lee
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Kang-Du Liu
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Wen-Yuh Chung
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
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50
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Lee CC, Yang HC, Chen CJ, Lin CJ, Wu HM, Chung WY, Shiau CY, Guo WY, Pan DHC. Empirical versus progression-guided stereotactic radiosurgery for non-functional pituitary macroadenomas after subtotal resection. J Neurooncol 2019; 142:291-297. [PMID: 30635763 DOI: 10.1007/s11060-019-03095-1] [Citation(s) in RCA: 8] [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] [Received: 11/21/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE There is a lack of consensus regarding whether if residual non-functional macroadenomas (NFM) should undergo empirical stereotactic radiosurgery (SRS) or be monitored until tumor progression before SRS treatment. The aim of this study is to compare the risks and benefits of empirical versus progression-guided SRS for NFM after subtotal resection. METHODS This is a retrospective study of consecutive NFM patients who subtotal surgical resection followed by SRS between 1999 and 2014. Patients were dichotomized into two groups: empirical SRS (SRS without evidence of tumor progression) and progression-guided SRS (SRS after demonstration of tumor progression) groups. Tumor response was categorized into: (1) regression, ≥ 10% decrease in tumor volume; (2) stable, < 10% increase or decrease in tumor volume; and (3) progression, ≥ 10% increase in tumor volume. Tumor control comprised stable tumor response and tumor regression. RESULTS Of the 112 patients who underwent SRS for NFM, 106 patients were treated for residual NFM after surgical resection, and included in the final analysis. The empirical SRS and progression-guided SRS groups comprised 46 and 60 patients, respectively. Overall tumor control rate was 88.7%. Higher rate of tumor control was achieved in the empirical SRS group compared to the progression-guided SRS group (95.65% vs. 83.33%, p = 0.047). Rates of new visual field deficit, cranial neuropathy and endocrinopathy were comparable between the two groups. Empirical SRS group had higher rates of progression-free survival compared to progression-guided SRS group (p = 0.015). Actuarial progression-free survival rates for the empirical SRS group were 93.2%, 93.2%, and 81.5% at 3, 5, and 10 years after SRS. Actuarial progression-free survival rates for the progression-guided SRS were 86.4%, 82.1%, and 68.4% at 3, 5, and 10 years after SRS. CONCLUSION Empirical SRS offers higher rates of tumor control and progression-free survival compared to progression-guided SRS in patients with residual NFM after surgical resection. Rates of new hypopituitarism and cranial neuropathies were comparable between the two groups.
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Affiliation(s)
- Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Cheng-Ying Shiau
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, ROC
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